CHAPTER 1

CASE ILUSTRATION

1. Patients Identity
Name : Mrs. R
Age : 75 years old
Sex : Female
Address : Ungaran
Occupation : Housewife
Religion : Islam
Race : Javanese
MR Number : 1923 xx
Date Of Admission : 2 February 2014
Date Of Discharge : 7 February 2014
Date Of Treatment : 2-7 February 2014

2. History Taking
History taking of patient by autoanamnesis and alloanamnesis ( patients son) had
been done by 2 February 2014 immediately when the patient arrived at Emergency
Department RSUD Ungaran.

1. Chief Complaint : Knee pain on both side and the difficulty to walk
2. Current Illness : Patient came to Emergency Department of RSUD Ungaran
brought by her family on 2 February 2014, 16.13 WIB with chief complaint of
pain on both knees and difficulty to walk. The pain occurred suddenly 2 days
before hospital admission. Pain is throbbing and needle prick-like. The pain
cannot be reduced by applying compression, massage oil, or pain killers. Pain
become worsen when the patients knees are folded and when there is any
movement occurred but is reduced when the patient is resting. Initially, the patient
said that the pain occurred when she wanted to go to the bathroom. When standing
still, the patient felt that both legs are very painful and difficult to move and then
the patient finally fall to the floor. Patient also denied that her head was knocked
down on the floor. Patient also denied the history of fainting, vomiting, nausea,
difficulty to breath, dizziness, and hemiparesis just after she fall on the floor. Her
appetite, micturition, and bowel movement are all on normal range. The pain on
both knees actually has begun about a year before hospital admission, initially just
a bit then it became worsen as the time pass by and then become worst when there
are swelling on both knees on about 2 days before hospital admission. At this
 time, the patient is unable to walk anymore. The swelling on both knees are seen
by the patient at about 6 months ago. The swelling make the patient difficult to
move both legs and the patient daily routines are greatly affected. However, the
patient still can walk a bit and slowly without any help. The swelling on the knees
are warm. The swelling also cannot be reduced although by applying compression
with cold water or even after resting.
Patient also felt rigid on both knees. The rigidity occurred in the morning
just after the patient woke up from sleep and it occurred for almost half an hour. When
the knees are rigid, the patient cannot move her leg and can only lied on her bed. With
the help from other people, the patient felt that her legs are moved a bit to the right or
the left and cannot be folded.
Patient has the history of massage treatment and also has the history of
medication from pharmacy to reduce the pain from her knees, but the patient forgot
the name of the medication.
Patient said that before her illness about a year ago, she can do many
household jobs such as cleaning the house and cooking but after the illness she could
barely walk.
At the time of examination at Emergency Department RSUD Ungaran,
patient felt that her illness become worsen, both of her legs become more painful, and
cant fold her knees.
3. History Of Past Illness
a. History of Same Chief Complaint : Agreed ( About a year ago, still can barely
walk)
b. History of DM : Denied
c. History of Hypertension : Agreed ( More than 2 years but not on routine
medication )
d. History of heart disease : Denied
e. History of kidney disease : denied
f. Food and drugs allergy : Denied
g. History of asthma : Denied
h. History of stomach disorder ; Denied
i. History of past operation : Denied

4. Family History
Denied

5. Psychososial History
Patient is currently a fulltime housewife and live a happy life with her sons and
daughter.

X Ray Genu Dextra et Sinistra

Results : Osteophytes can be seen on condylus lateralis and medialis os tibia
femoralis dextra and also with joint narrowing of tibia femoralis lateralis dextra.
So can be concluded as osteoarthritis genus dextra grade 3.

Osteophytes on condylus lateralis and medialis os tibia femoralis sinistra with

joint narrowing of femoro tibialis sinistra with irregular shape on tibia fibula
bones at around the joints and also with subcondral sclerotic. Can be concluded as
osteoarthritis genu sinistra grade 4 with osteoarthritis/ inflammation.

Pelvic X Ray AP Position

Results : Opaque lesion can be seen on cavum pelvis. Supected as mass DD

vesicolithiasis ( USG abdomen suggested )

No fracture or dislocation detected