PK 1 Astri 19 April Final

8/17/2019 PK 1 Astri 19 April Final

1/47

Case Presentation I

Tuesday, 19 April 2016

CASE PRESENTATION

PHYSICAL MEDICINE AND REHABILITATION MANAGEMENT OF PATIENT

WITH OSTEOSARCOMA OF RIGHT PROXIMAL TIBIA ENNEKING III POST

STANDARD TRANSFEMORAL AMPUTATION OF RIGHT LEG WITH

PULMONARY METASTASES

Presented by

dr! Set"# W#t" Astr" Ar"$"n

E%#&"ner

dr! I Ny'n M(rd)#n#* S+KFR,K

Presented "n T)e C'(rse '$ T#-"n. Res"den/y Tr#"n"n.

P)ys"/#0 Med"/"ne #nd Re)#b"0"t#t"'n Pr'.r#&

Med"/#0 F#/(0ty Un"1er"ty '$ Ind'nes"#

2#-#rt#

3456

Kepada Yth.

dr. I Nyoman urdhana, !pK"#$K


2/47

CONTENT

CONTENT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!"

CHAPTER 5 LITERATURE RE7IEW!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!5

5!5! OSTEOSARCOMA !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!5

5!3! ABO7E KNEE %TRANSFEMORAL8 AMPUTATION !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!9

5!:! REHABILITATION IN TRANSFEMORAL AMPUTATION !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!6

CHAPTER 3 CASE REPORT!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!53

3!5! IDENTITY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!53

3!3! ANAMNESIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!53

3!:! PHYSICAL EXAMINATION!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!59

3!;! SUPPORTI7E EXAMINATION!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!3:

3!9! RESUME!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!36

3!6! DIAGNOSIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!3<

3!

3!=! REHABILITATION PROGRAM!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!3>

3!>! PROGNOSIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:5

CHAPTER : CASE ANALYSIS!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:3

REFERENCE!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!::

APPENDICES !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!:6

i


3/47

CHAPTER 5

LITERATURE RE7IEW

5!5! OSTEOSARCOMA

5!5!5! De$"n"t"'n

The term osteosar&oma 'as (irst used in the early 1)00s *y Ale+is oyer, the

imperial (amily sur-eon (or Napoleon.%1 /steosar&oma is de(ined as a mali-nant

mesen&hymal tumor in 'hi&h the &an&erous &ells produ&e *one matri+.

/steosar&omas are &lassi(ied as primary and se&ondary. Primary are (urther su*$typed

as intramedullary&entral and sur(a&e osteosar&omas as per orld !health

/r-aniation &lassi(i&ation.%2

5!5!3! E+"de&"'0'.y

/steosar&oma is the most &ommon primary *one tumor.%3 The in&iden&e is

0.2$.0.3100.000year, hi-her in adoles&ents %0.)$1.1100.000year at a-e 14$19,

'here it a&&ounts (or 510 o( all solid &an&ers. Adults are less a((e&ted 'ith a se&ond

pea7 in&iden&e *et'een 40 and 80 years. This later in&iden&e is usually asso&iated

'ith se&ondary osteosar&oma that &ould arise in Pa-ets disease, *one in(ar&ts and(i*rous dysplasia. The male$(emale ratio is 1.:;1.%:

5!5!:! C0"n"/#0 M#n"$est#t"'n

The tumours usually arise in the metaphyseal re-ion o( the lon- *ones o( the

e+tremities, un&ommonly o&&ur in the diaphysis %9.%2,: The most &ommon

anatomi& sites o( osteosar&oma at initial presentation are the lon- *ones o( the lo'er

lim*s. "i(ty per&ent o( osteosar&omas are lo&ated around the 7nee, in the distal (emur, pro+imal ti*ia, or pro+imal (i*ula. Appro+imately 10 o( tumors o&&ur in the mid or

