First Name: ANTHONY

Middle Name:
Last Name:
D.O.S.: 04/21/2015
D.O.B.:
PT Number: 133887
Report Type: Initial Visit
Insurance:
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HISTORY OF PRESENT ILLNESS: Anthony is a 70-year-old patient

known to this practice who presents today with complaints of left
knee pain. He reports it has been troubling him for a couple of
weeks, although he is feeling better over the last couple of
days. The intensity of the pain is not as severe. He reports
that there was no particular event. He reports that he did some
swelling and tenderness and he was limping initially. He has
been using over-the-counter medications and ointments. He
reports that he is going to be starting his golfing season and
wants to make sure it is okay for him to begin the physical
activity.

MEDICAL HISTORY: None.

SURGICAL HISTORY: Fatty tissue removed in 2004 and 2005.

MEDICATIONS: Vytorin, lisinopril, fish oil, glucosamine and

chondroitin ______01:00_______.

ALLERGIES: None.

SOCIAL HISTORY: He is married. He has one adult child. He

enjoys golf. He reports three alcoholic beverages per week, no
street drug. He is a former smoker.

FAMILY HISTORY: Significant for cancer.

WORK HISTORY: He is retired.

REVIEW OF SYSTEMS: Unremarkable other than musculoskeletal as in

HPI.

EXAMINATION: Anthony is a well-appearing 70-year-old. He is

ambulating normally. The knee itself shows no appreciable
effusion. He does have some medial compartment tenderness, but
there is no joint line tenderness. He is able to fully flex and
extend the knee. He does have meniscal signs and neurovascularly
he is intact.

IMPRESSION: Three-week history of left knee pain with almost

complete resolution of his symptoms. He was instructed at this
time since his symptoms are getting better, we can continue to
monitor and he can resume his activity as tolerated. Should he
have repeat event of swelling and pain and difficulty with
weightbearing, he should notify the office or sooner.
Prescription for physical therapy was given with the focus on
home exercise program. He will follow up in four weeks or sooner
should the need arise.

Jeanette Schultz, APRN

for William F. Flynn, Jr., M.D.
JS: mub/atf

cc: ________00:13__________

D: 04/21/2015 T: 04/22/2015