OSTEOARTHRITIS

OF THE RIGHT
KNEE

PATIENTS IDENTITY
Name
Gender
Age
Occupation

: Mr. SK
: Male
: 65 years old
: Retired

Medical Record
: 064771
Date of admission : 14/10/2016

HISTORY
TAKING
Chief Complain
Pain of the right knee

Anamnesis
Patient was suffered pain since 2009. The pain was felt
continuosly and decreased when rest. Pain felt worst
especially when walked and took the stairs. The patient
also complained stiffness in the morning after woke up and
decreased after 10 minutes. History of prior treatment (+)
examined by internist and get injection at the right knee.
History operation of benign prostate hypertropy and renal
stone (+) at 2004. History of CABG operation in 2006, and
history of DM (+)

PHYSICAL EXAMINATION

General status
Overweight (BMI 25) / composmentis

Vital status

BP : 130/80 mmHg
HR : 72x/min
RR : 18x/min
Temp : 36.5 C

LOCALIZED STATUS

Right
knee
region

Look : varus deformity (?) because I dont do

the examination, wound (-), swelling (-),
hematoma (-), skin color same as
surrounding
Feel : tenderness (+)

Move : active and passive extension-flexion

0o - 90o
NVD : Sensibility is good, posterior tibial
artery & dorsalis pedis artery pulse are
palpable, capillary refill time is <2
seconds

LOCALIZED STATUS

Left
knee
region

Look : deformity (-), wound (-), swelling (-),

hematoma (-), skin color same as
surrounding
Feel : tenderness (-), effusion (-)
Move : active and passive extension-flexion
0o - 130o
NVD : Sensibility is good, posterior tibial artery
& dorsalis pedis artery pulse is palpable,
capillary refill time is <2 seconds

CLINICAL FINDING

Anterior view

Lateral view Right Knee

RADIOLOGICAL FINDING
Alligment of bone is good
Bone fracture (-) and destruction(-)
Osteofyte in medial condylus and
and lateral of tibia at
anteroposterior and
posterosuperior aspect of right
patella.
Narrowing (+) medial femorotibial
joint space
Mineralization of bone is good
Soft tissue around the knee is
good

LABORATORIUM
FINDING
N
o

1
.

3
.
4
.

5
.

7
.

Blood Test

Result

Normal Value

Unit

WBC

8.0 x 103

4.00-10.0 x 103

/uL

RBC

5.30 x 106

4.00-6.00 x 106

uL

Platelet

176 x 103

150 - 400 x 103

/uL

Hb

15.3

37-48

GDS

210

140

mg/dL

Ureum

50

10-50

mg/dL

Creatinin

1.5

<1.3

mg/dL

SGOT

23

<38

U/L

SGPT

36

<41

U/L

Natrium

145

126-145

mmol/L

Kalium

4.3

3.5-5.1

mmol/L

Chloride

106

97-111

mmol/L

RESUME
A man , 65 years old came to the hospital with chief complaint pain at
right knee. Patient was suffered pain since 2009. The pain was felt
continously and decreased when rest. Pain felt worst especially when
walked and took the stairs. The patient also complained stiffness in the
morning after woke up and decreased after 10 minutes. History of prior
treatment (+) examined by internist and get injection at the knee.
History operation of benign prostate hypertropy and renal stone (+) at
2004. History of CABG operation in 2006, and history of DM(+)
From physical examination, general status was obesity, vital status within
normal limit. Localized status on right knee region were found varus deformity,
tenderness on palpation, range of motion was limited.
From imaging of Right knee X-Ray AP/Lat find osteofyt in medial condylus
and lateral of tibia at anteroposterior and posterosuperior aspect of right
patella. Narrowing of femorotibial space

DIAGNOSIS
Right knee osteoarthritis grade III
( Classification Kellgren Lawrence )

MANAGEMENT
Farmacologic
Analgesic

Operative
Plan for Right
Knee
Arthroscopic +
Debridement
Micro Fracture
Drilling