Leprosy Case Report

Medical Rehabilitation on Morbus Hansen –

BL type, RFT, deformity grade 2
claw-hands deformity digiti V on manus dextra
et sinistra
absorption of DIP digiti III & V on manus dextra
et sinistra
regional ulcer-repairing process on right
plantar pedis
claw-toes deformitiy digiti I, II, III, IV pedis
dextra et sinistra
absorption
Yeanita ofModerator
digiti I, II, III,
: dr. IV & V Sp.KFR
Wahidah, pedis dextra
et sinistra
 IDENTITY

 Name : Tn. S
 Age : 51 years old
 Sex : Man
 Addre ss : Cepu, Blora
 Religion : Moeslem
 Occupation : -
 Registration : 274849
 Examination date : September 13, 2018
 Clinical History
 Chief Complain :

Control the wound on the right foot

History of Present Illness
Patient came to Tugu Hospital to control the wound on the right

foot since 3 years ago which did not heal even though it was

treated. The wound was caused by being trampled on a rock, the

wound was deep enough so that the patient had been treated twice at

Tugu Hospital to heal the wound in 2015 and 2016. At the moment

the wound has begun to dry up, but it still hasn't closed. Both feet

feel numb when pinched or touched. Patient uses axillary crutches

to walk because he is afraid of aggravating the wound with his body

weight.
 History of Present Illness
 Patient has been released from treatment of leprosy since 2003, he said

there were no new numbing spots on his body. The skin color looks

the same as the surrounding skin, dry and scaly skin.

 Patients can carry out daily life activities independently. No difficulty

in eating, drinking, holding a dipper (bathing), combing hair, buttoning

clothes and holding small objects. No difficulty on mobilization even

though using axillary crutches. Patients can still pray in mosques and

attend social and spiritual activities in his neighborhoods.

 History of Past Illness
2001 - A wound arise in patient's right arm because of exposure of hot water, after
undergoing some therapy, patient was diagnosed with leprosy and began treatment.

2003 - patients were released for treatment and did not take leprosy medication anymore.

2013 – A large wound arise in patient's left leg and are recommended for amputation.

Patient underwent inpatient care at the hospital for approximately 40 days, the wound
slowly improved and the leg did not become amputated.

2015 - A wound arie on patient's right leg and still on treatment until now. Patient routinely
control for wounds on his feet every month at Tugu Hospital.

Patient began to realize that his toes were shrinking since ± 8 years ago.

History of hypertension and diabetes is denied.

 Clinical History
Family History :
No family member suffers from illness like this

Socio Economic profile:

 Patient’s currently not working, his previous job was
masonry. He stopped working when his wife was accepted as
a civil servant teacher in 2013. He had 3 children, of which 2
children had worked independently, 1 child was still in the
junior high school. Patient lives at home alone with his wife
and youngest child. Medical expenses by BPJS.
 Impression : sosio economic enough
 PHYSICAL EXAMINATION

 General Condition :
Awareness compos mentis
Weight = 62 kg Height = 165 cm
IMT = 22.77 kg/m2 (normal)
Contact, communication, cognitive : good

 Vital Sign :
T : 120 / 80 mmHg RR : 20 x/menit
N : 80 x/menit Temperature : 37 0 C
PHYSICAL EXAMINATION
 PHYSICAL EXAMINATION
N. V / Trigeminus :
 Strengths :
M. Temporalis : contraction +
M. masseter : contraction +
M. pterigoideus : contraction +
 Corneal sensibility : wnl
 Cheek sensibility : wnl

N. VII / Facialis :
 Strengths :
M. Orbicularis Occuli : contraction (+/+)
M. Orbicularis Oris : contraction (+/+)
M.Frontalis : contraction (+/+)
 2/3 anterior tongue sensibility : wnl
PHYSICAL EXAMINATION
Upper Ekstremity
INSPECTION Dextra Sinistra
+,
Wounds -
palmar area - dry
Drop-hands deformity - -
Claw-hands deformity + digiti V + digiti V
Claw-thumb deformity - -
Atrophy
• Thenar + +
• Hipothenar + +
Contracture - -
Joint swelling + PIP digiti III, V + PIP digiti V
Absorption + DIP digiti III, V + DIP digiti III, V
Mutilation - -
Hypopigmented macules - -
Eritema macules - -
Eritema nodules - -
Inflammation signs - -
Scars - -
PALPATION
Tenderness - -
Non/Pitting edema - -
 Upper Extremity ROM Dextra Sinistra
Finger 1 CMC
S : (Ext – 0 – Flexi) S : (50 – 0 - 15) Full ROM Full ROM
F : (Abd – 0 Add) F : (70 – 0 - 40 ) Full ROM Full ROM
Finger 1 MCP
S : (Ext – 0 – Flexi) S : (0 – 0 – 60) Full ROM Full ROM
Finger 1 IP
S : (Ext – 0 – Flexi) S : (10 – 0 – 80) Full ROM Full ROM
Fingers II s/d V
Digiti II : Full ROM Digiti II : Full ROM
Digiti III : Full ROM Digiti III : Full ROM
MCP – S : (Ext – 0 – Flexi) S : (20 – 0 – 90)
Digiti IV : Full ROM Digiti IV : Full ROM
Digiti V : Full ROM Digiti V : Full ROM

