Orthopaedic Consultation

Date of consultation: 1 November 2024 68y/o Male, now presenting with right knee pain, secondary to osteoarthritis, and complicated by mild functional limitation. General Medical History: # Hypertension: Well-controlled with Amlodipine 5mg OD, BP 128/78 mmHg. Latest blood results: Na 140 mmol/L, K 4.1 mmol/L, Creatinine 85 umol/L. # Type 2 Diabetes Mellitus: Managed with Metformin 500mg BID, HbA1c 6.8%. No reported complications. # Allergies: Penicillin - rash. History of Presenting Complaint: Patient reports a 6-month history of worsening right knee pain. Onset was gradual, with pain described as a dull ache, intermittently sharp, particularly with activity. Severity is rated 6/10 at its worst, interfering with daily activities like walking and climbing stairs. Pain is localised to the right knee, anteriorly and medially, with no radiation. Aggravating factors include prolonged standing, walking, and cold weather. Relieving factors include rest and paracetamol. Associated symptoms include occasional stiffness in the morning lasting approximately 15 minutes. Patient has tried over-the-counter NSAIDs with limited relief. No prior investigations. General Examination: Vital signs: BP 130/80 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C. Patient is alert and oriented, in no acute distress. Appears comfortable at rest. Cardiovascular and respiratory examinations are unremarkable. Orthopedic Examination: Right Knee Inspection reveals no significant swelling, erythema, or deformity. Mild quadriceps atrophy noted on the right compared to the left. Palpation elicits tenderness along the medial joint line. Range of motion is limited with flexion to 110 degrees (normal 140) and extension to 5 degrees (normal 0). There is crepitus noted on movement. Strength is 4/5 in knee flexion and extension due to pain. Neurological assessment of the lower limb is intact, with normal sensation and reflexes. No specific instability or meniscal signs were elicited on special tests, though pain limited full assessment. Special Investigations: 1. X-ray Right Knee (25 October 2024): Moderate tricompartmental osteoarthritis, more pronounced medially, with joint space narrowing and osteophyte formation. Management Plan: Conservative management initiated. Advised regular paracetamol and topical NSAIDs as needed. Encouraged weight loss (BMI 29) and commencement of a low-impact exercise program, such as swimming or cycling. Patient education provided regarding the chronic nature of osteoarthritis and the importance of lifestyle modifications. Discussion of potential future options including physiotherapy or intra-articular injections if conservative measures are insufficient. Referral: Referral to physiotherapy for a structured exercise program and pain management strategies for the right knee osteoarthritis.