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diagnosed right knee arthritis.

/in /by

NR601 W5 Case Study

1

Apr 19 CCK, CU 041419MT

Mrs. Wong, a 59-year-old Asian female, presents to the office for a planned 3 month follow up

visit for her recently diagnosed right knee arthritis. She is experiencing less knee pain and

increased mobility with the treatment plan but reports some new concerns today. She reports that

she has been experiencing increasing fatigue for about the last 2 months. She is also gaining

weight since menopause 4 years ago. She has a health club membership and attends twice a

week. She walks on the treadmill at least 30 minutes as you directed and lifts light weights but

she has not lost any weight, in fact she has gained 4 pounds. She doesn’t understand what she is

doing wrong. She reports that exercise seems to make her even more hungry and thirsty, which is

not helping her weight loss. She requests evaluation as to why she is so tired and get some

weight loss advice.

Current medications: Tylenol 500 mg 2 tabs in AM for knee pain. Daily multivitamin and

turmeric. USES CBD oil for her knee, find it helps.

PMH: Has right knee arthritis diagnosed 3 months ago. Had German measles as a child.

Vaccinations up to date. Colonoscopy WNL 4 years- repeat in 10 years

GYN hx: G1 P1: daughter delivered@37 weeks, wt 8lbs 15oz. LMP 4 years ago. ASCUS pap

1998, all further paps WNL. Mammogram last year BI-RADS 1.

FH: parents deceased, child alive, well. No siblings.

SH: Divorced. works from home as an administrative assistant., 1-2 glasses wine one or two

times a week. Former smoker, quit 12 years ago.

Allergies: allergic to Bactrim, cats and pollen. No latex allergy

Vital signs: BP 112/76; pulse 80, regular; respiration 16, regular

Height 5’1.5”, weight 165 pounds

General: female in no acute distress. Alert, oriented and cooperative.

Skin: warm dry and intact. No lesions noted.

HEENT:. Eyes without exudate, sclera white. Wears contacts. Tympanic membranes gray and

intact with light reflex noted. Pinna and tragus nontender. Nares patent without exudate.

Oropharynx moist without erythema. Teeth in good repair, no cavities noted. Neck supple.

Anterior and posterior cervical lymph nontender to palpation. No lymphadenopathy. Thyroid

midline, small and firm without palpable masses.

CV: S1 and S2 RRR without murmurs or rubs.

Lungs: Clear to auscultation bilaterally, respirations unlabored.

Abdomen- soft, round, nontender with positive bowel sounds present; no organomegaly; no

abdominal bruits. No CVAT.

Musculoskeletal: full ROM both knees. Nontender to palpation bilaterally. Gait normal.

NR601 W5 Case Study

2

Apr 19 CCK, CU 041419MT

GU: bladder nontender upon palpation

Labwork: (fasting labs drawn this morning)

CBC: UA:

WBC 6,300/mm3 pH 5

Hgb 12.8 gm/dl SpGr 1.010

Hct 42% Leukocyte

esterase

negative

RBC 4.6 million nitrites negative

MCV 93 fl Glucose 1+

MCHC 34 g/dl Protein negative

RDW 13.8% ketones negative

CMP:

Sodium 136 Hemoglobin

A1C

6.6%

Potassium 4.4

Chloride 100 TSH 2.31

CO2 29 Free T 4 0.9 ng/dL

Glucose 127
Cholesterol:

BUN 12

Creatinine 0.7 TC 215 mg/dl

GFR est non-

AA

99

mL/min/1.73

LDL 144 mg/dl

GFR est AA 101

mL/min/1.73

VLDL 36 mg/dl

Calcium 9.4 HDL 32mg/dl

Total protein 7.6 Triglycerides 229

Bilirubin, total 0.5 EKG:

Alkaline

phosphatase

72

normal sinus rhythm

AST 25

ALT 29

Anion gap 8.10

Bun/Creat 17.7

 

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