Documente Academic
Documente Profesional
Documente Cultură
7 Oktober 2019
I. IDENTITY
Name : Mr. MR
Age : 41 years old
Occupation : Seller
Religion : Moslem
Date : September 30th, 2019
II. ANAMNESA
Chief complaint : Pain and stiffness in the right foot
Present history of illness :
On October 16, 2018 the patient had a traffic accident.
The patient was hit by a truck and entered under the truck.
There are open sores on right foot. After the accident the
patient is still conscious. After that the patient was taken
to the Demak District Hospital and was referred to the
Kariadi Hospital. The patient underwent STSG surgery 7
times since being treated at the Kariadi Hospital. The last
operation was in May 2019. There were no bones fracture.
The patient was admitted to the medical rehabilitation
department due to pain and stiffness in the right ankle.
Previously the patient mobilized in a wheelchair and was
practicing using crutches at home. The patient is no longer
working.
Past history of illness : HT (-), DM (-)
Social economics :
The patient work as a seller. The patient lives with his
wife and two children. Financing with BPJS PBI. Poor
socioeconomic impression.
IV. DIAGNOSIS
Clinical diagnosis : Post STSG ec skin degloving
regio pedis dekstra and cruris dekstra
Functional diagnosis :
- Body structure function : Ankle stiffnes, ankle pain,
limited ROM of the ankle
- Activity : Walking and mobilization difficulty
- Perticipation : Unable to work yet
- Environment : Patient have family support
- Personal : Patient can accept her condition and
have positive thought
V. GOAL
Short term goals : - Reduce pain and edema
-Increase ankle ROM
Longterm goals : Patient able to walk, undergo daily
activities, and working
VII. PROGNOSIS
Ad vitam : Bonam
Ad functionam : Dubia ad Bonam
Ad sanationam : Bonam