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IDENTITY

Name : Kadek Asri 21051782


Sex : Female
Age : 58 y.o.
CM : 21051782
Address :-
Phone : 087860085666
Insurance : BPJS
Admitted :-
Ward :-
History
Chief Complain
Pain on left knee

Present History
• Patient complained pain on her left knee since last 7 months (February 2021), The pain
felt more worse when patient was walking and relieved when patient resting.
• Pain on right knee appeared since 2 months ago (July 2021)
• Patient was reffered from Parama Sidhi Hospital by Ortopedic surgeon with diagnosis OA
knee Bilateral

Past History
• History of taking analgesics since 7 months ago, but patient forgot the name of the
medicine
• History of trauma (-)
• History of physiotherapy (-)
• DM and hypertension was denied

Social History
Patient work as a fruit seller at the market
Refferal Letter
Left Knee Region:
L : Swelling (-), Deformity (+) Varus 15 deegree, Bruise (-)
F : Tenderness (-), dorsalis pedis artery (+) palpabe, SpO2 99%, normal sensation
M : Active ROM Knee 0/100
Active ROM Ankle 20/50
Active ROM MCP-IP 0/90
Right Knee Region:
L : Swelling (-), Deformity (+) Varus 5 degree, Bruise (-)
F : Tenderness (-), dorsalis pedis artery (+) palpabe, SpO2 99%, normal sensation
M : Active ROM Knee 0/90
Active ROM Ankle 20/50
Active ROM MCP-IP 0/90
Diagnosis:
OA Right Knee Kellgreen and Lawrence Grade IV
OA Left Knee Kellgreen and Lawrence Grade IV

Planning:
Right TKR

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