pro+imal (emur, and 9 o&&ur in the pro+imal humerus.%4,6

The most &ommon presentation is site spe&i(i& pain. This is -enerally

'orsened *y physi&al e+ertion. Appro+imately 20 &omplain o( ni-ht pain.%8 Ni-ht

pain -radually de


4/47


5/47

throu-h the &orte+ and li(ts the periosteum resultin- in rea&ti


6/47

sal


7/47

The most important pro-nosti&ator is the presen&e o( metastasis at

presentation. The se&ond pro-nosti&ator is the response o( tumour to neo$ad=u


8/47

easurements are ta7en (rom an easily identi(ied *ony landmar7 to the palpated end

o( the lon- *one, the in&ision line, or the end o( so(t tissue. In the trans(emoral lim*

the startin- pla&e (or measurement &an *e the is&hial tu*erosity or the -reater

tro&hanter.%22

Ta*le 2. @es&ripti


9/47

itsel(. Phantom lim* sensation is the per&eption that the e+tremity is still present and

o&&asionally distorted in position. Phantom lim* sensation typi&ally (ades a'ay

'ithin the (irst year a(ter amputation. Phantom lim* pain is di((erentiated as a pain(ul

per&eption 'ithin the a*sent *ody part. Pain at the sur-i&al site, in&ludin- in&isional

dis&om(ort, is &ommon and should resol


10/47

5!:!: P'st,'+er#t"1e P)#se

This phase *e-ins immediately post$operatiuipment pres&ription, and &ontinued

patient edu&ation and emotional support.

Time to (ittin- o( prosthesis is usually 6$) 'ee7s or lon-er, on&e stump has

matured. In the meantime, -ait trainin- is initiated 'ithout a prosthesis. "un&tional

mo*ility trainin- (or indi


11/47

e((e&ti


12/47

systems (or prostheti& -ait. e(ore startin- the prostheti& trainin-, there are seuate (or 'ei-ht *earin- and there are no a*rasionss7in

tears on 'ei-ht *earin- sur(a&es or lo&ation o( straps $ !tump shape is appropriate (or

prostheti& use, that is, the distal end should *e narro'er than the pro+imal end $

Patient is a*le to tolerate su((i&ient pressure on stump to *e-in 'ei-ht *earin- $ Pain

is reasona*ly under &ontrol

*. o*ility le


13/47

>uadrilateral desi-n and the is&hial &ontainment desi-n.

2. !uspension;

There are


14/47

CHAPTER 3

CASE REPORT

3!5! IDENTITY

Name ; N

A-e ; 36 years old

Address ; ?e*a7, #an-7as*itun-

/&&upation ; ouse'i(e

Bdu&ation ; 3rd &lass Blementary !&hool

arital status ; arried 'ith t'o &hildrens

edi&al re&ord ; :113239@ate o( e+amination ; April )th, 2016

3!3! ANAMNESIS

istory 'as ta7en on April ), 2016 (rom autoanamnesis, patients &ousin,

patients hus*and and (rom patients medi&al re&ord.

3!3!5! C)"e$ /'&+0#"ntPost trans(emoral amputation o( ri-ht le- 1 'ee7s a-o.

3!3!3! H"st'ry '$ t)e Present I00ness

Patient under'ent sur-i&al trans(emoral amputation o( the le(t lim* on ar&h

30, 2016 at #!C. !he 'as re(erred (rom /rthopedi& @epartment (or reha*ilitation

pro-ram a(ter amputation.

A*out 10 years a-o %2006, there 'as a small lump in the *a&7 side o( *ehind

her ri-ht 7nee. The lump had &lear *order 'ith (irm &onsisten&y, immo*ile, pain(ul

and tender on palpation and 'as -ettin- *i--er pro-ressi


15/47

lon- time, the lump re&urred in the same lo&ation %*ehind the ri-ht 7nee. The

&hara&teristi& o( the lump 'as same 'ith pre


16/47

Patient is not a*le to stand 'ith one le- 'ithout hand support (or more than 10

se&onds. o*iliation 'as helped *y usin- *ilateral &rut&shes (or near distan&e, *ut

(or (ar distan&e she usually use 'heel&hair helped *y her hus*and or her sister. !he

