Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Encounter]
Subjective:
Symptoms:
Duration and severity of knee pain (at rest, with activity, at night)
Stiffness (duration, morning stiffness)
Swelling
Crepitus (grinding sensation)
Functional limitations (difficulty with stairs, walking distance, etc.)
Prior treatments: Medications (topical, oral), injections (corticosteroid, hyaluronic acid), physical therapy, assistive devices (cane, brace)
Impact on daily life: Limitations due to pain and stiffness
Objective:
Vital Signs: (BP, HR, RR, Temp)
Physical Exam:
Gait observation (limp, antalgic gait)
Lower extremity:
Range of motion (flexion, extension)
Joint tenderness
Joint effusion (swelling)
Muscle strength (quadriceps, hamstrings)
Varus/valgus deformity (bowlegged/knock-kneed appearance)
Imaging (if available): X-ray of the knee may be obtained to assess joint space narrowing, osteophytes (bone spurs), and other degenerative changes.
Assessment:
Knee osteoarthritis (confirmed based on clinical presentation and possibly X-ray findings)
Severity of osteoarthritis (mild, moderate, severe) based on pain, functional limitations, and X-ray findings (if available)
Plan:
Non-pharmacological treatment:
Weight management: If overweight or obese, weight loss is a cornerstone of management.
Exercise: Regular physical therapy program to improve strength, flexibility, and range of motion.
Assistive devices: Consider a cane or brace to offload weight and improve stability.
Heat/ice therapy: For pain relief.
Pharmacological treatment:
Over-the-counter pain relievers: Acetaminophen or NSAIDs (nonsteroidal anti-inflammatory drugs) for pain management. Consider risks and benefits of NSAIDs with the patient.
Topical analgesics: Creams or gels for localized pain relief.
Prescription medications: Consider stronger pain medications or topical capsaicin cream if over-the-counter options are not effective.
Joint injections: Corticosteroid injections for short-term pain relief, or hyaluronic acid injections for lubrication in some cases.
Education: Educate the patient on osteoarthritis, risk factors, and self-management strategies.
Referral (if indicated): Consider referral to a physical therapist for a personalized exercise program or to an orthopedic surgeon if conservative management fails or for evaluation of potential surgical intervention (joint replacement) for severe cases.
Follow-up:
Schedule next appointment in [interval] to monitor response to treatment, adjust plan as needed, and address any concerns.