Department of orthopaedics

History taken by Raya Jadaan

Patient Profile:
Nemat Awad is a 60 year old married
housewife lives in Maan, she was
admitted to the hospital via outpatient
department on August 7th 2016 at
12:30 am, history was taken by Raya
Jadaan a 5th year medical student on
Aug 9th 2016 at 10:30 am from the
patient herself.
Chief Complain:
She was admitted for left TKR surgery.
History of Present Illness:

The patient was admitted to the

hospital after being appointed for a
TKR surgery on 2016 2 years ago from
now. She was suffering from severe
bilateral anteromedial knee pain of
two years duration that worsened over
time; worse on the left one. The pain
is dull in nature, continous,
exacerbated by exertion, relieved by
laying down and not moving, it
radiates to lower back and to foot,
associated with numbness and
tingling. She doesnt recall having any
trauma.
The pain has significantly impaired her
life as she cant perform the minimal
activities without an escort, her
motion is limited, she cant get out of
bed or stand up from a chair by her

own, it is hard for her to get dressed

by her own and would be impossible.
The patient visited a private
rheumatology clinic before coming to
JUH, she was given 3 steroid injections
to each knee that partially relieved
her. There is no associated fever,
chills, anorexia or night sweats,
neither did she complain of weight
loss or fatigue or loss of appetite. The
pain is worse in winter. The patient
lives in her sons house with his wife
and chidren in an independent house
on ground floor and she had never
worked outdoor or performed any
abnormally exhausting activities or
even did household chores. Her KFT is
normal . Her older sister had a TKR at
about her same age.

Past Medical History:

Hypertenson 10 years of duration
Past Surgical History:
Hemorrhoidectomy 10 years ago
Lumbar disc prolapse
Allergy: No known drug allegy
Drugs : Hydrochlorthiazide 160/12.5
she is compliant.
Social History:
The patient lives wither sons family
she has five children 2 males and
three females all living in Maan. She

is ensured in JUH , she doesnt smoke,

drink alcohol or takes hooka.

Family history:
Her sister had TKR surgery, 2
hypertensive brothers, a diabetic and
hypertensive sister.
Review of systems:
Free other the hypertension that was
mentioned above.
Physical examination:

The patient was sitting upright

conscious, oriented, alert to time
place and person, she was not
connected to ventilators or IV lines.
On inspection there is no erythema,
bruising or discoloration of the knee.
The musculature of both legs is
symmetrical and normal, no signs of
atrophy.
On palpation the knee is tender, not
worm.
The patient cant flex her leg more
than 15 degrees, she cant extend
them, there is crepitus, locked knees,
positive effusion. No popping, No
giving away. Not all tests could be
performed due to the extreme pain
the patient was in.