LAPORAN KASUS

BAGIAN REHABILITASI MEDIK

Name : Mr. A
Sex

: Male

Age

: 72

Address:
Occupation :
Religion

Ethnic :
Referred from : Rheumatologi
Chief Complain : Nyeri Lutut pada kaki kiri dan kanan
History of Pressent Illness : nyeri pada lutut dan mengalami kekakuan. Pasien ini
merupakan pasien lanjutan terapi. Awalnya pasien mengeluhkan nyeri
pada sendiinya itu sejak satu tahun tiga bulan yang lalu. Memburuk
sejak 5 hari terkhir pada kedatangan pertama kali. Gangguan AKS

(berdiri dan berjalan) Susah untuk jongkok, nyeri ketika beratifitas, dan sholat
terganggu.
Histrory of Past Illness :
Riwayat pemeriksaan asam urat tinggi (+)
Riwayat trauma (+)
Riwayat penyakit yang sama dalam keluarga (-)
Riwayat Hipertensi (+) sejak 3 tahun yanga lalu. Berobat teratur
Riwayat DM (-)
Pain on the knee and having rigid. This patience was an advanced therapies.
Initially the pasien have complained about pain on their joints since 1 year and 3
months ago. Got worse since 5 days ago on the day one (7-7-2015). AKS
(standing and walking) disruption, hard to squat, pain when doing activity, pray
disturbed
(+/positive) stiff less than 30 minute

(-/negative) get warm

(-/negative) redness
(-/negative) warm bodies

History of past illness (riwayat penyakit)

(+/positive) history of uric acid medical check up
(+/positive) traumatic history
(-/negative) history of same diseased in family
(+/positive) hypertension history since 3 years ago. Regular treatment
Physical Examination

GENERAL STATUS

Compus Mentis, Independent ambulation

Body Weight : 52 kg.

Body Height : 154 cm.

BMI : 21,92 (Normal)

Blood Preasure : 130/70 mmHg,

Heart Rate : 84 x/mnt

Respiratory Rate : 16 x/mnt

Head & Neck : no anemia, icterus, cyanosis & dyspneu

Thorax
- Cor

:
: S1S2 sound, murmur -, gallops -

- Pulmo : vesiculer, wheezing -/-, ronchi -/

Abdomen

: Meteorismus -

Hepar / Lien : unpalpable

Extremities

Upper extremity : N

Lower extremity : Pain at right knee and left knee

B. Local status (region Genu )

I : Inflamation (-) swelling (-), redness (-), deformity (-)
P : - Warm : +/- Crepitation : +/+
VAS : 4
C. Diagnosis

: OA Genu Bilateral

D. Functional diagnosis
Impairment : Degenerative knee joint
Disability
:- Pain at ringht and left knee joint
- Difficult to squat and get pain if doing activity
Handicap
:
E. Problem List :
Surgical
Medical

:
: OA Genu Bilateral

F. Planning
Surgical

Medical

Rehabilitation Madicine :
1. USD
2. Tens
3. Exercise therapy.
1x week (4x)