OFFICE-NEW PATIENT
SEX: M AGE: 71
DOS: 1/1/20XX
MD: Dr. Brandon Andrews
CHIEF COMPLAINT: Right knee pain.
HISTORY: The patient is a male with a history of an anterior cruciate ligament tear and MCL tear with subsequent reconstruction. The patient has done very well. His injury and surgery was in 20XX. Over the last year or so he reports progressive knee pain and symptoms. For the last six months it has been rather significant. He complains of pain through the medial compartment, crepitation but no frank locking. It is affecting his ability to exercise. He recently saw Dr. Scott Jones who ordered a CAT scan and was concerned about a meniscus tear. He ordered a CAT scan due to metal interference screws.
PAST MEDICAL HISTORY: Denies.
PAST SURGICAL HISTORY: Appendectomy and ACL reconstruction.
MEDICATIONS: Multivitamins.
ALLERGIES: Penicillin.
SOCIAL HISTORY: Negative tobacco. Occasional alcohol.
REVIEW OF SYSTEMS: Negative other than the musculoskeletal knee pain.
PHYSICAL EXAMINATION: On exam, the right knee has surgical scars and a mild joint effusion. There is moderate tenderness through the medial femoral condyle and joint line. There is slight crepitation with full range of motion of the ACL and PCL. Collateral instability is completely intact.
IMAGING STUDIES: X-rays brought in by the patient and the CT scan were reviewed. They show metal interference screws and a well maintained joint space. His CT scan shows no evidence of a meniscus tear. There is mild osteoarthritis of the patellofemoral and medial compartment.
DIAGNOSIS: Chondromalacia of patella and early Osteoarthritis, right knee, following ACL reconstruction.
TREATMENT: I discussed the situation at length with the patient. This is a common scenario and the natural history of the knee following ACL tear and ACL reconstruction. He most likely is having symptoms from cartilage deterioration. Whether it is a focal defect or a diffuse thinning, I am uncertain. An MRI scan would be a better test to determine this, even with the metal screws present. I discussed nonsurgical management and I have recommended that he consider a series of hyaluronic acid injections. He does have arthritis based on physical examination, his subjective complaints and objective findings on CT scan. After verbal informed consent, the right knee was injected with the first syringe of Hyalgan 1 dose under sterile technique using ultrasound guidance. He tolerated the injection well. He will return in a week for a second injection. If this fails to improve his symptoms, I would recommend either an MRI with or without intra-articular gadolinium or a diagnostic arthroscopy. There is a small chance he has a focal contained defect and would benefit from a marrow stimulating technique i.e. microfracture in the future.
Brandon Andrews, MD
Electronically signed by BRANDON ANDREWS, MD 1/1/20XX
