Office Note Sample:

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OFFICE NOTE

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

CHIEF COMPLAINT: 
Right knee pain.

The patient is a 59-year-old Caucasian female, with right knee pain and off for the last 8 years.  She states that the pain increases with activities and decreased with activities.  It decreases with rest.  She states that her pain level is 5/10. She states that she has good days and bad days.  The patient states that she has night pain.  The patient has stiffness.  The patient denies catching, popping or locking.  The patient states that she has difficulty getting out of a chair, getting out of a car, sitting, standing and walking, both on flat and incline surfaces.    She has been treated with Relafen, Celebrex and Motrin over the years with minimal effect.   Examination of the right knee demonstrates no effusion. The knee is in 10 degrees of varus.  There is medial and lateral joint line tenderness.   There is reduced painful forced flexion. Extension is full.  There is a negative Lachman test.  The patella is nontender.

X-RAY:  X-ray of the right knee done on 9-16-06 demonstrates decreased medial joint space, subchondral sclerosis and spiking of the tibial spines.  These findings are compatible with degenerative joint disease. 

IMPRESSION: 
1.   Degenerative joint disease right knee.

TREATMENT:  The knee was sterilely prepped and injected with steroid and Lidocaine preparation. She is given a prescription for physical therapy for the right knee. She will not wear any form of immobilization, since she has changes of chronic venous disease and has had a saphenous vein stripping in the past.  She will be seen again in four weeks.

ADDENDUM:

The patient was given a prescription for Relafen 750 mg, b.i.d.