This is the note:
CHIEF COMPLAINT
81-year-old female with complaints of right knee pain.
REASON FOR VISIT
Patient is seen and assessed today with regards to her right knee. She has had a recurrence of her right knee swelling and she is concerned about this. She says that the knee generally feels better, but it is tender. When I asked her about her knee, she says that it swells, and it is markedly swollen. She says that it does not lock. She has pain over the joint itself, it does not buckle out from under her, it does not snap and pop, range of motion is about 2 degrees and she cannot really bend it much past 90 degrees without experiencing pain because of tightness, she says because of swelling in the joint. Activities such as walking are limited, the limb feels weak and it gets stiff when she stands from a seated position.
HISTORY OF PRESENT ILLNESS
Patient is an 81 year old female.
• Medication list reviewed.
CURRENT MEDICATION
Patient takes no medications.
PAST MEDICAL/SURGICAL HISTORY
Reported:
Surgical / Procedural: Surgical / procedural history Gallbladder Surgery.
Diagnoses:
Hypertension.
Rheumatoid arthritis
Total Knee Replacement, left.
Surgical:
• Tonsillectomy with adenoidectomy
• Hysterectomy
SOCIAL HISTORY
Behavioral: No tobacco use and smoking status: Unknown if ever smoked.
Alcohol: Alcohol.
Drug Use: Not using drugs.
Marital: Widowed.
ALLERGIES
Patient has no known drug allergies.
FAMILY HISTORY
Hypertension
Arthritis
REVIEW OF SYSTEMS
Systemic: No fever, no chills, no recent weight loss, and no recent weight gain.
Head: No headache.
Otolaryngeal: No epistaxis.
Cardiovascular: No chest pain or discomfort, no palpitations, and the heart rate was not fast.
Pulmonary: No dyspnea, no cough, and no wheezing.
Gastrointestinal: No dysphagia and no heartburn. No nausea, no vomiting, and no hematochezia.
Genitourinary: No hematuria and no increase in urinary frequency. No dysuria.
Endocrine: No polydipsia and no excessive sweating.
Hematologic: No easy bleeding and no tendency for easy bruising.
Neurological: No vertigo and no convulsions.
Psychological: No anxiety and no depression.
Skin: No rash and no sore:
PHYSICAL FINDINGS
On physical examination today, the patient is a cooperative, orientated, pleasant, 5 foot 4 inch, 122 pound, 81-year-old, female. Examination of her right knee reveals a rather tense effusion.
TESTS
No new x-rays were taken on today's visit.
ASSESSMENT
Right knee osteoarthritis primary
Right knee effusion.
PLAN
I elected to aspirate and inject her knee here today and did so under sterile conditions. I prepped the right knee with Betadine and alcohol then utilizing ethyl chloride as an analgesic I passed a 22 gauge needle into the joint utilizing a lateral approach on the lateral side of the patella and proceeded to aspirate 70 cc's of straw colored fluid. I discarded this as it certainly did not look infected. I then injected 40 mg of Depo-Medrol and 3 cc’s of Xylocaine. The patient tolerated the procedure well. A Band-Aid was applied. We will reassess on a PRN basis.