Bilateral knee pain

The patient is a very pleasant 75-year-old female, who presents with her daughter today for evaluation of her bilateral knee pain for consideration of moving forward with viscosupplementation injections. She had a history of a right total knee replacement with Dr. in 1995. She was last seen by Dr. approximately two years ago. She states that she has been diagnosed with “peripheral neuropathy”. She does have non-insulin dependent diabetes. She states that the right knee replacement helped for some time, but that on plain x-rays taken at office sometime after the total knee replacement, there was some type of “abnormality” with a screw. She states that there was concern as to what this may be and she is worried that this may have become dislodged. It ultimately resolved.

She states her left knee is actually worse than her right. She complains of constant sharp pain in the front and back of the knee joint. She has severe difficulty when walking and has been relegated to the use of a scooter to get around, especially in social situations and when trying to shop.

She has been treated by Dr. in the past for neck and low back issues. She has imaging study reports in the last 10 years to view today. She presents today for evaluation.

ASSESSMENT:
This is a 75-year-old, 5 feet 9 inches and 240 pound non-insulin dependent diabetic with the aforementioned imaging studies. She comes in today for assessment of her candidacy for viscosupplementation injections combined with physical rehabilitation for her knee pain. She is status post right total knee replacement in mid 1990s with Dr.

IMPRESSION:
1. Right knee pain; the patient is status post right knee replacement by approximately 17 years-most likely will need to be reassessed for replacement.
2. Left knee pain; most likely degenerative osteoarthropathy; no recent imaging.
3. Osteopenia.
4. Low back pain with suspected lumbar radicular pain; please see MRI as above.
5. Cervical spondylolysis with suspected cervical radicular pain.

PLAN:
I had a lengthy visit with the patient and her daughter today. I told her that we can very easily move forward with viscosupplementation injections of the left knee as a regimented course of physical therapy. However, I do not think this is in her best interest. Taking into account her severe deconditioning, obesity, and the degenerative nature of her disease, I feel it is more prudent to obtain appropriate imaging of the knees and we will order plain x-rays of her knees. Additionally, she does have pain in the L4 dermatomal distribution bilaterally, and combined with her prior extensive degenerative spondylosis noted, I would like to obtain an MRI of her lumbar spine as well. Also, she continues to have pain throughout the right neck and arm and we will therefore move forward with MRI of her cervical spine.

After we obtain these imaging studies, I would like to see her back in follow-up next month so we can decide if she is an appropriate candidate for a rehabilitation course or if it may be more prudent for surgical referral. Her daughter spoke about getting her a consultation at the Hospital for Special Surgery while the patient did speak about re-consulting with Dr. I think it will be a good idea for her to consult with both physicians so that she can make an appropriate educated choice.

The patient and her daughter were happy with their consultation today and we will move forward to obtain imaging studies and following up with me next month. If the patient requests, we will give her a prescription for Valium for her MRIs.

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