Left medial knee pain

The patient is a very pleasant 52-year-old kitchen worker and corrections officer. He is 5 feet 8 inches and 325 pounds. Approximately one-month ago, when pulling up his left leg to put on his sock, he felt pain in his left medial knee. It has remained tender and sore up until approximately a week ago when it progressively worsened to early morning stiffness, which eventually loosens up as the day goes on. The pain is specifically over the medial aspect of the knee joint itself and he has not noticed any specific swelling or change in function except for the discomfort. He presents today for evaluation.

ASSESSMENT:
This is a very pleasant 52-year-old 5 feet 8 inches 325 pounds non-insulin dependent diabetic with one-month history of left medial knee pain of unknown etiology.

IMPRESSION:
1. Left medial knee pain; query medial compartment osteoarthritis versus medial collateral ligament strain versus other pathology.
2. Morbid obesity.
3. Non-insulin dependent diabetes.

PLAN:
I had a nice consultation with him today and we discussed this case in detail. At this time, I would like to obtain standing x-rays of his bilateral knees and I will start him on Celebrex 200 mg q.a.m. I would like to fit him for an unloader knee brace at this time and I would like him to follow up in the next two weeks after he has had his x-rays with any provider here at the office. At that time, a decision can be made whether or not we can move forward with his candidacy for our knee program. This would entail regimented viscosupplementation injections combined with physical rehabilitation modalities. I do not want to look forward with any type of therapeutic modalities at this time until we have at least plain film of the bilateral knee joints.

She is in agreement with this plan and understands the rationale for the decision making. I will see him back in follow-up here in the office in the next two to four weeks or sooner if needed. They understand to call with any questions or concerns regarding this treatment.

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