FORMULIR FISIOTERAPI

UNIVERSITAS INDONESIA
PROGRAM VOKASI
BIDANG STUDI RUMPUN ILMU KESEHATAN
PROGRAM STUDI FISIOTERAPI

Physiotherapist : Chanrina Kapitan Amd.FT : FT A

Doctor : dr. Luh KW, Sp.KFR - K Room : Poli A lantai 2
Register Number : 377-26-03 Examination Date : 19 September 2016

I. PATIENT IDENTITY DATA COLLECTION: (S)

Full name : S. Q. M
Place and date of birth : Jakarta, 29 May 2012 (4 years
old)
Address : Jalan Kali Anyar x Number 15,
West Jakarta
The last education : (Mom): High School
Job : (Mom) : Housewife
Hobbies : Roll Over
Medical diagnosis : Hemiplegic Cerebral Palsy, GMCFS
level 3
II. DATA COLLECTION HISTORY OF DISEASE
Primary Complaint : Patient is unable to sit steady
Present Disease History:
At the age of 5 months, patient was able to roll over and learn
to sit, but having seizures so that the patient should be treated at the
Sumber Waras Hospital for 10 days. Patient got seizures 3 times a day.
Patient had done a CT scan in Sumber Waras Hospital and the result
was the patient had an inflammation of the lining of the brain, so it
had to be examined MRI. Due to the limited facilities, patient was
referred to the General Hospital of Tarakan, and referred again to the
Cipto Mangunkusumo Hospital. In the Cipto Mangunkusumo
Hospital, the patient wasnt checked with MRI, but directly went to
the child neurologist. Patient couldnt do anything except lying. Then,
the patient was referred to Medical Rehabilitation departement and
recommended to do Physiotherapy. The first time patient came to
physiotherapy was on September 7th 2013. The patient was already
58 times come to Physiotherapy. Now, patient is able to roll over and
to sit independently.
Past Disease History : - Seizures: at the age of 5 months
Family Disease History : None
Prenatal History : -Mothers pregnant age 35 years old
-Control routine to a doctor
-No bleeding, spots and fall
-Never taking medicine or drugs
Natal History : -Blue (-)
-Yellow (-)
-Gave birth spontaneous
-Birth at the age of 9 months
-BBL: 2.7 kg
-PBL: 50 cm
-Gave birth at the health center
-Birth assisted by midwives
Post Natal History : -Seizures, fever, vomiting and diarrhea at the
age of 5 months, and was treated at the Sumber
Waras Hospital for 10 days, the seizures about
30 minutes and happened 3 times a day

Immunization History: Basic Immunization Completed

Growth And Development History:
Before Sick
-2 month : Head control
-2.5 month : To Prone
-3 month : Rolling
-5 month : To sit
After Sick
-1 year : Head control
-2 year : To Prone
-2 year : Rolling
-3 year : To sit, speak aaa
-4 year : Able to sit independently
Psycho-social History : -The forth child in the family
-Having 3 older brothers
Eat and Drink History :
6 months : Breast Milk
9 months : Eat soft porridge
1 year : Eat rough porridge
2 year : Eat Rice till now

Talk History : Patient is able to speak "aaa" at

the age 2 years
III. EXAMINATION (O)

A. General Examination:
-ways arrival : with wheelchair
-consiousness : compost mentis
-cooperatif / uncooperative : cooperative
-head circumference : 46 cm (normal: 46-
52cm)
-pulse : 82 bpm
-RR : not measured
-nutrition status : BB = 11 kg, TB = 88 cm
Impression : good
enough
-temperature : afebrile
B. Specific Examination:
Observation Of The Position And Motion
Patterns:
1. Supine
Head: move freely
Shoulder: symmetrical
Elbow: flexion
Wrist: right netral, left flexion
Finger: right semiflexion, left Rigid
Hip: symmetric
Knee: semiflexion
Ankle : inversion
Finger feet = right : flexion
left : extension
2. prone: 4. sit
Head lifting (+) - W pattern position
Head control (+) - Head control (+)
Forearm support (+) - Trunk position with a hip lock
Hip: semiflexion (round back)
Knee: semiflexion - Trunk control (+)
Ankle: Plantar flexion - Sitting balance (+)
- Protective reaction (+)
3. rolling - Hip: endorotation, abduction
- Via hip - Knee: flexion
- trunk rotation (+) -Ankle: plantar flexion and
inversion.
-WB on sacrum
5. stand (positioned)
- Fixation on Axilla
-Hip: semiflexion
- Knee: extension
- Ankle: plantar flexion, inversion
-WB: Right : Toes
Left : The side of foot
test spasticity:
-UE: Right : ashworth scale (1+)
Left : ashworth scale (2)
-LE: Right : ashworth scale (1)
Left : ashworth scale (1)
Clonus tests: (-)
Tighness Test on :
-Wrist Flexor
-Achilles Tendon
Test 7 primitive reflexes:
1. ATNR (-) =0
2. STNR (-) =1
3. Neck Righting (-) =1
4. Extensor Thrust (-) = 0
5. Moro reflex (-) =1
6. Parachute (+) = 0
7. Foot Placement (+) = 0
Score = 3
(Prognose to walk is Bad
Playing function:
Play function is similiar to 5
months age child.
-Able to look and follow the object
-Able to listen to object with sound
-Right hand able to grasp the object
-Able to follow the instruction
IV. WRITTEN DATA COLLECTION SUPPORTING
EXAMINATION

