CHAPTER II

CASE REPORT

IDENTITY
Name : Mr. EH
Age : 72 years old
DOB : May 13th, 1945
Sex : Male
Method of payment : BPJS
Education : ??
Occupation : Unemployed

ANAMNESIS
Taken on August 8th, 2017 by autoanamnesis.

Chief Complaint
Nyeri pada kedua lutut bila berdiri lama

Additional complaint
Berat Badan yang tidak turun-turun

History of Present Illness

Pasien merasakan nyeri pada lutut kanan sejak 4 tahun lalu, nyeri terasa tumpul dari
dalam lutut. Nyeri dirasakan hilang timbul, muncul terutama saat pasien berdiri lama
dan menghilang dengan istirahat. Tidak ada kaku pagi hari. Pasien mengaku saat itu
lutut kanan pasien bengkak dan merah namun pasien masih mampu berjalan dengan
perlahan.VAS (7) Bengkak hilang setelah pasien minum obat yang diberikan oleh
dokter penyakit dalam namun nyeri masih tetap ada. Nyeri tidak bertambah berat saat
pasien jalan menanjak maupun menurun juga pada saat berubah posisi dari duduk ke
berdiri. Pasien menyangkal riwayat trauma ataupun terbentur pada lutut. Selain itu
pasien juga mengalami kenaikan berat badan sejak saat masih bekerja di bidang
pelayaran selama 30 tahun, saat itu pasien harus banyak menjamu konsumen sehingga
berat badan pasien mencapai 106 kg. Pasien kemudian di rujuk ke Poli Obesitas
Rebilitasi Medik RSCM dan di diagnose OA Knee dan Obesitas. Kemudian pasien
mendapatkan beberapa therapi seperti TENS dan latihan termasuk ergocycling,
strengthening dan fleksibility exercise sebanyak 2x seminggu. Setelah terapi, nyeri
berkurang dengan VAS 5.

Satu tahun lalu lutut kiri pasien juga mengalami nyeri VAS 4, namun tidak sampai
bengkak. Nyeri muncul perhalan dan hilang timbul. Nyeri terutama saat berdiri lama
dan membaik dengan beraktivitas. Pasien masih mengikuti program latihan yang
diberikan oleh divisi Obesitas Rehabilitasi Medik secara rutin 2-3 x/ minggu.

Saat ini pasien masih mengeluh nyeri pada kedua lutut dengan VAS 4 untuk lutut kanan
dan VAS 3 untuk lutut kiri. Nyeri dirasakan sudah berkurang bila dibandingkan pada
awal serangan (VAS 7). Menurut pasien nyeri hilang timbul, muncul terutama saat
pasien berdiri lama lebih dari 30 menit dan berubah posisi dari duduk ke berdiri, nyeri
biasanya menghilang setelah pasien beristirahat rebahan. Kadang-kadang nyeri muncul
bila pasien naik turun tangga. Nyeri terasa tumpul dari dalam lutut. Pasien juga
mengatakan bahwa saat ini pasien kesulitan untuk duduk jongkok. Berat badan pasien
sudah berkurang menjadi 95 kg dan pasien mengaku tubuhnya sudah mengecil karena
mampu mengenakan pakaiannya di masa muda. Pasien mengatakan selain berlatih 2-
3x seminggu di poli Obes, setiap pagi pasien rutin berjalan pagi kurang lebih 2,5 km
selama 30 menit dan mengatur pola makan seperti yang dianjurkan bagian gizi. Namun
pasien mengaku ingin tetap mengurangi berat badannya dan meningkatkan
kebugarannya.

History of Using Hormonal Birth Control

There was no history of using hormonal birth control.
History of Past Medical Condition
Pasien memiliki riwayat Ca Prostat dan sudah di Operasi pada Feb 2016.
Pasien juga menderita Age Related Macula Degenerative pada mata kanan dan mata
kiri.
Patient has no history of diabetes, stroke or heart disease.
Patient has hypertension since ???? and currently on medication (Telmisartan 1x40mg
and Amlodipine 1x5mg). His blood pressure is well controlled as he routinely
controlled to Internal Medicine Department. He has hyperuricemia and currently on
medication (Allopurinol 1x100mg). He takes the allopurinol daily and his uric acid
level is well controlled.

History of Family Illness

There was no history of obesity, diabetes, hypertension, and heart disease.

Functional History
Patient is a housewife doing domestic chores such as cooking, washing by
washing machines, ironing and cleaning the house. Patient likes to watch TV and
read some book in her leisure time. Patient was a bechelor degree and worked as an
english teacher, and currently not working.
Mobility Activities: Patient can walk independently without any walking aid.
Activities of daily living: Patient was fully independent in feeding, grooming,
dressing, bathing, and toileting Activities
Community activities: Patient is still active in her community activities, such as
going to Church weekly and Arisan regularly.
Cognition: Patient has adequate orientation, memory skills, judgment and
capacity of abstract thought.
Communication: Patient has no problem in verbal communication.
Psychosocial History
She was married with one daughter. Her husband passed away 2 years ago. She is
former teacher. Her child works as a english teacher. She lives with her daughter in her
own permanent house, around 135 m2. It consists of a living room, 2 bathrooms with 1
sitting toilet for patient & her daughter and 1 squatting toilet for the quest, 3 bedrooms,
a dining area, and a kitchen area.
Electricity is from PLN and water is from PAM. She never smoke and never
consume alcohol. There were no histories of depression, anxiety, and suicidal attempt
or other psychological problem

Medication and allergies

She consumes medication regularly from internal medicine department RSCM for
her hypertension (Valsartan 1x80mg and Amlodipine 1x5mg) and dyslipidemia
(Simvastatin 1x10mg daily). She has no history of allergy to any drug.

Review of system
Skin: no history of skin rash or wound.
Cardiopulmonary status: no history of asthma, pulmonary or heart disease
Gastrointestinal status: no history of nausea, constipation and darkened stool.
She defecates regularly.
Genitourinary status: no problem in urination. She menopaused 12 years ago.
Nutritional status: obesity gr I

Daily diet
Time Portion and menu Calories
06.00 1 cup of tea with sugar 25
1 slice of bread with butter 146
08.00 1 cup of rice 1 242
scrambled egg 237
13.00 1 cup of rice 242
100 gr of fried fish/chicken/meat 238
1 cup of vegetable soup 100
 16.00 500 gr of Papaya 195
20.00 1 cup of rice 242
100 gr of fried fish/chicken/meat 238
1 cup of vegetable soup 100
TOTAL 2005 calories/day

Daily Physical Activity

Time Physical activity METS

05.00 Wake up 0.9
05.00-06.00 Preparing breakfast 2.0
06.00-06.15 Bathing 1.5
06.15-06.30 Eating 1st breakfast 1.5
06.30-08.00 Cooking 2.0
08.00-08.15 Eating 2nd breakfast 1.5
08.15-10.00 Cleaning the house 3.5
10.00-12.00 Watching television 1.3
12.00-12.30 Eating lunch 1.5
12.30-15.00 Taking a nap 1.8
15.00-16.30 Washing & Ironing clothes 3.5
16.30-16.45 Bathing 1.5
16.45-18.00 Preparing Dinner 2.0
18.00-20.00 Watching television/chatting with her daughter 1.3
20.00-20.15 Eating dinner 1.5
20.15-21.00 Watching television/chatting with her daughter 1.3
21.00-05.00 Sleeping 1.0
TOTAL 28.6

Total Energy Expenditure

BW x METs in 24 hour = 73 x 28,6 = 2087,8 cal/day

BMR using Harris Bennedict formula

655 + (9.6xBW in kg) + (1.8xBH in cm) (4.7x age in years)
= 655 + (9.6x73) + (1.8 x 159) (4.7 x 67)
= 1327,1 cal/day

Physical Activity Level

= TEE / BMR
= 2087,8 / 1327,1
= 1,57 (limited activity)

SF-36
Physical functioning : 850 (85%)
Role limitations due to physical health : 400 (100%)
Role limitations due to emotional problems : 300 (100%)
Energy/ fatigue : 300 (75%)
Emotional well being : 400 (80%)
Social functioning : 200 (100%)
Pain : 140 (70%)
General health : 400 (80%)

