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
... [Show More] 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 and toes?
- Do you experience: SOB, wheezing, difficulty catching breath, chronic cough, sputum production?
- Do you have problems with: N/V, constipation, diarrhea, coffee grounds in your vomit, dark tarry stool, bright red blood in your BM, early satiety, bloating?
- Do you have any of the following: dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, tremor?
- Do you have problems with: headaches that don’t go away with ASA or Tylenol, double or blurred vision, difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats, difficulty swallowing?
- Have you noticed: any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding?
- Do you have any of the following: heat or cold intolerance, increased thirst, increased sweating, frequent urination, change in appetite?
- When you urinate, have you noticed: pain, burning, blood, difficulty starting or stopping, dribbling, incontinence, urgency during day or night or any changes in frequency?
- Have you noticed any breast: discharge, lumps, scaly nipples, pain, swelling, or redness?
- Do you have any problems with: itchy scalp, skin changes, moles, thinning hair, brittle nails?
- Do you have any problems with: nervousness, depression, lack of interest, sadness, memory loss, or mood changes, or ever heard voices or see things that you know are not there?
Not asked:
- Have you been taking your medications as prescribed?
- Where more precisely is the pain in your knees? [Show Less]