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Knee NoteAge: 67 Occupation: retired Involved Side:right Sports: none Chief Complaint Date of Injury:none “right knee pain” History of Present Illness is a 67 year old retiree seen at the request of Dr. for evaluation of right knee pain. She has noted gradually worsening right knee pain over several years. The pain is 8-9/10 diffuse knee pain. Worse with activity. Increased pain with stairs, or prolonged standing. She complains of constant pain worsened by bending, walking and any moving activity. The knee pain significantly limits her ADL's. Pain Severity: 8 /10 Pain location: diffuse about the right knee Pain at rest: 8/10 Exacerbating factors: activity Pain with activity: 10 /10 Ameliorating Factors: rest Pain Duration:constant Pain night: wakes her from sleep Previous treatment: NSAIDs, cortisone injection times 2 with no improvement; physical therapy, knee arthroscopy 4 months ago with no improvement.
PMH: high cholesterol, hypothyroid PSH: right knee scope Family History: Patient questionnaire was reviewed, signed and dated in the chart and was noncontributory. Medications: levothroxin, fosamax D, cholestol pill Allergies: NKDA Social History: no smoking, no alcohol use ROS: Patient questionnaire was reviewed, signed and dated. Pertinent findings: no fevers, no chills, no drastic changes in weight, no known metal allergies.
Physical Exam Height: 5’3 Weight: 116 Pulse: 76 BP: General Appearance: Well-nourished, well developed in no acute distress Orientation: Oriented to person, place and time. Mood / Affect: Calm Gait: normal Coordination: normal Elbow Exam (Bilateral) Inspection/Palpation UE (R/L): Nontender, no effusion bilaterally Elbow ROM (R/L): 0-125 / 0-125 Suppination (R/L): 80/80 Pronation (R/L): 80/80 Elbow Stability (R/L): no varus or valgus laxity bilaterally Biceps (R/L): 5/5 / 5/5 Triceps (R/L): 5/5 / 5/5 Wrist Extension (R/L): 5/5 / 5/5 Wrist Flexion (R/L): 5/5 / 5/5 Intrinsics (R/L): 5/5 / 5/5 Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally Vasculature: 2+ radial pulse bilaterally UE Skin (R/L): no rashes or lesions bilaterally Lymph UE (R/L): no axillary lymphadenopathy DTR UE (R/L): Biceps (2+/2+), Triceps (2+/2+) Knee Exam (Bilateral) Inspection / Palpation LE (R/Lmild right medial and lateral joint line tenderness Knee ROM (R/L): 5-95 / 0-115 Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+) Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+) Strength LE: 5/5 EHL, tibialis anterior, plantar flexion Sensation: Subjective normal distal sensation bilaterally Vasculature: 2+ dorsalis pedis pulse bilaterally LE Skin: no rashes or lesions bilaterally Lymph LE: no inguinal lymphadenopathy DTR LE: Patellar (2+/2+); Achilles (2+/2+)
Diagnostic Studies A/P and lateral views of the right knee from an outside office demonstrate complete loss of the joint space with tricompartmental sclerosis and osteophyte formation
Assessment Right Knee Osteoarthritis
Plan We discussed the natural history of arthritis and both operative and non-operative treatment options. We discussed the risks, benefits and expected rehabilitative course of both operative and non-operative treatments. All questions were answered. Available links to further peer-reviewed written information on the diagnosis were provided. Risks, benefits, expected rehab course and alternatives to surgery were discussed thoroughly with the patient. Risks of total knee replacement discussed include but are not limited to: infection, bleeding, damage to nerves, tendons and blood vessels, poor healing, need for more surgery, continued pain, postoperative knee stiffness requiring manipulation or revision; postoperative infection requiring removal of implants, prolonged IV antibiotics and salvage surgery, DVT, PE and the risks of anesthesia including heart attack, stroke, and death. She would also need pre-operative medical clearance prior to surgery. She will consider her treatment options and follow-up with further questions and for continued management. We will continue with conservative management including activity modifications and NSAIDs. Occupation: |
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