HPI: Mrs. Mabel Johnson is a 76 y/o female who presented with bilateral knee pain
that has been increasing over the las two years. The pain it is worse when walking
for more than a block, exercising, and climbing stair
...
HPI: Mrs. Mabel Johnson is a 76 y/o female who presented with bilateral knee pain
that has been increasing over the las two years. The pain it is worse when walking
for more than a block, exercising, and climbing stairs. Patient stated that her pain
usually is 4-5 and sometimes when exacerbated can go up to 7-8 on the pain scale
of 0-10. Patient also states that the pain used to be intermittent but now is
constant. There is nothing that makes it better, but the cold weather makes the
pain worse. Patient used to take ibuprofen for pain but stopped because GI bleed.
Now takes Acetaminophen 2 tablets three times a day but it does not help. Patient
reported no injury or trauma to her knees. Denies dizziness, nausea, vomit, and
diarrhea.
Current Medications: Amlodipine 10 mg tablet once daily, Lisinopril 10 mg tablet
once daily, Simvastatin 20 mg daily, hydrochlorothiazide 25 mg tablet once daily,
Protonix 40 mg tablet once daily.
Allergies: No known allergies.
Pertinent PMHx: Patient is up to date with his childhood immunizations.
Soc Hx: Patient denies alcohol intake, denies cigarette smoking and/or tobacco
chewing. Patient Wears seat belts all the time, is not depressed.
Fam Hx: Grandparents unknown, father unknown, mother arthritis, and patient
children are in good health.
History questions asked:. List out each question you asked the patient/parent. This
is a focused exam unless a school or yearly physical.
1. How can I help you today?
2. How severe (1-10 scale) is the pain in your knee?
3. Do your knee catch, lock?
4. Is there any stiffness in your knees?
5. Did your knees give away?
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A CLAUSE IHUMAN REVIEW
6. Is there any instability in your kness?
7. Does anything make the pain in your knees better or worse?
8. Does the pain in your knees radiate someplace else? Where?
9. Have you been having fevers?
10. Any tingling or numbness in your leg?
11. Does the pain in your knee keep you from sleeping?
12. Have you fallen before?
13. Do you have arthritis?
14. Are you able to do housework?
15. Can you tell me about any current or past medical problems you have
had?
16. Have you ever been hospitalized?
17. Do you have any allergies?
18. Are you taking any over the counter or herbal medication?
19. Are you taking steroids?
20. Are you taking any prescription medication?
21. Tell me about the health of your grandparents, parents and children?
22. Do you drink alcohol? If so, how many drinks per day?
23. Do you now or have you ever smoked or chew tobacco?
24. Do you always wear seatbelt?
25. Do you have medical insurance?
26. Have you ever had trauma of your knees?
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