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Bản thân: Điều trị thoái hóa khớp gối: - Thời gian dùng thuốc NSAIDs : tháng - Thời gian dùng thuốc điều trị cơ bản: tháng - Thời gian mắc bệnh thoái hóa (tính từ khi có triệu chứng đau khớp gối lần đầu tiên): năm (< 1 năm: 99) 2.2 Các phương pháp điều trị trước đó: Chọc hút dịch khớp: 1 Tiêm nội khớp 2; Nội soi khớp: 3 2.3 Thói quen sinh hoạt, lao động ảnh hưởng đến khớp gối Ngồi xổm hoặc ngồi khoanh chân: 1; Mang vác nặng, đứng nhiều thường xuyên: 2. Thường xuyên lao động, sinh hoạt trong môi trường ẩm ướt: 3. TS chơi thể thao: 4  Bệnh nội khoa khác 2.2. Gia đình 3. Triệu chứng lâm sàng Chiều cao:.cm Cân nặng:. kg BMI.............. 3.1 Khớp tổn thương Khớp gối phải: 1; Khớp gối trái: 2; Cả hai khớp: 3 Thời gian mắc bệnh: năm (<1 = 99) 3.2 Khớp gối phải Thời gian mắc Sưng: 1; Nóng 2; Đau kiểu viêm: 3; Cứng khớp buổi sáng: 4; Lạo xạo xương: 5; DH bào gỗ: 6; Bập bềnh xương bánh chè: 7; Kén Baker: 8 Các thang điểm: Điểm VAS: Điểm Lequesne Điểm WOMAC: Điểm WOMAC đau Điểm WOMAC vận động : Điểm WOMAC cứng khớp Biên độ vận động: Gấp: Độ; Duỗi: Độ 3.3 Khớp gối Trái Thời gian mắc Sưng: 1; Nóng 2; Đau kiểu viêm: 3; Cứng khớp buổi sáng: 4; Lạo xạo xương: 5; DH bào gỗ: 6; Bập bềnh xương bánh chè: 7; Kén Baker: 8 Các thang điểm: Điểm VAS: Điểm Lequesne Điểm WOMAC: Điểm WOMAC đau Điểm WOMAC vận động : Điểm WOMAC cứng khớp Biên độ vận động: Gấp: Độ; Duỗi: Độ 4. Cận lâm sàng: 4.1. Chẩn đoán hình ảnh: Hẹp khe khớp: Đùi chày trong mm; Đùi chày ngoài: mm; Đùi chè mm Gai xương: Đùi chày trong 1; Đùi chày ngoài: 2; Đùi chè 3 Đặc xương dưới sụn: Lồi cầu trong: 4; Lồi cầu ngoài: 5; Mâm chày trong: 6; Mâm chày ngoài: 7; Mặt bánh chè: 8 Giai đoạn thoái hóa trên X-quang: Trục khớp gối: vẹo trong: 1; Vẹo ngoài: 2 4.2. Tổn thương trên siêu âm Khớp gối Phải: Bề dày sụn LLC: mm; LCN: mm; LCT: mm; Bề dày màng hoạt dịch: mm; Bề dày dịch khớp: mm Cấu trúc âm sụn không đồng nhất: 1; Bề mặt sụn LCN không đều: 2; Bề mặt sụn LCT không đều: 3; Bề mặt xương dưới sụn mặt trong khớp không đều: 4; Mặt ngoài khớp không đều 5; Gai xương khe đùi chày trong: 6, gai xương khe đùi chày ngoài: 7; Kén Baker: 8; Nốt canxi hóa MHD: 9 TB dịch khớp Tổn thương trên cộng hưởng từ: Phiếu kèm theo 4.2. Xét nghiệm máu: Hồng cầu Hb Bạch cầu Tiểu cầu Máu lắng Glucose Creatinin GOT GPT A.uric Cholesterol Triglycerid CRP hs IL-6 RF 4.3. Đo mật độ xương: CSTL T-score: ; CSTL BMD: CXĐ T-Score: CXĐ BMD: Hà Nội, ngày tháng năm Người làm bệnh án