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    Giovanni Felicityana
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    The document summarizes a case report of a 66-year-old female patient with osteoarthritis of the right and left knees. She presented with pain in the right knee for 3 years that was worsened by walking and relieved by rest. Physical examination revealed valgus deformity and tenderness of the right knee with limited range of motion. X-rays showed advanced osteoarthritis in the right knee and mild osteoarthritis in the left. Laboratory tests were unremarkable except for anemia. She was diagnosed with grade IV osteoarthritis in the right knee and grade II in the left. Her management included IV fluids, medications, and a planned total right knee arthroplasty.

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    The document summarizes a case report of a 66-year-old female patient with osteoarthritis of the right and left knees. She presented with pain in the right knee for 3 years that was worsened by walking and relieved by rest. Physical examination revealed valgus deformity and tenderness of the right knee with limited range of motion. X-rays showed advanced osteoarthritis in the right knee and mild osteoarthritis in the left. Laboratory tests were unremarkable except for anemia. She was diagnosed with grade IV osteoarthritis in the right knee and grade II in the left. Her management included IV fluids, medications, and a planned total right knee arthroplasty.

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    3 views13 pages

    Case Report OA Edit

    Uploaded by

    Giovanni Felicityana
    The document summarizes a case report of a 66-year-old female patient with osteoarthritis of the right and left knees. She presented with pain in the right knee for 3 years that was worsened by walking and relieved by rest. Physical examination revealed valgus deformity and tenderness of the right knee with limited range of motion. X-rays showed advanced osteoarthritis in the right knee and mild osteoarthritis in the left. Laboratory tests were unremarkable except for anemia. She was diagnosed with grade IV osteoarthritis in the right knee and grade II in the left. Her management included IV fluids, medications, and a planned total right knee arthroplasty.

    Copyright:

    © All Rights Reserved
    Download as PPTX, PDF, TXT or read online from Scribd
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    of 13

    CASE REPORT

    OSTEOARTHRITIS
    Yustika Swasiyka Yusuf
    C014202078

    Residents
    dr. Putu Acarya Nugraha
    dr. Ardian Mario
    dr.Faidzin
    dr. Timothy Alexander Liwang
    dr. Zulkifli

    Supervisor
    Dr.dr.Karya Triko Biakto, Sp.OT(K) Spine
    PATIENT IDENTITY

    Name : Mrs.R

    Age : 17/07/1956 (66 years old)

    Gender : Female

    Registration Number : 1005059


    HISTORY TAKING
    Chief complain: Pain in the right knee

    Pain in the right knee since 3 years ago. Pain worsen with walking and relieve by rest, pain was
    intermittent. Patient felt stiffness in the right knee every morning for < 30 min. Patient was able to walk
    with cane before it worsen in last 3 months. Patient unable to walk in last 3 months due to pain. Patient
    consumed NSAID to relieve her knee pain.
    The patient currently using wheelchair to move.
    • There was no history of hypertentision
    • There was no history of diabetes mellitus
    • There was no history of trauma
    PHYSICAL EXAMINATION

    General Status
    • GCS 15 (E4M6V5) / Conscious
    • Vital Signs :
    • Blood pressure: 120/70 mmHg
    • Pulse rate : 88 x/min
    • Respiratory rate : 20 x/min
    • Temperature : 36.7°C
    • NPRS : 5/10
    • BMI : 20,6 kg/bb
    CLINICAL FINDING
    CLINICAL FINDING
    PHYSICAL EXAMINATION

    Localization Status
    Right Knee
    Look Valgus Deformity (+), swelling (-) hematoma (-), Wound (-)

    Feel Tenderness (+)


    Move Active and passive movement of knee joint within normal limit
    ROM Extension and Flexion 0-125 degree

    NVD Sensibility is good. Pulsation of dorsalis pedis and tibialis posterior


    arteries are palpable. Capillary refill time < 2 seconds.
    Leg Length Discrepancy

    RIGHT LEFT

    ALL 87 cm 92 cm

    TLL 81 cm 86 cm

    LLD 5 cm
    RADIOLOGY FINDING

    X-RAY RIGHT
    KNEE
    (06/01/2023)
    RADIOLOGY FINDING

    X-RAY LEFT KNEE


    (06/01/2023)
    LABORATORY FINDINGS ()
    17/02/2022 PEMERIKSAAN HASIL NILAI RUJUKKAN SATUAN
    WBC 11.8 4,00 – 10,0 10^3 / ul
    RBC 4.12 3,80 – 5,20 10^6 / ul
    HGB 10.7 12,0 – 16,0 Gr/dl
    HCT 34 37,0 – 48,0 %
    MCV 83 80,0 – 97,0 Fl
    MCH 26 26,5 – 33,5 Pg
    MCHC 31 31,0 – 35,0 gr/dl
    PLT 288 150 - 400 10^3 / ul
    Prothrombine Time 9.9 10-14 menit
    APTT 28.9 22-30 menit
    Ureum 16 10-50 mg/dl
    Kreatinin 0.69 P(<1.1) mg/dl
    SGOT 18 <38 U/L
    SGPT 8 <41 U/L
    Hbs Ag Non reactive 0-25,00 U/ml
    DIAGNOSIS MANAGEMENT

    • Osteoarthritis genu joint dextra grade


    IV (Kellgren and Lawrance • IVFD Ringer Lactate
    Classification) • Asam Mefenamat 500 mg/8 hour/oral
    • Osteoarthritis genu joint sinistra grade • Ranitidine 30 mg/8 hour/oral
    II (Kellgren and Lawrance • Pro total knee Arthroplasty Right Kne
    Classification)

    • Anemia
    Thanks!

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