IDENTITY

Name : Mr. BM
Age : 76 years old
Address : Puwatu
Occupation : Retired civil servants
Admission : July, 16th 2018 at 10.00
WITA
Doctor in Charge : dr. Benny Murtaza,
M. Kes, Sp.OT
 HISTORY TAKING
• Chief complain : Pain at both knee
• Anamnesis (Alloanamnesis) :
• Since 6 years ago and become worse in 1 week
• The pain felt intermitten and like being stabbed The pain got
worse when he did heavy exercise like lifted some things,
stand up and walk away. The pain decrease when patient
took a rest and slept.
• Previous medication : analgetic
• History of disease in the family (-), DM (-), HT (-), fever (-),
lose of body weight (-), decreased appetite (-), trauma (-).
General State

The patient was conscious with mild ill, obesity

nutritional status
Vital Sign

BP = 150/80 mmHg
Pulse = 82x/m, regular, strong
RR = 20x/m, regular, symetris
Temperature = 36,6oC/axillary
VAS = 7/10
Status Present
Head: Within normal limit
Face : Within normal limit
Eyes : Within normal limit
Nose : Within normal limit
Mouth : Within normal limit
Ears : Within normal limit
Neck : Within normal limit
Chest : Within normal limit
Abdomen : Within normal limit
Upper limb : Within normal limit
Lower limb : Localized state
LOCALIZE STATE
•Genu Region
I : Deformity (-), swelling (+), hematoma (-), wound (-)
P : Tenderness (+) at both knee
ROM: Active and passive motion at knee joints are limited due to pain
NVD : Sensibility Deep Peroneal Nerve is good, Dorsalis pedis artery is palpable,
tibialis posterior artery is palpable. Capillary refill time s < 2 second.
Clinical Finding
Planning Diagnostic :

X-Ray Genu D/S AP/Lateral

Position
Routine Blood
Chemistry Blood
X-Ray Finding
Routine Blood

PARAMETER Nilai Nilai rujukan

WBC 14,19 x 103/uL 4,00 - 10,00

5,10 x 106/uL 4,00 - 6,00

RBC
14,5 g/dL 12,0 - 16,0
HGB

37,0 - 48,0
HCT 42,6 %
218 x 103/uL 150 – 400
PLT
Chemistry Blood
PARAMETER Nilai Nilai rujukan

84 mg/dl 70 - 180
GDS
38 mg/dl 19 - 44
Ureum
1,1 mg/dl 0,7 - 1,2
Creatinin
3,5 - 7,2
Urat Acid 5,5 mg/dl
217 mg/dl ≤200
Total Cholesterol
47 mg/dl ≥35
HDL-Cholesterol

136 mg/dl ≤130

LDL-Cholesterol

18 U/L <45
SGOT

26 gr/dl <41
SGPT
 DIAGNOSIS

Osteoarthritis Genu D/S Grade

4
DD/ - Gout Arthritis at Genu
- Rheumatoid Arthritis at Genu
MANAGEMENT
Non-Pharmacology
• Rest
• Compress ice
• Education
Pharmacology
• IVFD
• Analgesic Inj
• H2 Receptor Agonis Inj
Consult Orhtopedic Surgeon
L/O/G/O

Thank You

BAGIAN ILMU
BEDAH