Digiti II : Full ROM Digiti II : Full ROM

Digiti III : S 0-0-90 Digiti III : Full ROM
PIP - S : (Ext – 0 –Flexi) S : (0 – 0- 100)
Digiti IV : Full ROM Digiti IV : Full ROM
Digiti V : S 0-0-80 Digiti V : S 0-0-80

Digiti II : Full ROM Digiti II : Full ROM

Digiti III : absorbtion Digiti III : absorbtion
DIP – S : (Ext – 0 Flexi) S : (0 – 0 – 80)
Digiti IV : Full ROM Digiti IV : Full ROM
Digiti V : absorbtion Digiti V : absorbtion
 Upper Extremity MMT Dextra Sinistra
Flexor elbow 5 5
Extensor elbow 5 5
Flexor wrist 5 5
Extensor wrist 5 5
Flexor digiti 5 5
Extensor digiti 5 5
Abductor digiti 5 5

Reflex Dextra Sinistra

Physiological Rf :
Biceps +2 +2
Triceps +2 +2
Pathological Rf - -
 Radial Nerve Dextra Sinistra
Palpation :
Enlargment - -
Tenderness - -
Sensoric Dorsum Manus:
Digiti I, II,III, part of IV dbN dbN
Motoric:
M. extensor carpi radialis longus 5 5
M. extensor carpi radialis brevis 5 5
M. extensor carpi ulnaris 5 5
M. extensor digitorum communis 5 5
M. extensor indicis propius 5 5
M. extensor digiti minimi 5 5
M. extensor pollicis longus 5 5
M. extensor pollicis brevis 5 5
M. abductor pollicis longus 5 5
Otonom : Dry skin Dry skin
Tonus N N
Trophy Eu Eu
 Median Nerve Dextra Sinistra
Palpation :
Enlargment - -
Tenderness - -
Sensoric :
Digiti I, II,III dbN dbN
Motoric :
M. pronator teres & quadratus 5 5
M. flexor carpi radialis 5 5
M. flexor carpi ulnaris 5 5
M. flexor pollicis longus & brevis 5 5
M. abductor pollicis brevis 5 5
M. oponens pollicis 5 5
M. lumbricales I, II 5 5
M. flexor digitorum superfisialis 5 5
M. flexor digitorum profundus II, III 5 5
Otonom : Dry skin Dry skin
Tonus N N
Trophy Eu Eu
Provocation Test :
Tinnel - -
Phalen - -
Prayer - -
 Ulnar Nerve Dextra Sinistra
Palpation :
Enlargment + +
Tenderness - -
Sensoric Dorsum Manus:
Palmar digiti IV, V anesthesia anesthesia
Dorsum Digiti V and part of IV anesthesia anesthesia
Motoric :
M. abd. digiti minimi 5 5
M. oponens digiti minimi 5 5
M. flexor digiti minimi 5 5
M. interosei dorsalis 5 5
M. interosei palmaris 5 5
M. lumbricales III, IV 5 5
M. flexor digitorum profundus IV, 5 5
V
Otonom : Dry skin Dry skin
Tonus N N
Trofi Eu Eu
Lower Extremity

INSPECTION Dextra Sinistra

Wounds +. Plantar pedis -
Drop-foot deformity - -
Valgus deformity - -
Claw-toes deformity + digiti I, II, III, IV + digiti I, II, III, IV
Atrophy - -
Contracture - -
Joint inflammation - -
+ digiti I, II, III, IV, + digiti I, II, III, IV,
Absorbtion
V V
Mutilation - -
Hypopigmented
- -
macules
Eritema macules - -
Eritema nodules - -
Inflammation signs - -
Scars - -
PALPATION
Tenderness - -
Non/Pitting edema - -
 Lower Extremity ROM Dextra Sinistra
HIP
S : (Ext – 0 – Flexi ) S : (30 – 0 – 120) Full ROM Full ROM
F : (Abd – 0 – Add) F : (45 – 0 – 30) Full ROM Full ROM
T (F90) : (Hip Flexi 90) T(F90) : Full ROM Full ROM
(Ext Rot – 0 –Int Rot) (45 – 0 – 45)
KNEE
S : (Ext – 0 – Flexi ) S : (10 – 0 – 135) Full ROM Full ROM
ANKLE
S : (Dorso – 0 – Plantar Flexi ) S : (20 – 0 – 50) Full ROM Full ROM
R : (Eversi – 0 – Inversi) R : (20 – 0 – 30 ) Full ROM Full ROM
Finger I
MTP - S : (Ext – 0 – Flexi ) S : (70 – 0 – 45) S 50-0-20, absorbtion Absorbtion
Fingers II s/d V
MTP - S : (Ext – 0 – Flexi ) S : (40 – 0 – 35) Digiti II : S 20-0-15, absorbtion Digiti II : absorbtion
Digiti III : S 20-0-15, absorbtion Digiti III : S 20-0-10, absorbtion
Digiti IV : absorbtion Digiti IV : S 20-0-10, absorbtion
Digiti V : absorbtion Digiti V : absorbtion

