Sample 1

HISTORY OF PRESENT ILLNESS: Xxxxx returns for repeat examination of the knee.
He has been treated for underlying medial and lateral meniscal tears with underlying
osteoarthritis. He actually had been doing well for quite some time but unfortunately he
has been noticing increasing soreness and discomfort about both the medial and lateral
aspects of the knees. He has had a couple of occasions of the knee buckling and actually
fell even once. At this point he would like to proceed with surgery. Recall the initial
injury to the knee while putting an extension ladder away when he treated it awkwardly
and felt a popping sensation.
PAST MEDICAL HISTORY: Hypertension and diabetes.
PAST SURGICAL HISTORY: Left knee surgery in the past.
CURRENT MEDICATIONS: Glyburide, insulin, Norvasc, lisinopril and
ALLERGIES: No known drug allergies.
SOCIAL HISTORY: The patient denies tobacco use and has two drinks per week.
WORK HISTORY: He is currently retired.
REVIEW OF SYSTEMS: Six-point review of systems negative.
PHYSICAL EXAMINATION: Repeat examination of the knee shows trace effusion
present. He has maintained near full extension, forward flexion to 125 degrees with a fair
amount of discomfort on extremes of flexion. He has marked tenderness about the medial
joint line with mild tenderness laterally. No focal neurologic deficits with no significant
ligamentous laxity.
1. Plain x-rays show no significant degenerative changes.
2. MRI of the knee consistent with complex tear about the posterior horn of the medial
meniscus as well as the anterior horn lateral meniscus.
IMPRESSION: Right knee medial and lateral meniscal tears symptomatic.
1. I discussed the treatment options available to Mr. Xxxxx. At this point given that the
persistent symptoms have not responded to nonoperative treatment he has elected to
proceed with surgery.
2. Xxxxx is a candidate for right knee arthroscopy with posterior medial and lateral
meniscectomies with generalized debridement. The risks and benefits of the procedure
discussed with the patient who understands and wishes to proceed at this time.
3. The patient had previously been provided with some literature on arthroscopy to read.
In addition, given the fact that he does have some degenerative changes, I informed
Xxxxx that he probably will have some residual symptoms, which he understands, even
after surgery.