PHYSICAL EXAMINATION
General Physical Examination
Level of Consciousness : compos
mentis Vital sign :
BP : 122/68 mmHg
HR : 76x/minute
RR : 16x/minute
Temperature: afebris
Oxygen Saturation: 98%
Borg Scale: 7-0-0
Nutritional status:
 Body Weight: 73 kg
Height: 159 cm
(BMI: 28,87 Obese grade I)
Ideal body weight : (Height-100) + 10% (Height-100) = 64,9 kg
Waist circumference : 94 cm
Neck circumference : 36 cm

Gait examination:
Patient walked independently, without any walking aid
Head : in midline, no deviation
Arms : swing symmetrically
Trunk : shoulders are symmetrical, no lateral movement
Hip : no anteflexion or retroflexion
Knees : normal knee flexion and locking
Ankle and feet : adequate heel strike and push off
Stability : normal base

Balance :
Static sitting balance : adequate
Dynamic sitting balance : adequate
Romberg test : >30s with opened eyes
>30s with closed eyes
Sharpen Romberg Test : >30s with opened eyes
<30s with closed eyes
Trendelenberg sign : negative/negative
Modified get up and go test : can stand up and sit down without holding to something
(5.45 seconds)

Posture:
Anterior:
- head in midline
- clavicles are symmetrical
- shoulders are symmetrical on both side
- body-arm distance are symmetrical Lateral:
- no forward head
- no hyperkiphotic thoracal
- hyperlordotic lumbal
- no knee recurvatum Posterior:
- head in midline
- shoulders are symmetrical
- body-arm distance are symmetrical
- vertebral alignment is normal
- no pelvic obliquity
- no deformity of ankle

General Physical Findings

Head : no deformity, head in the midline
Hair : black hair, wavy, hard to be pulled out
Eyes : no anemic conjunctiva, no icteric sclera, isochoric pupils, pupil diameter
4 mm/4 mm
Nose : no septal deviation, normal nasal mucosa, no secretion, no sign of
inflammation.

Oral cavity : symmetrical lips, good oral hygiene

Throat : tonsil T1/T1 and not hyperemic, symmetrical pharyngeal arch, no
deviation of uvula

Neck : trachea in the midline, normal JVP, no thyroid or lymph node

enlargement

Chest :
- Lung :
- Inspection: thoracoabdominal breathing pattern, symmetrical in
static and dynamic chest movement, no accessory muscle activity
 - Palpation: no mass, vocal fremitus of both sides were equal
- Chest expansion: 3-5-6 cm
- Percussion: sonor in both side
- Auscultation: vesicular in both side. No ronchi or wheezing.
-Heart : normal heart sound I-II, no murmur, no gallop
Abdomen : distented, no defense muscular, no enlargement of liver and
spleen, tympanic sound on percussion, normal peristaltic sound

Functional Examination
Fine Coordination : in normal limit
Mobility activities : independent

Neurologic Examination
Higher Function and Mental state :
Cognitive state : Mini Mental State Examination score: 30 (no cognitive impairment)
Mental State
- Appearance and behavior: no sign of self-neglect, no appearance of anxiety and
depression, mood was stabil, behavior was appropriate
- Mood: normothym
- Affect: normal
- There was no vegetative symptoms and symptoms of anxiety
Communication : in normal limit
Language : in normal limit
Memory : in normal limit
Sensory agnosia : in normal limit

Cranial Nerve Examination : in normal limit

Motoric:
- Muscle tone : normotonus
- Physiologic reflexes
 o Biceps :
+2/+2 o Triceps
: +2/+2 o
Brachioradialis:
+2/+2 o Patella
: +2/+2 o
Achilles :
+2/+2 - Pathologic
reflex : negative

Sensoric: normal sensibility

Musculoskeletal Examination
CERVICAL
Look : No deformity
No sign of inflammation
Feel : Spasm of upper trapezius muscles bilateral
Move : Pain on flexion and lateral flexion to the both side VAS 1
ROM MMT
Movement Right Left Movement Right Left
CERVICAL
Flexion 0-400 Flexion 5
Extension 0-450 Extension 5
Lateral Bending 0-450 0-450 Lateral Bending 5 5
Rotation 0-800 0-800 Rotation 5 5

Special test:
Spurling/compression test : negative/negative
Distraction test : negative

