Orthopaedic Outpatient Clinic Letter

Orthopaedic Outpatient Clinic Letter Patient’s Name: Mr. Arthur Pendelton Date of Birth: 15/03/1968 Unit Number: 123 456 7890 Seen by: Dr. Evelyn Reed Date of Consultation: 1 November 2024 Dear Mr. Pendelton, Re: Right Knee Pain and Swelling It was good to see you in the Orthopaedic Outpatient Clinic today to discuss your ongoing right knee issues. Summary of Concerns: - You reported persistent pain and swelling in your right knee for the past six months, which has been getting worse, especially with walking and going up/down stairs. - Your main concern was the impact on your daily activities, including your ability to walk your dog and perform gardening tasks. - We discussed your history of previous right knee arthroscopy ten years ago for meniscal tear, and your current medications include paracetamol and ibuprofen, which provide limited relief. Examination and Findings: - On examination, your right knee showed mild effusion and tenderness along the medial joint line. Range of motion was limited at the extremes of flexion and extension, with crepitus noted throughout. - Ligamentous stability was good. There was mild quadriceps wasting compared to the left. Test Results: - We reviewed the X-rays taken last week, which showed moderate tricompartmental osteoarthritis in your right knee, predominantly medial, with joint space narrowing and osteophyte formation. - In simple terms, the cushioning cartilage in your knee has worn down, particularly on the inner side, leading to bone-on-bone rubbing and some bony growths, which is typical for 'wear and tear' arthritis. Diagnosis: - Right knee osteoarthritis, moderate tricompartmental, likely post-traumatic given your previous meniscal injury. Treatment Plan: - We agreed to proceed with a trial of a corticosteroid injection into your right knee to help reduce inflammation and pain. This will be arranged for you next week. - You will also be referred for physiotherapy to focus on strengthening the quadriceps and improving knee flexibility. - I advised you to continue with regular pain relief as needed and consider wearing a knee brace for support during activity. - We will arrange a follow-up appointment in approximately three months to assess your response to the injection and physiotherapy. If symptoms persist significantly, we will discuss surgical options, including total knee arthroplasty. Important Information: - It is important to continue with gentle exercises and try to maintain an active lifestyle as much as pain allows. Weight management can also significantly help reduce the load on your knee. I hope this letter provides a clear summary of our discussion today. Please do not hesitate to contact us if you have any questions or concerns before your next appointment. Yours sincerely, Dr. Evelyn Reed Consultant Orthopaedic Surgeon City General Hospital Department of Orthopaedics, Main Street, Anytown, AB1 2CD cc: Dr. Sarah Jenkins, The Family Practice, 123 High Street, Anytown, AB1 2DE