Note Report Sample:

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

The patient presents complaining of bilateral knee pain. She is known to have degenerative disc disease with osteoarthritis of the knees. 

On examination, both knees are tender, minimally swollen and warm.  Straight leg raising test is negative.  The sensory examination of the back is unremarkable and the back is nontender.

Under ultrasound guidance I did first the right and then the left knee injections, each with 20 mg of Kenalog and a cc of lidocaine.  A total of 40 mg of Kenalog were used and two ultrasonographic images were recorded of each procedure.

DIAGNOSIS:  Osteoarthritis of the knees, synovitis, and degenerative disc disease of the back.  Routine visit.