TRUNK
Look : Shoulders are symmetrical
Hyperlordotic lumbal
Body-arm distances are symmetrical
Accumulation of fat on upper back, belly and waist
Feel : Tenderness on both sides of paralumbal
No pelvic obliquity
Spasm of paralumbal bilateral
Move : Patient feel pain when doing trunk flexion and rotation

ROM MMT
Movement Right Left Movement Right Left
Thorakolumbal
Flexion 0-600 Flexion 5
Extension 0-250 Extention 5
Lateral Bending 0-300 0-300 Lateral Bending 5 5

Special test:
SLR test: >700/>700
Patrick : negative/negative
Contra-patrick : negative/negative
Braggard : negative/negative
Thomas test : negative/negative

UPPER EXTREMITIES
Look : Both arm in neutral position, no sign of inflammation
Accumulation of fat in the upper arms
Feel : Tenderness on greater & lesser tubercle of humerus sinistra, no signs of
inflammation, no muscle spasm
Normotone
Normal sensibility
Normal proprioception (identifying direction & position)
Move : Pain on left of shoulder flexion, abduction and internal rotation
ROM MMT
Movement Right Left Movement Right Left
SHOULDER
Flexion 0 180 0 180 Flexion 5 5
Extension 0 60 0 60 Extension 5 5
Adduction 0 45 0 45 Adduction 5 5
Abduction 0 180 0 180 Abduction 5 5
Internal Rotation 0 90 0 90 Internal Rotation 5 5
External Rotation External Rotation 5 5
ELBOW
Flexion 0 140 0 0 140 Flexion 5 5
Extension 0 Extension 5 5
FOREARM
Supination 0 90 0 90 Supination 5 5
Pronation 0 90 0 90 Pronation 5 5
WRIST
Flexion 0 80 0 60 Flexion 5 5
Extension 0 70 0 70 Extension 5 5
Ulnar deviation 0 30 0 30 Ulnar deviation 5 5
Radial deviation Radial deviation 5 5
THUMB
Abduction 0 70 0 70 Abduction 5 5
Adduction 0 0 Adduction 5 5
MCP flexion 0 50 0 50 MCP flexion 5 5
IP flexion 0 90 0 90 IP flexion 5 5
MCP extension 0 0 MCP extension 5 5
IP extension 0 20 0 20 IP extension 5 5
FINGERS
Abduction 0 20 0 20 Abduction 5 5
 Adduction 0 0 Adduction 5 5
MCP flexion 0 90 0 90 MCP flexion 5 5
PIP flexion 0 100 0 100 PIP flexion 5 5
DIP flexion 0 90 0 90 DIP flexion 5 5
MCP 0 30 0 30 MCP extension 5 5
PIP extension 0 0 DIP extension 5 5
DIP extension 0 10 0 10 DIP extension 5 5

Special test for the shoulder

Neer test : negative/positif
Hawkins Kennedy test : negative/positif
Emptycan test : negative/negative
Droparm test : negative/negative
Speed test : negative/negative
Yergason test : negative/negative
Lift off test : negative/positif

LOWER EXTREMITIES
Look : No sign of inflammation
No deformity
Accumulation of fat in the gluteus and thighs
Feel : Femorotibia angle 50/50
No effusion
No tenderness
Normotonus
Normal sensibility
Normal proprioception (identifying direction & position)

Move : No pain on movement

Crepitation positive in both knees

ROM MMT
 Movement Right Left Movement Right Left
HIP
Flexion 0 120 0 120 Flexion 5 5
Extension 0 30 0 30 Extension 5 5
Adduction 0 30 0 30 Adduction 5 5
Abduction 0 45 0 45 Abduction 5 5
Internal 0 35 0 35 Internal 5 5
External 0 45 0 45 External 5 5
KNEE
Flexion 0 135 0 135 Flexion 5 5
Extension 0 0 Extension 5 5
ANKLE
Dorsiflexion 0 20 0 20 Dorsiflexion 5 5
Plantarflexion 0 50 0 50 Plantarflexion 5 5
Inversion 0 35 0 35 Inversion 5 5
Eversion 0 15 0 15 Eversion 5 5
GREAT TOE
MTP flexion 0 45 0 45 MTP flexion 5 5
IP flexion 0 90 0 90 IP flexion 5 5
MTP extension 0 60 0 60 MTP extension 5 5
IP extension 0 0 IP extension 5 5
TOES
MTP flexion 0 40 0 40 MTP flexion 5 5
PIP flexion 0 35 0 35 PIP flexion 5 5
DIP flexion 0 60 0 60 DIP flexion 5 5
MTP extension 0 40 0 40 MTP extension 5 5