&an do most o( the a&ti


17/47

&osmesis reason. Patient 'ants to return to her a&ti

13.00 J 18.00 Ta7e a nap, &hat 'ith her roommates and nei-h*or,learnin- usin- *ilateral &rut&hes and mo


18/47

!B

Nutritional !tatus

Gait Pattern

alan&e

24

ody 'ei-ht ; 32 7-ody hei-ht ; 140 &mI ; 1:.2 %Dnder'ei-thIdeal *ody 'ei-ht O %*ody hei-ht$100 J

10%140$100 $10 O :4 7-A*ouate

Normal

alnutrition

!ittin- *alan&e;

normal

!tandin- *alan&e

impaired

General Physi&al "indin-s

Syste& P)ys"/#0 F"nd"n.s I&+ress"'n

Inte-ument

!7in; *ro'n$&olored, no rash, no dry s7in, no

hyperpi-mentation, normal temperature

Normal

air; no hair loss Normal Nail; no yello'ish, no si-n o( anemi&&yanoti& Normal

ead No masstumor, no haematoma, no edema, nolesiontrauma si-n

Normal

Ne&7

No de(ormity, no mass, tra&shea in the midline,

symmetri&al, no enlar-ement o( lymph nodes,

&arotid pulsation normal

Normal

Byes

Con=un&ti


19/47

alon- the le(t mid&la


20/47

CN II; /pti&us

Fisual a&uity test %-ross e+amination 'ith


21/47

CN FIII; Festi*ulo&o&hlear

$ Auditory test; patient &ould shear ru**in- (in-ers pla&ed at distan&e (rom *oth ear.

Impression; normal

CN IQ, Q; Glossopharyn-eal, Fa-us

$ !ymmetri& ar&h o( pharyn+ and u


22/47

$ ?ateral;"or'ard head, strai-ht &eruate

Palmar preshension;

Tripod -rip ; ade>uateade>uate

Pin&h -rip ; ade>uateade>uate

Plate -rip ; ade>uateade>uate

Cylindri&al -rasp ; ade>uateade>uate

!pheri&al -rasp ; ade>uateade>uate

Coordination test

Inde+ (in-er J inde+ (in-er ; -ood-ood

Inde+ (in-er J nose ; -ood-ood

20


23/47

Inde+ (in-er J nose J inde+ (in-er ; -ood-ood

Pronation J supination ; -ood-ood

ROM MMT

o


24/47

$ ip

#i-ht ; no de(ormity, no in(lammation si-n, normotrophy

?e(t ; no de(ormity, no in(lammation si-n, normotrophy

$ Thi-h

#i-ht ; a*o


25/47

?e(t ; normotonus, no tenderness, no spasm

$ Pulse; A. (emoralis RR re-ular, -ood

A. poplitea NTR re-ular, -ood

A. dorsalis pedis NTR re-ular, -ood

o


26/47

3! ;! SUPPORTI7E EXAMINATION

?A+r"0 55* 34568

M"n" Ment#0 St#te E%#&"n#t"'n 23 %Normal (or le


27/47

CT S/#n T)'r#% ?M#r/) 3:* 34568

Kesimpulan;

Nodul paru multipel %se*a-ian *er7alsi(i7asi disertai lim(adenopati su*7arina, sesuai

lesi metastasis.

L#b'r#t'ry

59@4:@56 :4@4:@56 59@4:@56 :4@4:@56

* 12.1 54!3 !G/T ;= $t :6!4 30.9 !GPT 30 $Britro&yte :.30 :!9< Al*umin 3.99 $C )3.8 )6.6 Natrium 1:: 139

CF 2).1 2).6 Kalium :.42 3.)2CC 33.6 33.0 Chlorida 103.0 103.6Throm*o&yte 339 39) Calsium %Ca

@arah$ ).)

