ASSESSMENT: MASLINA BINTI PAIMAN
Ms Ax:
A) Patient Hx:
Name: Maslina binti paiman
Age: 37 y/o
Gender: female
Date of referral: oktober 2021
Date of ax: 27/10/2022
Dr’s Dx: Left ankle with lateral malleolus
syndesmotic joint disruption
tibotalar sublaxatin ans deltoid ligament tear.
Dr’s mx:
B) SUBJECTIVE Ax:
Pt c/o: pt c/o pain, on & off swelling over left ankle
Pain scale (VAS) : at rest: 5/10
Move : 9/10
Nature of pain : dull ache pain
Aggravating factor : prolong sitting >1 hr, prolong standing >1hr, prolonged walking >1/2 hr, sit
to stand, climbing up & down stairs.
Ease factor : rest, self-massage put oiling
24 hrs : non specific
Irritability : medium
Current hx: gradual onset of pain at left ankle, reduce left ankle stability since few months ago.
Pt went to hospital sulatanah aminah for follow up but condition remain the same. Pt was
referred by Perkeso for further management.
Past hx: On 26 mac 2022, pt was accidentally hit on his left foot . Pt quickly pull off his ankle by
twisting the ankle and run off from there. Accident by her self after working hours want going
back to home,on that day,she not feeling well sudently faiting and faling [Link] at that
palce call her husband and thir boss.,call ambulance and going Hospital Kulai, Doctor did Xray
and found out his talus bone dislocate, all ankle’s ligament tear. Doctor bandage the ankle and
pt wore crutches. After 1 month, pain became worsen and pt’s body temperature increase. Pt
went to klinik kesihatan hospital segamat for further x-ray. After 4 days Doctor at Has did MRI
(bone dislocate and all ligament were tore) and surgery with 1 screw insertion at left ankle
bone.,and do internal fixation, Pt stay in ward for21 days after surgery. After that pt used
walking frame for walking about 2 months. In 20 july 2022 pt did surgery to remove the screw at
hospital segamat and gradually put weight on left leg. Pt use walking frame about 2 weeks
before start to walk without walking aid.
ASSESSMENT: MASLINA BINTI PAIMAN
PSHx: nil
Ix : x-ray and MRI done
Medication: nil
[Link]: healthy
Social hx:
occupation: technician factory, repair mother board computer
work nature: prolong standing and walking
marital status: married
house: single story house, using sit toilet
dominant hand/leg: right
non smoking
functional limitation: prolong sitting, prolong standing, prolong walking, climbing up & down
stairs, sit to stand
ambulation: independent w/o walking aid since august 2022
Objective Ax:
g/o: an medium body size middle age female malay.
l/o:
swelling: over left ankle
redness: no
palpation: tenderness: grade 2 over left ankle
temperature: warmness
muscle tightness of left calf and soleus muscle
posture: asymmetrical
gait: antalgic gait, reduce Lt ankle dorsiflexion during heel strike, weightbearing more on Rt>Lt
during stance phase.
measurement:
Ankle Lt Rt
Active Passive
Dorsiflex 0°- 3° 0°- 5°
Plantarflex 0° - 30° 0° - 35°
Inversion 0-5° 0-5° AFROM
Eversion 0-11° 0-11°
Muscle power:
Lt Rt
Ankle Dorsiflexor 2+/5 5/5
Plantarflexor 3/5 5/5
Knee Flexor 4/5 5/5
Extensor 4/5 5/5
Hip Flexor 3+/5 5/5
Extensor 3+/5 5/5
Abductor 3+/5 5/5
Adductor 3+/5 5/5
ASSESSMENT: MASLINA BINTI PAIMAN
- Reduced in Rt toes flex compare to Lt side.
Muscle bulk measurement:
Lt (cm) Rt (cm) Diff (cm)
Hamstring (15 cm) 46.9 49.8 2.9
Quadriceps (10 cm) 43.5 44.0 0.5
VMO (5 cm) 41.5 41.0 0.5
Calf (10 cm) 36.0 35.4 +0.6
Swelling
Lt (cm) Rt (cm) Diff (cm)
Ankle 25 cm 20 5cm
Analysis: - Pain and swelling at Lt ankle d/t underlying injury
- Reduced range of motion of Lt ankle d/t pain and muscle tightness
- Reduced range of motion of Lt ankle d/t pain and joint stifness
- Reduced muscle power Lt ankle, knee and hip d/t lack of muscle activity
- Reduced ankle stability and dynamic standing balance
- Reduced normal gait pattern
- Reduced ADL function
Stg: To reduce pain and swelling over left ankle
To increase range of motion of ankle
To improve M power of Lt ankle, knee and hip
To improve ankle stability and dynamic standing balance
To improve gait pattern
Ltg: To improve ADL activities
Plan & intervention:
- Ankle free movement exercise;circle motion clockwise & anti-clockwise (20 reps)
- Active movement exercise of ankle using theraband for dorsiflexion, plantarflexion,
inversion and eversion (10 sec hold, 20 reps)
- Active movement exercise for knee and hip in supine ly, side ly and prone ly
- Stretching exercise for calf muscle, hamstring
- Isometric exercise using gymball for quadriceps and hamstring (hold 10 sec, 20 reps)
- Toes flexion exercise (hold 10 secs, 20 reps)
- TENS over Lt calf (15 mins)
Review: check for pain scale,swelling, range of motion, ankle stability & next exercises.
