A 46-year-old male with osteoarthritis of his right knee comes in for a routine follow-up visit. He received an intraarticular corticosteroid injection of his right knee six weeks ago, with reported improvement in knee pain and stiffness. During follow-up, the patient reports to the nurse that he has stiffness in the knee lasting five to 10 minutes after long car rides, as well as in the morning one to two times per week. He reports mild knee pain with climbing stairs, but has no other complaints and no co-morbidities. The patient is currently on etodoloc and ranitidine as needed.
On examination, the patient has normal vital signs, height of 5’10”, weight of 190 lbs, and a body mass index of 27.3. His lungs sound clear, and his heart has regular rate and rhythm with no murmurs or friction rubs. The abdomen is soft, nontender, and has no mass or hepatosplenomegaly. The right knee has crepitus and mild tenderness on extreme of flexion, but no warmth or effusion. The left knee is unremarkable with full range of motion and no tenderness.
Diagnosis: Osteoarthritis of the right knee, clinically stable.
Plan: The patient is given prescriptions to continue etodolac and ranitidine and is counseled regarding benefits of daily exercise and weight loss in the 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, or sooner if problems arise.
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