MEDICATIONS:
1. Tylenol No.3 p.r.n.
2. Colchicine 0.6 mg b.i.d.
3. Cozaar 100 mg a day.
4. Lasix 20 mg as needed.
5. Glipizide 5 mg a day.
6. Insulin.
7. Metformin 850 mg b.i.d.
8. Vytorin.
REFERRING
PHYSICIAN: Dr. Harris.
REASON FOR
CONSULTATION: Evaluate patient with knee
pain to advice on management.
PATIENT’S CHIEF
COMPLAINT: Bilateral knee pain.
HISTORY OF
PRESENT ILLNESS: Patient is a 75-year-old
African‑American female who has had knee pain off and on for years. Symptoms are getting worse. She is able to walk in shopping malls but
only go a certain distance. Then she has
to sit and rest. Patient finds her level
of activities becoming more and more restricted. The use of ibuprofen is associated with
stomach upset. Minimal pain relief with
the use of Tylenol No.3. No pain at
rest.
REVIEW OF SYSTEMS: No current cough or shortness of breath. No swelling in the legs. No abdominal pain.
PAST MEDICAL
HISTORY: Diabetes and hypertension.
EXAMINATION:
VITAL
SIGNS: Weight is 227 pounds, blood
pressure 144/77, with a pulse of 102, temperature 98.5.
MUSCULOSKELETAL: No swelling in the joints of the hands, the wrists,
the elbows. There is limitation of
motion of the cervical spine. In the
lower extremity, no pain with range of motion of the hips. Both knees lack hyperextension. They were slightly warm to touch when
compared to mid shaft and tibia. No
anterior knee effusions. No lateral
instability. Joint line is not tender. No pretibial edema.
IMAGING
STUDIES: Weightbearing radiographs of both
knees were obtained today and reviewed with the patient. There is obliteration of the medial tibiofemoral
joint spaces bilaterally.
IMPRESSION: Osteoarthrosis, both knees.
MEDICAL DECISION
MAKING: I recommend knee replacement
surgery. Anything else, at this point in
time, will probably be futile. However,
patient does not want to consider surgery.
Therefore, I referred her to the Osteoarthritis Clinic at the Center for
Athletic Medicine for their management expertise.
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