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September’s Coding Challenge
A 46-year-old male patient with osteoarthritis in his right knee comes in for a routine follow-up office visit. The patient had an intraarticular corticosteroid injection in his right knee six weeks ago with reported improvement in knee pain and stiffness. The patient reports stiffness in the knee lasting 5 to 10 minutes after long car rides and in the morning one to two times per week. He reports mild knee pain when climbing stairs. The patient has no other complaints and no comorbidities. He is currently on etodoloc and ranitidine as needed.
On examination, the patient has normal vital signs. His height is 5’10”, his weight is 190 pounds, and his body mass index is 27.3. His lungs are clear. His heart has regular rate and rhythm with no murmurs or friction rubs. His right knee has crepitus and mild tenderness on extreme of flexion, but no warmth or effusion. His left knee is unremarkable with full range of motion and no tenderness.
Diagnosis: Osteoarthritis right knee, clinically stable.
Plan: The patient is given prescriptions to continue etodolac and ranitidine. He is counseled regarding benefits of daily exercise and weight loss in management of osteoarthritis. Ways to incorporate daily physical activity into his schedule are discussed, along with recommendations to reduce fat and caloric intake. The patient is requested to return in four months for a follow-up appointment, sooner if problems arise.
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