New Patient - Note [Orthopaedic Surgeon]

Summary: - 62-year-old male presents with right knee pain and swelling. - Diagnoses: Diagnosis: Osteoarthritis of the right knee. - Plan: Plan: Discussed conservative management options including physiotherapy and analgesia. HOPC: - History of presenting complaint: Patient reports gradual onset of right knee pain over the past six months, worsening with activity and relieved by rest. He also reports stiffness in the morning and occasional swelling. - Specific musculoskeletal concerns such as joint pain, stiffness, swelling, injuries, fractures, deformities: Right knee pain, stiffness, and swelling. - Onset, duration, severity, aggravating/alleviating factors, associated symptoms, previous injuries or trauma: Onset was gradual six months ago. Pain is worse with activity and better with rest. Associated symptoms include morning stiffness and occasional swelling. No previous injuries or trauma. - Previous treatments such as physiotherapy, medications, surgeries and their outcomes: Patient has tried over-the-counter analgesics with limited relief. - Patient’s goals for this visit: Patient wants to understand the cause of his knee pain and explore treatment options. - Patient's ideas, concerns, and expectations: Patient is concerned about the possibility of needing surgery. Past medical and surgical Hx: - Past medical history: Hypertension, well controlled with medication. - Previous surgeries: Appendectomy at age 30. Medications: - Current medications: Lisinopril 10mg daily. Allergies: - Allergies including type of reaction if mentioned: NKDA. Social history: - Details such as handedness, employment, sports/physical activities, smoking, alcohol use, drug use, home supports, hobbies: Retired, non-smoker, occasional alcohol use. Lives with his wife. Examination and Investigations: - Musculoskeletal examination including inspection, palpation, ROM, strength, joint stability, deformity, swelling, tenderness: Inspection revealed mild swelling of the right knee. Palpation elicited tenderness along the medial joint line. Range of motion was limited due to pain. No instability noted. - Investigations including date (month/year), type (e.g., X-ray, CT, MRI), imaging provider (e.g., PRC, SKG, i-Med), and findings: X-ray of the right knee (October 2024) showed mild joint space narrowing and osteophyte formation. Discussion and Plan: - Discussion including diagnosis explanation, treatment options (operative/non-operative), informed consent, education, post-operative instructions, complications to watch for, rehabilitation plan, family/patient concerns addressed, and relevant referrals: Explained the diagnosis of osteoarthritis. Discussed conservative management options including physiotherapy, weight management, and analgesia. Informed patient about the potential need for joint replacement in the future. Referred patient to physiotherapy for strengthening exercises. Addressed patient's concerns about surgery.