Follow Up Report Sample:

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RE:   David Jones
DATE 12/01/10
MR:  240804
DOB: 12/01/65

Mr. Leed comes in for follow up of his lupus.  He is tolerating the Plaquenil without any difficulties.  He had a right knee arthroscopy done and repair of a meniscal tear.  He also underwent viscosupplementation, but he is not sure it made much of a difference.  His left knee is bothering him and he was told that he needs viscosupplementation there, so he is going to be going back next week for that.  He complains of cramping in his right > left hamstring and calf muscles.  The Voltaren 75 mg b.i.d. has not helped at all.  He complains of pain with weightbearing and has had swelling of his right knee without warmth.

PE:  Weight: 244 lbs.  BP: 144/88.  Pulse: 60.  R: 20.  Pleasant gentleman in moderate discomfort due to right knee pain.  No inflammatory rashes or nodules.  No Raynaud's or digital ulcerations.  EOMI, pupils reactive.  Mucous membranes normal.  Neck:  Supple.  Lungs:  Clear.  Heart:  Regular.  Abdomen:  Soft and nontender.  No C/C/E.  Cardiopulmonary and abdominal exams are benign.  Muscle bulk and strength, touch sensation, and gait are normal.  No actively inflamed peripheral joints.  No spinous process tenderness.  He has moderate degenerative changes of his hands.  No actively inflamed peripheral joints.  He has a moderate effusion of the right knee with a small Baker's cyst and moderate right and mild left calf tenderness.  Right knee lacks a few degrees of extension.  Both hips have good mobility.

1.   FM.
2.   OP (DEXA 03/10).
3.   Bilateral shoulder impingement syndrome.

1.   At the patient’s request, after sterile prep, the right knee was aspirated of 46 cc of class I yellow fluid.  Synovial fluid analysis is pending.  Using ultrasound for guidance the right knee was then injected with 40 mg of Kenalog and 2 cc of 1% lidocaine.

2.   Discontinue Voltaren; if he has enough discomfort of his knees he will try Daypro 1,200 mg p.o. q.d. with food.
3.   Plaquenil 400 mg p.o. q.d.  He has an appointment to see the eye doctor in another few weeks and if his ocular changes persist we will decrease to 200 mg a day.
4.   Follow up in 4-6 months, sooner p.r.n.