Special test for the knee

Patella gridding test : negative/negative
Anterior Drawer Sign : negative/negative
Posterior Drawer Sign : negative/negative
Valgus test : negative/negative
Varus test : negative/negative
McMurray Test : negative/negative
Appley compression test : negative/negative
 Appley decompression : negative/negative
test
Leg length discrepancy : no leg length
discrepancy

SUPPORTIVE FINDINGS

Hematology (31th January 2017)

Fasting blood glucose 88 mg/dl
Asam Urat 6,6 mg/dl*
Triglyceride 99 mg/dl
Total cholesterol 197 mg/dl*
HDL cholesterol 50 mg/dl
LDL cholesterol 136 mg/dl*

Radiology
Radiography of vertebrae thorakal (15-08-2016)
Kedudukan dan kelengkungan vertebra masih baik. Tak tampak listhesis.
Struktur tulang intak, tak tampak fraktur/destruksi.
Formasi osteofit marginal diaspek anterolateral korpus vertebra thorakalis dengan
bridging spur terutama pada sisi kanan
Tampak penyempitan celah diskus T9-10, T10-11
Tampak sklerotik sendi facet T4-5 s/d T10-11
Jaringan lunak paravertebra tidak menebal
Kesimpulan:
Spondiloarthrosis thorakalis dengan degenerasi diskus T9-10, T10-11
Degenerasi sendi facet T4-5 s/d T10-11
Osteoporosis

Radiography of lumbal vertebrae AP and lateral (15-08-2016)

Tampak lateralisasi ringan vertebra lumbal dengan konveksitas ke kiri.
Tidak tampak listesis
Multiple osteofit di korpus vertebra L1-L5
Tampak penyempitan celah diskus sisi posterior L3-4 hingga L5-S1
Tampak sklerotik pada superior endplate L5
Jaringan lunak paravertebra tidak menebal
Kesimpulan:
Skoliosis lumbal
Spondiloarthrosis lumbalis dengan degenerasi diskus L3-4 hingga L5-S1
Saran : MRI Lumbal

Radiography of genu AP and lateral (05122016)

Kedudukan tulang masih baik. Tak tampak subluksasi / dislokasi
Struktur tulang intak, tidak tampak fraktur / destruksi
Formasi osteofit pada condylus medial tibia kanan.
Tampak entesofit pada eminensia intercondylaris sisi medial kanan-kiri dan basis
patella kanan
Tak tampak pseudocyst dan sklerosis subkondral
Sendi femorotibial kiri kompartemen medial tampak menyempit dengan sklerosis
subkondral
Celah sendi femorotibial kanan baik
Ossifikasi di regio poplitea kanan
Kesimpulan:
Osteoarthritis genu kiri grade III dan Osteoarthritis genu kanan grade II

Ultrasonography (9th March, 2017) : Left Shoulder

Tampak efusi perisentrik pada tendon sheath bisep bisipitalis disertai
hiperlvascularisasi Tampak akumulasi cairan pada tendon subscapularis yang
berkoneksi dengan bursa SASD yang menebal
Supraspinatus heteroechoic menebal dan korteks irregular
Terdapat kalsifikasi bentuk noduler berukuran 0,5x0,25 cm pada intersubstan
supraspinatus Kesimpulan:

Partial tear pars bursa subscapularis muscle

Calcified tendinosis supraspinatus
Tenosinovitis bisep bisipitalis
CASE SUMMARY
Patient, female, 67 years old, from anamnesis on February 27th, 2017 had a chief
complaint of low back pain. The additional complaint is pain in left shoulder. Patient
has been gaining body weight after she was married and gived birth about 25 years ago.
Since about 10 years ago, patient has felt pain on her both knees. She felt pain on her
knee when she walks for around 500 meters, climbs up and going down the stairs with
VAS 5 for both knees. Patient got some therapies such as diathermy, TENS, laser and
exercise at the knees. Since 7 years ago, patient felt pain on her low back everytime she
change position from sitting to standing and get up from lying down to sitting position.
The pain was dull, VAS 6, without any sign of radiculopathy. She got treated at Poli
Geriatric Rehabilitasi Medik with TENS and stretching exercise. Two years ago,
patient accidently injured her left arm by grabbing on something while she was slipping
on the ground. Eversince, she always feel pain everytime she elevated her arm and
doing the back rub. The pain was dull, VAS 3, without any sign of radiculopathy. She
hasnt got any therapy for her left shoulder pain. Currently, she is still feeling pain in
his left shoulder with VAS 3. Since 7 months ago, patient felt that low back pain
became worsening when she rotate her trunk with VAS 5. She got treated at obesity
policlinic with TENS and stretching exercise. With the treatments, the pain reduced
with VAS 3. Patient has history of hypertension and dyslipidemia since 2016 and
currently well controlled. Physical activity level of patient is 1,57 / sedentary.
On physical examination: BMI 28.87 kg/cm2 (obese grade I), waist
circumference 94 cm, neck circumference 36 cm. On examination of balance, Sharpen
Romberg Test is inadequate. On local stase of cervical, there was spasm on upper
trapezius muscles with pain on flexion and lateral flexion to the both side. On the trunk,
there were tenderness and spasm on both sides of paralumbal with pain on flexion and
rotation. On the left shoulder, there were tenderness on greater & lesser tubercle of
humerus sinistra with pain on flexion, abduction and internal rotation and positive neer,
hawkins, and lift off special test. On the lower extremity, there was crepitation in both
knees without any pain.
 From hematology, there were high uric acid , borderline LDL and total
cholesterol level. Radiological finding were Spondiloarthrosis thorakalis and lumbalis
with degenerative of facet joint T4-5 to T10-11, bilateral knee osteoarthritis grade II in
right side and grade III in left side. Ultrasonography of left shoulder finding were partial
tear of pars bursa subscapularis muscle and calcified tendinosis supraspinatus.
Medical Diagnosis :
Sarcopenic Obesity
Spondyloarthrosis lumbal
Spondyloarthrosis thorakal with narrowing of intervertebral disc of T9-10 and T10-
11
Subscapularis tear
Bilateral knee osteoarthritis
Hypertension
Dyslipidemia
Hyperuricemia

Rehabilitation Diagnosis :
Sarcopenic Obesity
Low back pain due to paralumbal spasm due to spondyloarthrosis lumbal
Left shoulder pain due to subscapularis tear with bursitis SASD and supraspinatus
calcified
Bilateral knee osteoarthritis
Bilateral upper trapezius muscle spasm e.c susp spondilosis cervical
Metabolic syndrome

International Classification of Functioning Disability and Health:

Body Functions :
b280 Sensation of pain b420
Blood pressure functions b530
Weight maintenance functions
b540 General metabolic function
b710 Mobility of joint functions
b789 Movement functions, other specified and unspecified
Body Structures :
 s720 Structure of shoulder region
s750 Structure of lower extremity
s760 Structure of trunk
Activities and Participation :
d410 Changing basic body position d415 Maintaining a body position
d430 Lifting and carrying objects d449 Carrying, moving and handling
objects, other specified and unspecified

GOALS
Short term goal :
Achieving weight loss
Reduced pain and muscle spasm in low back
Reduced pain and muscle spasm in the neck
Reduced pain and in the left shoulder
Mantaining normal blood pressure
Mantaining normal blood lipid
Improving balance

Long term goal :

Improve the Quality of life
Preventing the recurrence of musculoskeletal problems :
low back pain
left shoulder pain
knee osteoarthritis progression (joint structure damage)
Improve the risk factors (hypertension, dyslipidemia)
Maintance muscle mass
Rehabilitation Program

PROBLEMS TARGET PROGRAMS

Sarcopenic Improve quality of Education:
Obesity life - About sarcopenic obesity and complications