PIP - S : (Ext – 0 – Flexi ) S : (0 – 0 – 40) Digiti II : Full ROM Digiti II : absorbtion

Digiti III : absorbtion Digiti III : absorbtion
Digiti IV : absorbtion Digiti IV : absorbtion
Digiti V : absorbtion Digiti V : absorbtion
DIP - S : (Ext – 0 – Flexi ) S : (30 – 0 – 55) Digiti II : S 20-0-40, absorbtion Digiti II : absorbtion
Digiti III : absorbtion Digiti III : absorbtion
Digiti IV : absorbtion Digiti IV : absorbtion
Digiti V : absorbtion Digiti V : absorbtion
Peroneus Superficial Nerve Dextra Sinistra
Palpation:
Enlargment - -
Tenderness - -
Sensoric dorsum pedis dbN dbN
Motoric :
M. Tibialis anterior 5 5
M. Peroneus longus 5 5
M. Peroneus brevis 5 5
M. Extensor digitorum longus 5 5
M. Extensor halucis longus 5 5
Otonom : Dry skin Dry skin
Tonus N N
Trophy Eu Eu
Tibialis Posterior Nerve Dextra Sinistra

Palpation :
Enlargment - -
Tenderness - -
Sensoric plantar pedis Anestesi Anestesi
Motoric :
M. gastrocnemius/soleus 5 5
M. tibialis posterior 5 5
M. flexor digitorum longus 4 not testable
M. flexor hallucis longus 4 not testable
Otonom : Dry skin Dry skin
Tonus N N
Trophy Eu Eu
 PHYSICAL EXAMINATION

Reflex Dextra Sinistra

Physiological Rf :
Patella +2 +2
Achilles +2 +2
Pathological - -

Status of localis ulcus on pedis dextra:

The wound looks clean, diameter 3 cm, depth 2 cm, muscle base, pain (-),
swelling (-), redness (-), pus (-), granulation tissue (+).
 BTA EXAMINATION
Microbiology Examination on April 14
2016:
BTA Right Ear : Negative
BTA Left Ear : Negative
Madarosis Megalobuli

Claw- toes deformity on digiti

I, II, III, IV pedis dextra et sinistra
Absorbtion on digiti I, II,III, IV
& V dextra et sinistra
Dry skin
 Atrophy thenar &
Ulcus on plantar pedis hypothenar
dextra
Joint enlargement on PIP
digiti III & V dextra, sendi PIP
digiti V sinistra
Claw-hands deformity on
digiti V manus dextra et
sinistra
Absorbtion on DIP digiti III
& V dextra et sinistra
CHANGES IN SKIN AND NERVE
 Therapy
Medical drugs

 Klaritromisin 2 x500 mg
 Vitamin B Complex 1 x 1 tab
 Vitamin C 1 x 1 tab
 Zinc 1x1 tab
 Levertanoint + GentamicynOint
 NaCl 0,9 % (Compress every 10-15
minutes)
 REHABILITATION
PROGRAM
 PT
 ROM Exercise active or passive joints for UE & LE : 5-10x per day to
prevent joint stiffness
 IR is continued by massage and stretching on the joints of toes to
prevent contractures

 OT
 Gradual sensory exercise for increasing right and left foot sensibility,
with walking exc on rough and smooth surfaces  immediately after
dextra plantar pedis ulcer repair
 Positioning and mobilization with axillary crutches

 OP : MCR sandal (Micro Cellular Rubber)

 REHABILITATION
PROGRAM
 SW
 Providing understanding to the family and the

surrounding community about the patient's

illness so they don’t stay away from the
sufferer and participate in daily activities
 Provide motivation for sufferers and families to

be able to maintain cleanliness and nutritious

food

 Psychology
 Give motivation to keep regular treatment
 Give motivation to keep regular training
 Home Program
Education
 Always check and treat the condition of the
hands and feet
 Always do routine exercises to strengthen the
muscles of LE
 Always routinely perform ulcer care every day
 Soak hands and feet 2-3 x a day for 20 minutes
with cold water then smear it with coconut oil /
baby oil / vaseline.
 Hand and foot protection
 Hands  use gloves when working, do not touch
glass or hot items, coat the handles of household
appliances with soft material.
 Legs  always wear footwear, limit walking,
wherever you can close and slowly, often raising
THANK YOU