MEDICATIONS:
1. Ibuprofen p.r.n.
CHIEF
COMPLAINT: Knee pain better.
HISTORY OF
PRESENT ILLNESS: I saw this patient
complaining of right knee pain in April of this year. At that time, I noticed that the right knee
was warm to touch when compared to the left, but there was also tenderness on
palpation, but no obvious anterior effusion.
She has noted relief with rest and use of ibuprofen. Ultrasound of the right knee was
unremarkable. Patient returns today
saying that her knee pain has improved.
EXAMINATION:
VITAL
SIGNS: Weight is 186 pounds, blood
pressure 121/83 with a pulse of 94, temperature 98.
MUSCULOSKELETAL: Both knees are cool to touch. Hyperextension is preserved bilaterally. No lateral instability. No anterior effusions. No tenderness on palpation. No pain with range of motion of the hips.
IMPRESSION: Resolving arthropathy, right knee.
MEDICAL DECISION
MAKING: Patient is able to return to
work on July 1st. Currently, she is laid
off. Insurance form is completed.
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