Mabel Johnson

83 y/o obese woman with CC of knee pain

Key findings:

- Chronic progressive knee pain, R > L - MSAP

- Morning stiffness of joints (knees and hands) for < 1 hour exacerbated by cold – related

- Right knee effusion (small) – related

- Moderate pain and swelling of the fingers – related

- Impaired activity of daily living and ambulation – related

- Obese – related

- Right side limp; bow-legged – related

- Lower extremity weakness – related

- Hypertensive rentinopathy – unrelated

- Hypertension: not controlled on current medications – unrelated

- PMH: PUD – resolved/PMH

Asked:

- How can I help you today?

- Any other symptoms or concerns we should discuss?

- Where more precisely is the swelling?

- Does anything make your swelling problem better or worse?

- When did the pain in your knees start?

- Does anything make the pain in your knees better or worse?

- Does the pain in your knees radiate someplace else? Where?

- What does the pain in your knees feel like?

- Do you have any allergies?

- Any new medical issues or diagnoses since your last visit?

- Are you taking any OTC or herbal medication?

- Is there a pattern to the pain in your knees?

- Do you have any of the following problems: fatigue, difficulty sleeping, unintentional

weight loss or gain, fevers, night sweats?

- Do you experience: chest pain discomfort or pressure; pain/pressure/dizziness with

exertion or getting angry; palpitations; decreased exercise tolerance; blue/cold fingers