MM SKENARIO 3

Wanita 68 thn

Klinik Pratama

Keluhan utama: nyeri lutut

Diagnosis banding:
Osteoartritis genu
Gout
Rheumatoid artritis

Anamnesis Pemeriksaan Fisik Pemeriksaan Penunjang

KU: compos mentis, GCS:456
VS:
Nyeri lutut sejak 5 bulan lalu, TD: 130/90 Pemeriksaan lab dan X ray:
tidak menjalar RR: 20x/mnt
Nyeri lutut diawali sebelah kiri, belum dilakukan
Nadi: 88x/mnt
kemudian kanan Suhu: 36,5C
Nyeri hampir tiap hari, hilang BB: 68 kg, TB: 156 cm, IMT: 27,9
timbul, tergantung aktivitas (obesitas I)
Nyeri pagi hari saat bangun
tidur 15 mnt Ekstremitas:
Nyeri ber(+): naik tangga, nyeri palpasi: nyeri tekan kedua lutut
ber(-): kompres panas
Pasien menopause kanan kiri, gerak sendi terbatas
Rutinitas: ibu RT, olahraga karena nyeri,
tennis 2x/minggu selama 20
mnt Pemeriksaan krepitus (+), keluhan
RPD: riwayat trauma terjatuh krepitasi muncul saat naik tangga
saat olahraga namun tidak ada
keluhan dan tidak berobat dan shalat
RPK: Almh. Ibu nyeri sendi

3/6 kriteria klinis +

Faktor risiko

Diagnosis:
Osteoartritis genu

Planning
 A 68 y.o Woman

Pratama Clinic

Knee pain
Differential Diagnosis:
Genu Osteoarthritis
Gout
Rheumatoid arthritis

Anamnesis Physical Examination Supporting Examination

Knee pain since 5 months ago,

doesn’t spreading Lab and X ray: not done yet
Knee pain begins on the left knee, KU: compos mentis, GCS:456
then to the righ knee VS:
Pain almost every day, BP: 130/90
intermittent, depends on activity RR: 20x/mnt
Pain in the morning when waking Pulses: 88x/mnt
up for ± 15 minutes Body Temp: 36,5C
Pain get worse when climb up the
BW: 68 kg, H: 156 cm, BMI: 27,9
stairs, get better with hot
compression (Obesity I)
Menopause woman Extremity:
Routinity: a housewife, does tennis palpatio: tenderness off both
twice a week for 20 minutes knees, limited motion due to pain
Past medical history: a trauma, fell Crepitus Examination (+), when
off during sport, but there were no climbing up the stairs and
complaints & no treatment
praying.
Family medical history: The
deceased mother has joint pain

3/6 Clinical Criteria +

Risks Factor

Diagnosis:
Genu Osteoarthritis

Planning
MM UNTUK PPT