LGregg1989
New
** the below patient is new to our practice, but has been seen by the same provider before at a different practice**
CC
Right knee pain.
HPI
This is a patient with right knee pain for the last 4-6 years. The patient got a cortisone shot 3 or 4 years ago and has helped. He has had viscosupplementation in the past and wants to start that series. He has known advanced arthritis. He has recurrent swelling. He has had it aspirated before in the past as well. He has been told in the past he is going to need a knee replacement. The pain is worse with standing and prolonged walking as well as up and down stairs.
PMHx
PSHx
FHx
Soc Hx
Medications
Allergies
No known allergies
Vitals
10 Jun 2024 - 02:01 PM -
Temp:97.8 °FHt/Lt:6' 6"Wt:260 lbs 6.4 ozBMI:30.09
EXAM
MUSCULOSKELETAL: Muscular male. No obvious effusion today. Minimal at best. Positive patellar grind and crepitus. Tenderness over the medial joint line. No real pain laterally. Somewhat limited motion. The ligaments are stable. No warmth and no erythema. Temperature 97.8.
Results
X-rays of the right knee show advanced arthritic changes with bone-on-bone findings, grade 4 in nature. Images were reviewed and independently interpreted by me today.
Diagnosis
Unilateral primary osteoarthritis, right knee (M17.11) Unilateral primary osteoarthritis, right knee
Right knee osteoarthritis.
Plan
Right knee injection. He will follow up to begin the viscosupplementation series. We talked about PRP injections as well as surgery. Will see how he is doing at his next visit. Ice recommended. He also wants to try some meloxicam. GI precautions discussed.
Procedure Note
Right knee injection:
The risks and benefits of an injection were thoroughly discussed with the patient which include, but not limited to, pain, swelling, infection, damage to cartilage, injury to nerve and/or vascular structures, injury to tendons and/or ligaments, discoloration of skin, soft tissue and skin atrophy, and increase in blood glucose levels. Patient understood these risks and was willing to proceed. All questions answered.
The right knee was prepped in normal sterile conditions. Then, 1 cc of Kenalog (40 mg total) and 3 cc of 1% lidocaine without epinephrine were injected under sterile conditions into the right knee. Patient tolerated the procedure well and understands it often takes 3-5 days to see any potential improvements.
CC
Right knee pain.
HPI
This is a patient with right knee pain for the last 4-6 years. The patient got a cortisone shot 3 or 4 years ago and has helped. He has had viscosupplementation in the past and wants to start that series. He has known advanced arthritis. He has recurrent swelling. He has had it aspirated before in the past as well. He has been told in the past he is going to need a knee replacement. The pain is worse with standing and prolonged walking as well as up and down stairs.
PMHx
- Arthritis
PSHx
- Right shoulder replacement - 2021 by Dr. T
- left shoulder arthroscopy - 2014 by Dr. S
FHx
- mother: Unknown, +None or non-contributory
Soc Hx
- Tobacco: Never smoker
- Alcohol: Frequently drink - 5-6 per wk
- Drug Abuse: No illicit drug use
Medications
- (Medication reconciliation last updated xx
meloxicam 15 mg tablet, One tablet per day as needed. take with food. do not take with other anti-inflammatory medicines
TylenoL 325 mg tablet
Allegra Allergy 180 mg tablet
multivitamin tablet
Allergies
No known allergies
Vitals
10 Jun 2024 - 02:01 PM -
Temp:97.8 °FHt/Lt:6' 6"Wt:260 lbs 6.4 ozBMI:30.09
EXAM
MUSCULOSKELETAL: Muscular male. No obvious effusion today. Minimal at best. Positive patellar grind and crepitus. Tenderness over the medial joint line. No real pain laterally. Somewhat limited motion. The ligaments are stable. No warmth and no erythema. Temperature 97.8.
Results
X-rays of the right knee show advanced arthritic changes with bone-on-bone findings, grade 4 in nature. Images were reviewed and independently interpreted by me today.
Diagnosis
Unilateral primary osteoarthritis, right knee (M17.11) Unilateral primary osteoarthritis, right knee
Right knee osteoarthritis.
Plan
Right knee injection. He will follow up to begin the viscosupplementation series. We talked about PRP injections as well as surgery. Will see how he is doing at his next visit. Ice recommended. He also wants to try some meloxicam. GI precautions discussed.
Procedure Note
Right knee injection:
The risks and benefits of an injection were thoroughly discussed with the patient which include, but not limited to, pain, swelling, infection, damage to cartilage, injury to nerve and/or vascular structures, injury to tendons and/or ligaments, discoloration of skin, soft tissue and skin atrophy, and increase in blood glucose levels. Patient understood these risks and was willing to proceed. All questions answered.
The right knee was prepped in normal sterile conditions. Then, 1 cc of Kenalog (40 mg total) and 3 cc of 1% lidocaine without epinephrine were injected under sterile conditions into the right knee. Patient tolerated the procedure well and understands it often takes 3-5 days to see any potential improvements.
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