Knee Osteoarthritis follow-up
Age: years old
Gender:
HISTORY:
Returns for a follow-up
Last visit was ago
Progress since last visit:
Updates on symptoms:
Physical activity changes: ,
Medication tried: , , , , , ,
Injections: , , ,
Physical therapy: ,
Dietary changes: ,
Supportive devices used:
X-ray:
EXAM:
Knee:
Inspection:
Palpation: on
Range of motion:
- Flexion:
- Extension:
Strength: , except on
Neurovascular: , distal pulses , cap refill sec, sensation
Special tests:
- Patellar tap:
- Bulge test:
- Lachman test:
- Anterior drawer test:
- Posterior drawer test:
- Valgus stress test:
- Varus stress test:
- McMurray test:
- Thessaly test:
- Patellar apprehension test:
- Pivot shift test:
- Patellar grind test:
- Apley test:
Gait: ,
ASSESSMENT:
,
DDx: osteoarthritis, post-traumatic osteoarthritis, rheumatoid arthritis, gout, pseudo-gout, septic arthritis, patellofemoral pain syndrome, bursitis, tendinitis, meniscal tear, ligament injury, bone contusion, IT band syndrome
PLAN:
Investigations:
- Knee X-ray
Treatments:
-
-
- Physical therapy
- Physiotherapy exercises
- Steroid injection
- Hyaluronic acid injection
- Knee brace
- Assistive devices: ,
- Weight loss counseling
Further care:
- Referral to orthopedic surgeon
- Follow-up in months
- Return if pain worsens or new symptoms develop
HISTORY: EXAM: Knee: ASSESSMENT: PLAN: