DATE OF ADMISSION: MM/DD/YYYY
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with right much greater than left knee osteoarthritis. She was last evaluated here six months ago, and at that time, she was found to be at arthroplasty-level symptoms with her right knee. A steroid injection was performed in the right knee with good short-term benefits. She has had a return of her arthritis symptoms and continues to desire a total knee replacement.
She has a distant history of conditions both in the right and left knees since childhood, which included patellar dislocations. She never required surgery, instability symptoms resolved in her 20s. She has had symptoms of pain since that time.
The patient had a twisting injury in May last year with increased swelling, which was temporarily relieved with a steroid injection. Her contralateral left knee symptoms are described as mild. Her right knee pain is primarily lateral-sided; however, a good portion is anterior. She takes three to four Vicodin a day for her symptoms. Over the past three years, she had management with steroid injections with decreasing effectiveness.
The patient denies paresthesias. She occasionally uses a cane. Her pain is 8 to 10/10, able to walk about 15 minutes. She describes reactions to some metal jewelry.
The patient has had medical evaluation by her primary care provider as well as cardiology evaluation and has been provided medical clearance to proceed with surgery.
PAST MEDICAL HISTORY: High blood pressure, high cholesterol, and asthma.
PAST SURGICAL HISTORY: Nasal polyps.
MEDICATIONS: Advair, alprazolam, desonide, Vicodin, Nexium 40 mg daily, paroxetine 40 mg daily, pravastatin 20 mg daily, ProAir, valsartan/hydrochlorothiazide 320 mg/25 mg daily, verapamil 240 mg daily, and fexofenadine 180 mg daily.
ALLERGIES: Sulfa.
SOCIAL HISTORY: The patient lives with her significant other. She does not smoke. She drinks once a week.
PHYSICAL EXAMINATION:
VITAL SIGNS: Weight 212 pounds, height 5 feet 5 inches, blood pressure 138/78, and pulse 72.
LUNGS: Clear to auscultation bilaterally.
HEART: Regular rate and rhythm.
ABDOMEN: Soft and nontender with normal bowel sounds.
NEUROLOGIC: Cranial nerves II through XII are intact.
EXTREMITIES: Standing alignment with minimal right-sided valgus deformity, knee with slight flexion contracture. The patient walks with moderate antalgic gait. Range of motion 3 to 90 degrees. There are no surgical scars or incisions, diffuse tenderness medially and laterally, also with patellofemoral compression. Stable ligamentous exam.
NEUROVASCULAR: Exam is intact.
DIAGNOSTIC DATA: X-ray exam, bilateral knee series, demonstrates tricompartmental arthritis laterally, greater than medial. Moderate lateral subluxation of the tibia as well as lateral subluxation of the patella on the sunrise view. MRI of the right knee from last year demonstrating chronic ACL insufficiency with medial and lateral meniscal degenerative tears and tricompartmental osteoarthritis.
ASSESSMENT:
1. Right much greater than left knee osteoarthritis.
2. Sensitivity to metal.
3. Obesity.
PLAN: We previously discussed options and the patient desires to proceed with right total knee replacement. We will use the Smith & Nephew Oxinium knee to minimize reaction to metal. The risks, benefits, and alternatives were discussed, including specific risks of loosening of components requiring revision, infection, damage to neurovascular structures, DVT, pulmonary embolism, and anesthetic complications to include death. All of her questions were answered, and informed consent was obtained. The patient will proceed with right total knee arthroplasty with the Smith & Nephew Oxinium knee.
