POST TEST

Osteoarthritis Grade IV Of The Right Knee

By :
Esmeralda Joseva Bangun
Mentor :
Dr. dr. Adrian Khu, Sp.OT, FICS
 PATIENT STATUS
 Room number : 1103 A
 Date of entry : October 24th 2018
 Doctor in charge : Dr. dr. Adrian Khu, Sp.OT, FICS

Patient Identity:
 Name : Tan Kim Gek
 Date of birth : 15 March 1947
 RM number : 08.08.96
 Age : 71 years old
 Gender : Female
 ANAMNESIS

Chief complaint : Pain at the right knee

Study : A 71-year-old female patient came to the Royal Prima Hospital

on October 24th 2018 with complaints of pain at the right knee and not
cured even though the patient get a painkillers. This is felt by patient
since 2 weeks ago.

History of previous disease : DM

 VITAL SIGN
General condition : Good
Sensorium / GCS : Compos Mentis / 15
Blood pressure : 140/90 mmHg
Heart rate : 84 x/i
Respiratory rate : 21 x/i
Temperature : 36 oC
Primary Survey
A : Airway clear
B : Adequate breath
C : BP: 140/90 mmHg, HR: 84 x/i, regular
D : GCS: 15 (E4V5M6)
E : T: 36 oC
Secondary Survey
“the local status of region of the right knee”
 GENERALIZED STATUS
9. Heart
1. Head : Normocephali Inspection: Ictus cordis is not visible
2. Eye : Pupil : Isokor (+/+) Palpation : Ictus cordis palpable
Sklera : Icteric (-/-) Percussion: Dull
3. Conjunctiva : Anemis (-/-) Auscultation: Normal, Gallop(-), Murmur(-)
Light reflex : (+/+) 10. Abdomen
4.Ear : Normal, sekret (-) Inspection : Symmetrical
5. Nose : Normal, hiperemis (-), deviation Palpation : Tenderness (-), hepatomegali (-),
septum (-) splenomegali (-)
6. Mouth : Normal, sianosis (-) Percussion : timpani
7. Neck : Enlarge lymph node (-) Auscultation: peristaltic (+)
8. Thorax (Lung) 11. Extremity
Inspection :symmetrical Superior : warm neurovascular perifer+/+,
Palpation : stem fremitus right=left pain -/-, edema -/-
Percussion : sonor Inferior : warm neurovascular perifer+/+,
Auscultation: vesikuler pain -/+, edema -/-
12. Genital: -
Orthopaedic Examination

Look
The patient's face looks in pain,
deformity (+)
Feel
Local pain (+), crepitus (-), warm
palpitations (+)
Move
ROM (+)
Temporary Diagnosis :
Osteoarthritis Grade IV Of The Right Knee

Advice :
 Laboratory examination (Complete blood count,
Blood sugar levels, Blood clots, Renal function,
Liver function, Electrolytes)
 X-ray (Right Knee)
Complete Blood Count (24 Oct 2018)

eburnation of bone
Diagnosis : Osteoarthritis Grade IV of the right knee

Proceeding :
 Supine position under general anesthesia
 Disinfectant and drapping procedure
 Posterior approach incision and identification it
 TKR mobile bearing
 Irrigate the wound and closed the wound
POST OPERATIVE
 Post operative assessment :
 General condition : Looks like in mild pain
 Awareness level : Compos Mentis/GCS 15
 Airway : Free
 Respiratory : Spontaneous

Education :
 To always move the patient's right foot by learning to sit and swing the foot
slowly when you’re sitting
 To always do the physiotherapy