The patient presents today for her first follow-up visit with me here. I consulted with her back on April 15, 2013 for her bilateral knee pain as well as her coexisting complaints of low back pain with lumbar radicular pain.
We had referred her out for plain x-rays of the bilateral knees as well as obtained MRIs of her cervical and lumbar spine. She comes in today for review and request that we treat her for her severe left knee pain.
1. Left knee pain; x-ray confirmed tricompartmental degenerative changes severe in the lateral tibial femoral compartment with medial meniscal chondrocalcinosis.
2. Right knee pain; status post total right knee arthroplasty with a fragmented and displaced fragment of screw in the Hoffa’s fat pad.
3. Multilevel lumbar spondylosis, spondylolisthesis, and central foraminal stenosis.
4. Cervicalgia with cervical radicular pain; multilevel spondylosis and stenosis.
I spend a great deal of time with Ms. today reviewing all of her imaging studies. How severe the issues are with her knees, I would like her to follow up with her orthopedic surgeon, if he is still in practice. Otherwise, I do recommend that she consult with an orthopedic surgeon. I have recommended an unloading brace for her left knee and she would like to move forward with viscosupplementation injection today.