A patient referred to a rheumatologist for bilateral knee pain
Reason for consult : Evaluation and management of knee pain
Requesting physician : John Doe, MD
HPI :The patient is a 52 year old male who states he has had worsening pain in both knees for about six months. The pain is described as a “dull ache” and is often worsened after walking long distances. He has had only partial relief with Tylenol.
PFSH is remarkable for hypertension which is well controlled on a thiazide diuretic
ROS
Musculoskeletal - Positive per HPI, plus occasional shoulder pain on the right, negative for
myalgias or joint swelling
Gastrointestinal - Negative for mid-epigastric pain, hematemesis, melena, GERD
Neurologic - Negative for lower extremity numbness, tingling, lumbago or sciatica
Physical Exam
General: NAD, conversant and well developed white male with normal attention to grooming
Vitals: 130/80, 72, 98.6
Neck: Supple, FROM
CV: RRR, no MRGs; no peripheral edema; pedal pulses intact and brisk bilaterally
Abdomen: Soft, non-tender
Musculoskeletal: Normal gait and station; both knees show mild symmetrical swelling and crepitation; passive and
active ROM is limited bilaterally, normal stability with no joint laxity; right and left lower extremities had normal and
symmetric muscle tone and strength with no evident atrophy; hands showed no normal nail beds with no pitting and
no active tenosynovitis or rheumatoid nodules
Skin: Both lower extremities showed no rash, joint erythema or warmth; normal skin texture with no tightening
Assessment
- Osteoarthritis with bilateral knee involvement
Plan
- OTC ibuprofen 400 mg po tid, prn
- Plain films of both knees
- PT/OT referral
- Return visit in one month with cbc and renal profile
- Will send a copy of this note to Dr. Doe
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