8/7/2019 Post-Op presentation by student Basrul B Baseri
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Basrul B Baseri
09DPY0008
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Case Study
Name: Muhammad Syafiq B Basri
Age:26
Race:Malay Relegion: Islam
MRN:613034
Date of Ref: 12.2.2011 Date of Diagnose: 10.2.2011
Doctors Diagnose: ACL Tear
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Subjective Assessment
Patients Complaint:
Pain at the Right knee while bending
Unable to walk properly
Feeling loose at the affected knee
o Current History
Patient feel pain while performing
movement on the right knee,Undergone ACL reconstruction a weeks
ago
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Past History
Patient fall during playing fulsal, then unable
to get up and walk, on the next day he cameto Jsh for treatment
o Other Medical History
No other Medical history
o Social History
Patient are non smoker
working as a technician at Tenaga Nasional
BerhadActive in sports
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Investigation
X-ray and MRI done on 10.2.2011 (MRI
indicates soft tissue tear)
Vital SignNBP: 120\80
H/R: 65Bpm
Temp: 37deg celcius/Normal
Resp/rate: 20Bpm
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Objective Assessment
General Observation
young adult Malay man walked into thephysio department with elbow crutches.
Self dependanto Local Observation
Redness present at the right knee.
swelling on the right kneeScar of surgery marked
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Palpation
No tenderness on the right knee
Slight increase in temperature on the left right
knee
o Special test
Anterior drawer test; +ve
Posterior drawer Test ; -ve
Valgus Test ;-ve
Varus Test; -ve
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Muscle Bulk
Muscle Bulk Right Left Differences
15cm upper 52.5 52.0 0.5
10cm upper 52.0 51.5 0.5
5cm upper 47.5 47.0 0.5
Middle Patella 42.0 40.0 2.0
5cm lower 40.0 36.0 4.0
10cm lower 44.5 40.5 4.0
15cm lower 43.5 42.5 1.0
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Interpretation
The differences on both knee and
increase in cm value on the right knee
indicates the swelling in the right knee
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Muscle Power
Knee Joint Right Left
Flexion 4/5 5/5
Extention 4/5 5/5
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Interpretation
Decreasing value of degree in right
knee indicates the limited range of
motion compared to the normal left knee
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Plan OfTreatment Short Term Goal
Reduce pain on the right knee 4/52
Increase muscle strength on the right knee,preventing muscle wasting
Increase range of motion on the right knee.o Long Term Goal
To gain back the full functionalities of the rightknee
To gain back the normal gait patternTo prevent further complication
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Intervention
Hot Pack
Patient supine lying, hot pack place on
the right knee for 20 minutes
o Strengthening exercise
static quad exercise, patient lying
supine and a curled towel placed under
knee. Patient has to lift up the foot bypressing the towel and hold for 10
second
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Straight leg rise
patient lying supine, the knee straight
and rise slowly and hold for 10 second,
repeat 20 times with 3 sets.
Prone knee bending
Patient lyiong prone and bend the knee
20 times with 3 sets
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Ultrasound
Given to the patient as to promote the
healing process.
o Home advise
Patient are asked to get the knee
support. Prescribing the home exercise
program and correct posture