?eu7o&yte 54!>5 5>!65 Calsium %CaRRIon

$ 1.22

?B@ ;4 a-nesium $ 1.)4PT "os(at Inor-ani7

%P$ :.0

Patient Kreatinin darah 0.60 $

Control 10.9 10.) Dreum darah 22 $APTT 10.) 10.8 G@! 94 8:Patient eG"# 118.6 $Control :2.6 39.1

3!9! RESUME

A 36 years old (emale patient re(erred to edi&al #eha*ilitation Poly&lini&

(rom /rthopaedi& Poly&lini& to -et reha*ilitation pro-ram a(ter amputation 1 'ee7s

a(ter ha


28/47

@epression !&ale s&ore is normal. Patient has already a&&epted her &ondition and

hopes she &ould still do her pre


29/47

B'dy str(/t(res

s.840; stru&ture o( lo'er e+tremity

s.:30; stru&ture o( respiratory system

A/t"1"t"es #nd P#rt"/"+#t"'n

Gener#0 t#s-s #nd Dends

d230;&arryin- out daily routine

M'b"0"ty

d.:34;mouisition o( -oods and ser


30/47

$ Improuate nutrition

$ ana-ement o( the stump

$ ana-ement o( phantom sensation and pain

$ Preuality o( li(e

Bdu&ation

$ A*out the &ondition and the treatment

o( the patient

$ Pro*lems that &an arise in a patient at

home li7e pain or (ati-ue, ho' to sol


31/47

$ #insin- the stump 'ell and to'el

dryin-

$ Clean the s7in (olds 'ith an appli&ator

or &otton s'a*

$ Any 'ound*ruise ha


32/47

se&onds, 10 repetitions, 3+day

$ amstrin- settin- e+er&ise %!B; hold 4

se&onds, 10 repetitions, 3+day4 Phantom pain and

sensation

No phantom pain

and no phantom

sensation

Bdu&ation ;

$ @o the desensitiation te&hni>ues;

massa-in- and tappin- o( residual lim*$ irror therapy

6 i-h ris7 o( (alls Pre


33/47

9 ilateral para&er


34/47

CHAPTER :

CASE ANALYSIS

32

ildly dependentA@?

i-h #is7 o( (all

Am*ulation 'ith *ilateral &rut&shes

prosthesis

?un-etastasis

Bner-ye+penditure

?imited a&ti


35/47

REFERENCE

1. Peltier ?; /rthopedi&s; a history and i&ono-raphy, Chapter 11No


36/47

&hildren and adoles&ents 'ith osteosar&oma. L Pediatr !ur-. 2006 LanE:1%1;19:$

9.

13. @in&*as "/, Ko&a !, andel N, et al; The role o( preoperati


37/47

24. Bs>uenai A, @iGia&omo #. #eha*ilitation a(ter amputation. L Am Podiatr ed

Asso&. 2001 LanE91%1;13J22.

26 @eFita FT, ?a'ren&e T!, #osen*er- !A. @eFita, ellman, and #osen*er-s

Can&er; Prin&iples W Pra&ti&e o( /n&olo-y. ?ippin&ott illiams W il7insE 200).

18:) p.

34


38/47

A++end"% 5! M"n" Ment#0 St#te E%#&"n#t"'n

D'"n Tested ?Test8 S/'re

/rientation

$ Year, month, day, date, time

$ Country, to'n, distri&t, hospital, 'ard

#e-istration

$ B+aminer names 3 o*=e&ts %e.-.; apple, ta*le, &oin

$ Patient as7ed to repeat 3 names J s&ore 1 (or ea&h &orre&t

ans'er

Attention and Cal&ulation

$ !u*tra&t 8 (rom 100, then repeat (rom result, et&. stop

a(ter 4

$ 100, 93, )6, 89, 82, 64

$ %Alternati


39/47

1. @BP#B!!B@ //@ %!adness, hopeless, helpless, 'orthless0OA*sent5T)ese $ee0"n. st#tes "nd"/#ted 'n0y 'n (est"'n"n.