- CT Scan Report ( February 2nd )

From Sumber Waras Hospital
Conclusion :
-dilatation of extracerebral space without dilatation of brain
ventricle (dd/normal variant infant brain)
- There isnt decreasing of parenchyma cerebry or there isnt
increasing of density and oedema cerebry
V. 1. THE ORDER OF PHYSIOTHERAPY PROBLEM
BASED ON PRIORITY

1. High Postural Tone

2. Core Muscle Weakness
3. Tightness of Wrist Flexor and Achilles Tendon
4. No Left Hand Support
5. WB : Right : Toes
Left : The side of the foot
2. PHYSIOTHERAPY DIAGNOSIS
Body structure and function:
1. High Postural Tone
2. Core Muscle Weakness
3. Tightness of Wrist Flexor and Achilles Tendon
4. No Left Hand Support
5. Centering : Right : Toes
Left : The side of the foot

Activity limitation : Patient cant sit stable yet

Participant restriction : play function does not correspond to
the real patients age (similiar to 5
months child)
VI. PHYSIOTHERAPY IMPLEMENTATION PROGRAM
1. Data collection Of physiotherapy program from doctor of
Medical Rehabilitation
Date : 4 August 2016
Doctor : dr. Luh Karunia Wahyuni, Sp.KFR(K)
Physiotherapy Program :
-NDT
-Sitting Balance Exercise
-To Stand exercise with AFO
2. Goal
a. Short-Term Goals
- Sitting steady
- Maintenance
b. Long-Term Goals
- Maintenance
3. Physiotherapy Management Method

No TYPE METHOD DOSE DESCRIPTION

1. Exercise NDT F : 1x/week - Muscles
Therapy Mobilization
- Proprioseption
and Postural
correct
- Foot support
(tilting table)

- through wrist
Stretching F : 1x/week flexors and
achilles tendon.
- Strengthen core
Strengthening F : 1x/week
muscle
4. Physiotherapy Action Description

Neuro-Developmental Treatment
Release Spastic (Mobilization Muscle)
Action location/target : Elbow Flexors, Wrist Flexors, Achilles
Tendon
Patients position : supine on the bed
Physiotherapy position : besides patient
Procedure:
Handling of the muscles that is going to be mobilized, the
movement in the opposite direction to the spastic pattern. Do it until
tightness lost and the postural tone getting lower than before.
 Stretching
- Wrist Flexors
Patients position : supine
Physiotherapist position : besides patient
Procedure :
- Fixation on distal Forearm
- Handling : On Patient Palm, move patients wrist to extend.
Keep its position for 6 seconds and release. Do it 3 times.

- Achiles Tendon
Patient position : supine
Physiotherapist position : besides patient
Procedure :
- Fixation on proximal tibia
- Flexion the knee about 30.
- Handling : On patient calcaneous or achilles, move patients
foot to dorsiflexion. Keep its position for 6 seconds and release.
Do it 3 times.
 Strengthening Core Muscle
1. Knee to Chest
Patients position : supine
Physiotherapists position : besides patient
Procedure
- Fixation on posterior femur and occipitalis
- Flexion the patients knees. Move the patients tights to flexion
toward the patients chest while the patients neck bent to the
chest. Keep its position for 6 seconds and release.

2. Knee through Midline

Patients position : side lying
Physiotherapists position : besides patient
Procedure
- Fixation on the patients knee
- On leg extension. Flexion one of patiens knees through
midline so that the foot flat with the bed or floor. Then, flexion
patients neck to the chest. Keep its position for 6 seconds and
release.
 Exercise in Sitting Position
Patient position : sit facing the table as high as patients chest
PT Position : behind of patient
Procedure:
- Physiotherapist positions the patient to sit facing the table as high as
patients chest. The pelvic is fouled with antislip. Both of patients
hand is put above the table. The patients hand is positioned with
elbow extension and wrist flat with the surface of the table.
- Physiotherapist stabilize the sitting position of the patient with
fixation on the patients hand.

Positioning in The Tilting Table

Patient position : standing in front of PT
PT Position : besides patient
Procedure:
- Physiotherapist pairs the AFO on patients foot. Positioning the
patient on the tilting table. Wide base of the foot same with the wide
of patients shoulder. Tilt the table 90, pairs the table as high as
patients chest , put the patients hand forward, and keep the position
for 30-60 minutes.
5. Home Program
- Sitting facing the table as high as patients chest and patients hand is put
above the table. Patient plays with one hand and one hand do exercise.
- Using AFO

VII. EVALUATION
1. Evaluation After Giving Therapy:
S : Patient can sit steady for 14 seconds
O : - Postural tone nearly normal
- Tightness in wrist flexor and achlles tendon decreasing
- Core Muscle weakness
- Left Hand Support : None
A : Unable to sit steady associated with the above condition
P : Sitting stable
Program : -NDT
-Stretching
-Strengthening
2. Evaluation Schedule to the doctor
after 2 months
THANK YOU