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By:
Rosmana Apolla Putera
030.12.243
Pembimbing:
Dr. Tjahja Nurroby, SpOT(K)Hand, M.Kes
Patients identity
Name Mrs. L
Age 69 y.o
Gender Female
Occupation Housewife
Address Cideng
Status Married
Nationality Indonesia
Date of admission March, 9th 2017
Anamnesis
(Autoanamnesis at March, 10th 2017)
Chief complaint
Pain on right knee
Additional complaints
Morning stiffness
Difficulty when walking
History of present illness
General Status
Consciousness Compos Mentis
Pain Mild pain
Nutrition Excess
Vital signs
Blood pressure 180/100 mmHg
Pulse 81 x/minute
Temperature 37oC
Breathing 20 x/minute
General Status
o Skin
o Warm, dry, normal turgor, no petechiae, ecchymoses, or rash
Chest/Lungs
Good chest excursion, Lungs clear to auscultation and pulse
Breasts
Symmetric, no apparent masses, discharge, discoloration, or dimpling
Heart
Normal S1 and S2, point of maximal impulse normal at 5th intercostal space,
regular rate and rhythmn,
No murmur/rub/gallop
Abdomen
Soft and non-tender without guarding, positive for bowel sounds, negative
organomegaly, bruits, and masses
General Status
Extremities
Full range of motion at left shoulder, elbows, and
ankles
Bilateral knee crepitus and enlargement but more
pronounced in right knee
Without breakdown, ulcers, erythema, or edema
Local Status
Look
Swelling on both right and left knees, same color with
skin
Feel
Redness, swelling (+)
Move
Limited movement less than 90o of knee bending
(active) and less than 120o of bending (passive) on right
knee.
Laboratory blood test result
Test Result Unit Normal Range
Haematology
Blood test
Leukosit 9,300 /L 5,000-10,000
Eritrosit 4.09 Million/ L 4.2-5.4
Hemoglobin 12.6 g/dL 12-14
Hematokrit 39 % 37-42
Trombosit 245 Thousand/ L 150-450
Haemostasis
Clinical chemistry
Bloods Glucose
GDS 104 mg/dL <200
HbA1c 6.0 % 4-6
Fat
LDL 127 mg/dL <130
Diagnosis
Working diagnosis
Billateral Osteroarthritis genu
Stage II Hipertension
Differential diagnosis
Rheumatoid arthritis
Planning
Pro athroscopy
Post athroscopy
Physiotheraphy for 1 month
TotalKnee replacement (If pain still persist after 1 month
of physiotheraphy)
Follow Up (March, 10th 2017)
anti-inflammatory medication
aspirin
Ibuprofen
Acetaminophen
Athroscopy
Physiotheraphy post-athroscopy
If pain still persist >>> Total Joint Replacement
Prognosis