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    Case Synopsis: Past History

    Uploaded by

    jayen_98
    Mrs. A is a 53-year-old homemaker who presents with 6 months of right knee pain exacerbated by walking, squatting, and stairs. Physical examination reveals valgus deformity, crepitus, and limited flexion of the right knee with pain. X-ray shows second grade osteoarthritis of the right knee. She has difficulty with mobility such as walking long distances or going up and down stairs due to her knee pain.

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    Case Synopsis: Past History

    Uploaded by

    jayen_98
    68 views5 pages
    Mrs. A is a 53-year-old homemaker who presents with 6 months of right knee pain exacerbated by walking, squatting, and stairs. Physical examination reveals valgus deformity, crepitus, and limited flexion of the right knee with pain. X-ray shows second grade osteoarthritis of the right knee. She has difficulty with mobility such as walking long distances or going up and down stairs due to her knee pain.

    Original Title

    Soca OA

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    Mrs. A is a 53-year-old homemaker who presents with 6 months of right knee pain exacerbated by walking, squatting, and stairs. Physical examination reveals valgus deformity, crepitus, and limited flexion of the right knee with pain. X-ray shows second grade osteoarthritis of the right knee. She has difficulty with mobility such as walking long distances or going up and down stairs due to her knee pain.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    68 views5 pages

    Case Synopsis: Past History

    Uploaded by

    jayen_98
    Mrs. A is a 53-year-old homemaker who presents with 6 months of right knee pain exacerbated by walking, squatting, and stairs. Physical examination reveals valgus deformity, crepitus, and limited flexion of the right knee with pain. X-ray shows second grade osteoarthritis of the right knee. She has difficulty with mobility such as walking long distances or going up and down stairs due to her knee pain.

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    Case Synopsis

    Mrs. A, 53 years old comes to you with chief complaint of pain on right knee
    since 6 months ago. Because of this the patient having difficulties walking
    for long distance, squatting or walking up and down stairs. The NRS is 7. The
    pain lessen, whenever the patient lying on the bed. She also complains of
    having morning stiffness at both knees until for about 15 minutes which
    dissipates when she starts an activity. There is also crepitus sound on her
    right knee whenever she tries to move it. There is no disturbance on
    sensibility. She still can walking independently in level surface with assistive
    device such as cane

    Past history.

    There is no history of trauma, or neuromuscular problem


    No cardiopulmonal or cardiovascular disorders

    Functional History

    Cognition, Communication, Mobility, ADL and IADL before the illness were
    normal.

    Personal History

    She does her regular prayer (shalat) in sitting position

    Social History

    She lives with her husband in two story house.


    Her room is in the second level and most of her activities are done in the
    second floor. The first level is a store, where they sell frozen food.From the
    main road to the house is about 15 meters with uneven surfaces. She
    doesn’t go the mosque regularly for Al Quran recitation anymore due to
    pain on her knee.

    Vocational History

    She is a home maker and also help her husband selling frozen food in their
    store. She uses BPJS Non PBI to seek medication. Their income is about 2
    million rupiahs/month.

    Physical Examination
    General examination :

    Composmentis, adequate contact


    Communication : comprehension is good, expressive is good
    Mobility : walking independent with cane
    Blood pressure 120/80 mm Hg
    Pulse 80x/min,
    Heart rate: 84x/min, regular.
    Respiration Rate : 20x/min, regular.
    Body temperature: 36o C.
    Body weight: 73 kg. Height: 150 cm. BMI = 32.4 kg/m2
    MMSE : 30

    Internal Status

    Head Neck : within normal limit


    Chest : No increasing of JVP at both side
    No lympnode enlargement at both side
    - Heart : within normal limit
    - Lung: within normal limit
    - Abdomen: within normal limit

    Neuromuscular examination

    Sensory, and vegetative function within normal limit


    Physiological reflexes:
    E -  Biceps reflexes were ++ / ++
    E -  Triceps reflexes were ++/ ++
    E -  Patellar reflexes were ++/ ++
    E -  Achilles reflexes were ++ / ++ Pathological reflexes: -/-

    Musculoskeletal Examination

    Head and neck : within normal limit


    Trunk : within normal limit

    Hip joint : No deformities, No inflammation signs


    ROM Full/Full to all direction
    Pain on movement -/-
    MMT are 5 in all direction at both sides
    Knee joint : valgus deformities +/-, no inflammation signs
    Pain on pressure at Pes Anserine -/-
    ROM Full/Full to all direction
    MMT are 5 in all directions (both knees)
    Pain on movement +/- at the end of knee flexion of the right knee
    Crepitation : +/+
    Grinding Femoral Test : +/-
    Collateral ligamentum laxity +/-
    Anterior Drawer Test -/- Posterior Drawer Test -/-

    Ankle Joint : No deformities, No inflamation signs


    ROM Full/Full to all directions
    MMT are 5 in all directions
    Ligamentum laxity -/-

    Supporting Examination
    Laboratory finding :within normal limit
    Chest X—ray : within normal limit
    ECG : within normal limit
    Knee X ray AP/LAT : Second Grade Osteoarthritis of the right knee
    Diagnosis :

    Medical Diagnosis : Right Knee Ostearthritis 2nd Grade

    Instruction :

    a. Please analyzed case that presented above to find out what


    functional problems that may be occur in this patient

    b. Please make a comprehensive management programs from


    your point a view as general physician in primary health
    center for this patient based on her medical and rehabilitation
    problems

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