Behavioral Modification :
- Increase patient motivation to have an active life style :
routine home exercise, less watching television
- Increase patient motivation to restriction diet with high
protein diet
Prevention of further
gain Diet Modification:
Reduce the body - Control diet program by consulting to nutritionist
weight - Motivation to eat healthy food
& - Suggestion to eat breakfast, lunch and dinner in smaller
Reduce waist portion
circumference - Low calorie diet : 1600 kkal with high protein diet

Physical exercise:
Warming up 5 minutes with hamstring, quadriceps, and
gastrocsoleus stretching
Aerobic exercise using static cycle -
Astrand test :
Patient start the exercise with initial loading 1 KP for 45
Maintance Muscle minutes and the frequency is 3 times a week
Mass - Determine target heart rate: (50-60% HR max) = 50-60%
(200-67) = 66-80x/ minutes. Evaluate the heart rate during
exercise.
- Evaluate BORG scale before and during exercise
- Educate the patient to cease exercise within 11-13 RPE
BORG
- Exercise should be done 2 hours after taking a meal and
routine medicine
Strengthening exercise using NK table
Cooling down 5 minutes with hamstring, quadriceps, and
gastrocsoleus stretching

Pharmacotherapy
Orlistat 120 mg, 1 times/day 10 minutes before lunch
Maintaining normal Behavioral Modification :
blood lipid - Increase patient motivation to have an active life style :
routine home exercise, less watching television
- Increase patient motivation to restriction diet
 Maintaining normal Diet Modification:
blood pressure - Control diet program by consulting to nutritionist
- Low fat, low salt and low purine diet, high protein

Preventing metabolic Physical exercise

syndrome and - Aerobic Exercise
reducing
cardiovascular Management of dyslipidemia, hypertension and
complication hyperuricemia
- Simvastatin 10 mg, 1 time/day
- Valsartan 80 mg, 1 time/day
- Amlodipine 5 mg, 1 time/day
- Continue integrated care with internal medicine
departement
Improving balance Physical exercise:
Balance exercise using balance board for 30 minutes, 3 times
a week.

Mechanical Reduced pain and Education:

Low Back Pain muscle spasm in - Joint protection (no heavy lifting, no trunk bending,
low back avoid trunk extension)
- proper posture and body mechanic when doing
Prevention of further household activities
gain
Reduce the body Physical exercise:
weight Home program: William Flexion exercise:
& - Single knee to chest
Reduce waist - Double knee to chest
circumference Hold 6 second, 3x10 repetitions, 3 times/day

Reduce pain and paralumbal muscle spasm

- Tapping regio back extensor
- Modality : US 2 times/day
 Left shoulder Reduced pain of left Education:
pain due to sholder Proper posture and body mechanic when doing household
subscapular tear activities
with SASD
bursitis Modality:
Laser therapy at tenderpoint at subscapular muscle and
SASD bursae with eksternal rotation and extension shoulder
position, 3 times/week

Physical exercise : Home program

- Towel exercise and pendulum exercise

Bilateral Upper Reduced upper Education:

Trapezius trapezius spasm Proper posture and body mechanic when doing household
muscles spasm activities

Confirming the Reduce pain and bilateral upper trapezius muscle

diagnosis spasm - Modality : US 3 times/day

Physical exercise : Home program

- Stretching bilateral upper trapezius muscle
Hold 6 seconds, 10 repetitions, 3 times a
day

Radiology Examination
- Radiography of cervicalvertebrae AP and
lateral
Preventing pain on Education:
Knee the knee - Joint protection (avoid squatting, standing or walking for
osteoarthritis a long time, climbing up and down stair)
Preventing - Weight management
progression of knee - Encourage patient to do home exercise routinely
osteoarthritis

Strenghtening Physical exercise:

quadriceps and - Quadriceps isotonic exercise with NK-table (using last
hamstring stress test results) 6,5-9,75-13 kg, hold 6s, 3x10
muscles repetition with 1 minute rest in between sets
- Hamstring isotonic exercise with NK-table (using last
stress test results) 3,5-5,25-7 kg, hold 6s, 3x10 repetition
with 1 minute rest between sets
Prognosis

ad vitam : bonam
ad functionam : dubia ad bonam
ad sanationam : dubia ad bonam

CASE ANALYSIS

REFERENCES