Ostheoarthritis of knee

CASE REPORT
PATIENT IDENTITY
Name : Mrs. Hj. H
Age : 68 years old
Sex : Female
Address : Pare-pare
Work :-
Date of admission : January 22, 2019
Medical record : 16 10 15

HISTORY TAKING
• Chief Complain : pain on both knees
• History: Both knee pain and difficulty walking 2.

Current Disease History Patients came with their families to POLI RSUD Andi
Makassau with complaints that both knees were painful and difficult to walk. This
complaint is felt by the patient suddenly.
Pain felt by the patient such as pulsating and punctured needles. The pain also
does not disappear with compresses, massage oils, or pain-reducing drugs. Pain gets
worse when the patient folds his knees and moves 1 2 legs but slightly reduced with
rest. Initially, the patient claimed to get complaints of pain and it was difficult to walk
when the patient wanted to move from his bed to the bathroom. When he is about to
stand, the patient feels that his legs are very painful and difficult to move until the
patient falls to the floor.
Actually, the patient had long felt pain on both of his knees, namely for 1 year
of (SMRS) , but slowly felt increasingly burdensome since there was swelling on both
knees and a peak because this patient's complaint caused him to be unable to walk
again. The patient admitted that he had just realized there was a swelling on his
knees - about the last 6 months (SMRS)
CLINICAL FINDING

LABORATORY FINDING

Pemeriksaan Hasil Nilai normal

WBC 6,08 5.00-10.0

RBC 4,09 3.80-6.50

HGB 12,7 11.5-17.0

HCT 37,4 37.0-54.0

PLT 265 150-500

RADIOLOGY FINDING

RESUME
Mrs .Hj.A, 68 years old female admitted to Andi Makkasau Hospital with that both
knees were painful and difficult to walk. Right and left knee (+). Look : Deformity (+),
Swelling (+),tenderness (+), active and pasif movement can not be evaluated due to
pain.

Localized status:
Genu dextra et sinistra

DIAGNOSA
Ostheoarthitis grade III
Therapy
Medikamentosa
IVFD RL 20 tpm micro drips
Ceftriaxone 1gr/IV pre-op
Operatif
Synovectomy (arthroscopy)
BAGIAN ORTHOPEDI CASE REPORT AND JOURNAL
FAKULTAS KEDOKTERAN JANUARI 2019
UNIVERSITAS MUSLIN INDONESIA

CASE REPORT : OSTEOARTHRITIS OF KNEE

JOURNAL : SUPRASPINATUS TEAR

DISUSUN OLEH:
Marinda Dwi Anggrainie
11120171011
PEMBIMBING:
dr. Ariyanto Arief, M.Kes, Sp.OT

DIBAWAKAN DALAM RANGKA TUGAS KEPANITERAAN KLINIK

BAGIAN ILMU KESEHATAN MATA
FAKULTAS KEDOKTERAN
UNIVERSITAS MUSLIM INDONESIA
2019