A 46-year-old male with osteoarthritis of his right knee came in for a routine follow-up visit. The patient had intra-articular corticosteroid injection of his right knee six weeks ago, with reported improvement in knee pain and stiffness. The patient reports stiffness in the knee that lasts five to 10 minutes after long car rides and in the morning. This stiffness occurs once or twice a week. He also reports mild knee pain when climbing stairs. The patient has no other complaints or comorbidities. He is currently on etodolac and ranitidine as needed.
On examination, the patient had normal vital signs; height 5’10”, weight 190 pounds, body mass index 27.3. His lungs were clear. The heart’s regular rate and rhythm had no murmurs or friction rubs. The abdomen was soft, not tender, with no mass or hepatosplenomegaly. The right knee was crepitus and had mild knee tenderness on extreme of flexion, but no warmth or effusion. The left knee was unremarkable with full range of motion and no tenderness.
The diagnosis is clinically stable osteoarthritis of the right knee.
As treatment, the patient was given prescriptions to continue etodolac and ranitidine. He was counseled regarding benefits of daily exercise and weight loss in management of the osteoarthritis. Ways to incorporate daily physical activity into his schedule and recommendations on how to reduce fat and caloric intake were also discussed. The patient was asked to return in four months for a follow-up appointment, sooner if problems arise.
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