Name : Mrs.

J
Age : 61 years old
Gender : Female
Clinic : Cerebellum Clinic
Supervisor : dr. Waode Sri Nikmatiah Sp.KFR

S: Patient came to the cerebellum clinic with chief complaint pain on the right knee since 1
years ago, but worsening in the last 1 month. The pain feel like sharp pain in the right knee
especially during walking more than 10 meters and when she began move from sitting to
standing and walking for the first 5 minutes. The pain was not radiating. She also feel morning
stiffness in the right knee for approximately 4-5 minutes, but when she walking further or doing
activities there are no stiffness. The NRS is 5-6/10 at the right knee when doing activities but
2/10 at rest. There are no history of trauma, surgery, DM, hypertension, and other medical
problem, theres no medication history before.

The patient lives with her husband, daughter and her grandchildren. Her house is 2 floor house,
but she barely went upstair since she felt the pain. She still doing housework like washing
dishes, cooking, and cleaning the house, without a housemaid. her activity mostly in her house.
Her toilet is sitting toilet and there is no complaint for toileting. She still sholat normally, but
there is pain when she want to sujud position.

O:
General status: compos mentis, vital sign within normal limit, ambulation: independent
Gait ; antalgic gait
Postur ?
• Nutritional Status : Body Weight 70 kg, Body Height 150 cm, BMI : 31.1(obese class 1: 30
– 34.9)
Musculoskeletal status :
ROM and MMT for neck, trunk and upper extremity within normal limit
ROM and MMT for hip within normal limit
ROM and MMT for the left knee within normal limit
ROM for right knee extension 110-0 degrees
ROM in flexion 0-110 degrees because of pain
MMT flexi 5/5
MMT EKSTENSI 5/5
Q angle 9 right/9 left
Thight circumference 42 right /42 left
Calf circumference 35 right /35 left

Special Test
• Patellar Grinding Test (+/-)
• Lachmann Test (-/-)
• Anterior and Posterior drawer test (-/-)
• Valgus and Varus Stress (-/-)

Local status on the right knee

• Look : No deformity, No inflammation sign, normothrophy, no contracture
• Feel : No warmness, Crepitation +, no edema, tenderness -
• Move : pain when move (flexion and extension), MMT normal and ROM is decreased in
the right knee on flexion.

Rontgen : OA genu grade 2, Osteoporosis senilis, celah sendi sedikit menyempit di medial
A: Knee pain dextra ec osteoarthritis genu grade 2
P: medika mentosa :
Natrium diklofenak 50 mg 2x1
Calsium lactat 1x1
Magnesium 500 mg
Rehabilitation program :
Physical therapy / fisiotherapy
Tens / laser
USD genu D
Isometric Strengthening Quadriceps D
Core stability exercise
Orthosis quadripod