Bilateral knee pain and some right hip and pain bilateral back pain.

The patient is a 70-year-old white female who comes in complaining of bilateral knee pain and some right hip and pain bilateral back pain. Predominantly, she would like us to address her bilateral knee pain and she was referred by a cousin of her who gets Supartz injection at this location. The patient claims that she has had knee pain for quite a long time and basically lives with it at this level 5/10. She states that her pain is made worse by walking and nothing makes it better. She had cortisone injections by Dr.to cruise and actually made her pain worse particularly in her left knee. The patient has had back surgery in 2001 and it helped for five years but now she has bilateral back pain again.

PAST SURGICAL HISTORY:
Significant for back surgery in 2001, gastric bypass in 2003, hysterectomy in 2013. The patient has had a left shoulder surgery four months ago.

CURRENT MEDICATIONS:
Plavix 75 mg, hydrochlorothiazide/metformin 25/500 two times a day, Altace 10 mg, simvastatin 20 mg, Paxil 30 mg and hydrocodone 7.5/325 mg one per day.

SOCIAL HISTORY:
The patient drinks three glasses of wine a day. She smokes tobacco. She does not use recreational drugs. She is divorced. She has three children. She has high school education and is here with her significant other, her boyfriend.
PHYSICAL EXAMINATION:
The patient is 5 feet 4 inches tall and weighs 205 pounds. She states that her pain is on her bilateral knees just predominantly stabbing. She also complains of some right hip pain. The patient has seen orthopedic surgeon because she may need a hip replacement but claims until she loses weight that she will not be a candidate for that. The patient is an obese white female pleasant, conversant, oriented x3. Her HEENT examination is completely normal. Her upper extremity exam is normal. Her heart S1, S2 normal with no S3, S4, rubs or gallops. Her lungs are clear to auscultation. On examination of her back, forward flexion is normal. Extension is limited. She has a large surgical scar in the midline of her lower back and rotation is limited and painful bilaterally. Her Patrick sign is negative bilaterally, but she does have some pain when you press on her hip, actually the left more than the right despite the fact that the surgery is on her right hip and right knee replacement. Sensory exam in the lower extremities is completely normal. Reflexes are 2+ bilaterally to patella and Achilles. Motor strength is 5/5 in the lower extremities.

RECOMMENDATIONS:
I spent quite a bit of time talking to her about her medical issues and management including the fact that she likely has osteoarthritis in her knees as well as in her hips that she likely has facet arthropathy related to her advanced age as well as having had a large surgical procedure in 2001 of her back and that we were to address her knees at the present time. The patient is going to get approval for an x-rays of her bilateral knees and if indicated get Supartz injections. Additionally in September, she would be able to start chiropractic and physical therapy after she finishes her therapy on her left shoulder that is at her request.

She had a rotator cuff repair four months ago. In the future, we will also address her lower back facet arthropathy. She may be a candidate for medial branch blocks or radiofrequency ablation of the L3, L4, and L5 dorsal ramus and medial branches.

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