Case # 1
SUBJECTIVE: **** is here today for evaluation of her left knee. *** has had left knee pain ever since mid-December. Prior to that she did not have any significant pain or problems and was able to ambulate without much difficulty. Now she has snapping, popping and significant pain to the lateral and posterolateral aspects of the knee, near locking episodes and the knee is unsteady for her although there is no gross instability complaints.
PLAN: At this time she does have some early degenerative changes as well as a lateral meniscal tear. However, I think she has lived with the degenerative changes for quite some time and the new onset of the lateral meniscal tear is quite symptomatic. Therefore, we have talked with her about treatment options. We have gone over the risks, complications, as well as benefits and expectations of surgery, postop protocol and follow-up. We will get this set up as soon as possible. Will get her medically cleared and I’ll see her back at the time of surgery. Until then, she will continue with ice, elevation, modification of activities, etc.