2OThese (eelin- states spontaneously reported


40/47

2O?oss o( interest in a&tiuen&y.A


41/47

1Oea


42/47

T't#0 S/'re :

4 , < N'r

) $ 13 O ild @epression1:$1) O oderate @epression19 $ 22 O !e


43/47

3 andiri ] ]

8 o*ilisasi*er=alan 0 Tida7 mampu1 isa *er=alan den-an 7ursi

roda

2 er=alan den-an *antuan 1oran-'al7er

3 andiri ] ]

) erpa7aian 0 Ter-antun- oran- lain1 !e*a-ian di*antu %misal;

men-an&in-7an *a=u2 andiri ] ]

9 Nai7 turun tan--a 0 Tida7 mampu

1 utuh pertolon-an ]2 andiri ]

10 andi 0 Ter-antun- oran- lain1 andiri ] ]

T/TA? NI?AI 20 1)

Keteran-an; !7or I %Nilai A@?; 20 ; andiri

535> Keter.#nt(n.#n r"n.#n

9J11 ; Keter-antun-an sedan- 4 J ) ; Keter-antun-an *erat

A++end"% ;! E#stern C''+er#t"1e On/'0'.y Gr'(+ ?E/'.8 S/'re @ (br'd S/'re

A++end"% 9! K#rn'$s-y Per$'rn/e St#t(s S/#0e De$"n"t"'ns R#t"n.

Ab0e t' /#rry 'n n'r #/t"1"ty #nd t' 100 Normal no &omplaintsE no e


44/47

'r- n' s+e/"#0 /#re needed!

disease.

>4Ab0e t' /#rry 'n n'r #/t"1"ty

&"n'r s".ns 'r sy&+t'&s '$ d"se#se!

)0 Normal a&ti


45/47

1. !ITTING T/ !TAN@INGIN!T#DCTI/N!; Please stand up. Try not to use your hand (or support.← % : a*le to stand 'ithout usin- hands and sta*ilie independently← % 3 a*le to stand independently usin- hands← % 2 a*le to stand usin- hands a(ter se % 2 a*le to trans(er 'ith


46/47

3; % 2 a*le to stand 3 se&onds39 % 1 una*le to 7eep eyes &losed 3 se&onds *ut stays sa(ely36 ? 8 4 needs )e0+ t' -ee+ $r'& $#00"n.

←

8. !TAN@ING DN!DPP/#TB@ IT "BBT T/GBTB#

IN!T#DCTI/N!; Pla&e your (eet to-ether and stand 'ithout holdin- on.3< % : a*le to pla&e (eet to-ether independently and stand 1 minute sa(ely3= % 3 a*le to pla&e (eet to-ether independently and stand 1 minute 'ithsuper % 2 a*le to pla&e (eet to-ether independently *ut una*le to hold (or 30se&onds:4 % 1 needs help to attain position *ut a*le to stand 14 se&onds (eet to-ether :5 ? 8 4 needs )e0+ t' #tt#"n +'s"t"'n #nd (n#b0e t' )'0d $'r 59 se/'nd

←

). #BACING "/#A#@ IT /DT!T#BTCB@ A# I?B!TAN@ING

IN!T#DCTI/N!; ?i(t arm to 90 de-rees. !tret&h out your (in-ers and rea&h(or'ard as (ar as you &an. %B+aminer pla&es a ruler at the end o( (in-ertips'hen arm is at 90 de-rees. "in-ers should not tou&h the ruler 'hile rea&hin-(or'ard. The re&orded measure is the distan&e (or'ard that the (in-ers rea&h'hile the su*=e&t is in the most (or'ard lean position. hen possi*le, as7su*=e&t to use *oth arms 'hen rea&hin- to a


47/47

IN!T#DCTI/N!; Turn &ompletely around in a (ull &ir&le. Pause. Then turn a(ull &ir&le in the other dire&tion.← % : a*le to turn 360 de-rees sa(ely in : se&onds or less← % 3 a*le to turn 360 de-rees sa(ely one side only : se&onds or less← % 2 a*le to turn 360 de-rees sa(ely *ut slo'ly← % 1 needs &lose super

PK 1 Astri 19 April Final

Documents

Transcript of PK 1 Astri 19 April Final