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Rosmana Apolla Putera

Dr. Tjahja Nurroby, SpOT(K)Hand, M.Kes
Patients identity
Name Mrs. L
Age 69 y.o
Gender Female
Occupation Housewife
Address Cideng
Status Married
Nationality Indonesia
Date of admission March, 9th 2017
(Autoanamnesis at March, 10th 2017)
Chief complaint
Pain on right knee
Additional complaints
Morning stiffness
Difficulty when walking
History of present illness

69 years old, overweight woman

Pain on right knee joint for 1 month
Throbbing pain
Worsening when the knee is bent or when the patient standing/walking for a long
period of time
Difficulties using stairs
Morning stiffness for around 20 minutes
History of past illness

History of allergy is denied

Has history of hypertension
History of Diabetes is denied
Physical examination

General Status
Consciousness Compos Mentis
Pain Mild pain
Nutrition Excess

Vital signs
Blood pressure 180/100 mmHg
Pulse 81 x/minute
Temperature 37oC
Breathing 20 x/minute
General Status

o Skin
o Warm, dry, normal turgor, no petechiae, ecchymoses, or rash

o Head, Eyes, Ears, Nose, Throat

o Normocephalic/Atraumatic
o Pupils equal, round, and reactive to light and accommodation
o Negative scleral icterus
o Tympanic membranes intact
o Mucous membranes moist
o Negative lateral deviation of tongue, pharyngeal edema, or
General Status
Neck/Lymph nodes
Neck supple, negative for thyromegaly, adenopathy, masses, jugular venous
distension, or carotid bruits

Good chest excursion, Lungs clear to auscultation and pulse
Symmetric, no apparent masses, discharge, discoloration, or dimpling
Normal S1 and S2, point of maximal impulse normal at 5th intercostal space,
regular rate and rhythmn,
No murmur/rub/gallop

Soft and non-tender without guarding, positive for bowel sounds, negative
organomegaly, bruits, and masses
General Status

Full range of motion at left shoulder, elbows, and
Bilateral knee crepitus and enlargement but more
pronounced in right knee
Without breakdown, ulcers, erythema, or edema
Local Status

Swelling on both right and left knees, same color with
Redness, swelling (+)
Limited movement less than 90o of knee bending
(active) and less than 120o of bending (passive) on right
Laboratory blood test result
Test Result Unit Normal Range

Blood test
Leukosit 9,300 /L 5,000-10,000
Eritrosit 4.09 Million/ L 4.2-5.4
Hemoglobin 12.6 g/dL 12-14
Hematokrit 39 % 37-42
Trombosit 245 Thousand/ L 150-450

Masa Pendarahan 200 Minute 1-3

Masa Pembekuan 1000 Minute 5-15

Clinical chemistry
Bloods Glucose
GDS 104 mg/dL <200
HbA1c 6.0 % 4-6
LDL 127 mg/dL <130

Working diagnosis
Billateral Osteroarthritis genu
Stage II Hipertension
Differential diagnosis
Rheumatoid arthritis

IVFD Ringer Laktat 20 tpm

Ceftriaxone 2x1 gr
Ketorolac 2x1 amp

Pro athroscopy
Post athroscopy
Physiotheraphy for 1 month
TotalKnee replacement (If pain still persist after 1 month
of physiotheraphy)
Follow Up (March, 10th 2017)

Subjective Objective Assesment Planning

Pain on right Consciousness: CM Osteoarthritis IVFD Ringer Laktat 20
knee, TD: 180/100 mmHg tpm
morning Nadi: 81x/minute Ceftriaxone 2x1 gr
stiffness for Suhu: 36.5oC Ketorolac 2x1 amp
20 minutes RR: 20x/minute
Eyes: CA -/-, SI -/- Pro athroscopy
S1S2 reg, m(-), g(-)
SNV (+), wh (-), rh (-)
Abdomen: BS(+), Pain(-),
Shifting Dullness (-)
Ekstremity: Warm (+),
OE - -
- -
Follow Up (March, 11st 2017)

Subjective Objective Assesment Planning

Pain on right Consciousness: CM Osteoarthritis IVFD Ringer Laktat 20
knee, TD: 170/110 mmHg tpm
Nadi: 84x/minute Ceftriaxone 2x1 gr
Suhu: 36.7oC Ketorolac 2x1 amp
RR: 20x/minute
Eyes: CA -/-, SI -/-
S1S2 reg, m(-), g(-)
SNV (+), wh (-), rh (-)
Abdomen: BS(+), Pain(-),
Shifting Dullness (-)
Ekstremity: Warm (+),
OE - -
- -
What is Osteoarthritis?
Osteoarthritis is a form of arthritis that
features the breakdown and eventual loss of
the cartilage of one or more joints.
Cartilage is a protein substance that serves as
a "cushion" between the bones of the joints
A joint inflammation that results from
cartilage degeneration.
Caused by:
Injury from trauma or disease.
The most common symptom:
Pain in the affected joint(s) after
repetitive use.
There is no blood test for the diagnosis
of osteoarthritis.
The goal of treatment in osteoarthritis is
to reduce joint pain and inflammation
while improving and maintaining joint

Pain and soreness on the joint(s)

Bony enlargement
Criteria for osteoarthritis (ACR 1986)

Knee pain plus at least 5 of the following 9 criteria:

age >50 years
stiffness <30 minutes
bony tenderness
bony enlargement
no palpable warmth
ESR <40 mm/hour
RF <1.40
synovial fluid signs of OA.

Treatment: Physical Therapy

There is no treatment to stop the erosion of
cartilage in the joints, but there are ways to
improve joint function.
Increase flexibility and strengthen the muscles
around the affected joints.
Application of hot or cold therapies such as
compresses to relieve pain.

anti-inflammatory medication

Pain-relieving creams or sprays can also help


Physiotheraphy post-athroscopy
If pain still persist >>> Total Joint Replacement

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