🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2026-08-04 22:25:09
Transcript
Doctor: Patient is a 61-year-old female presenting with hypertension, follow-up and new complaint of right knee pain for two weeks, no trauma. Blood pressure today 148 by 92, above full. Increasing glystenopril from 10 mg to 20 mg daily. Knee exam shows mild swelling, tenderness along the medial joint line, full range of motion, no instability, likely osteoarthritis, ordered x-ray of right knee, this was a level 4 established patient visit, more direct complexity, addressing two problems approximately 30 minutes.
Clinical Notes
Clinical Note
Reason for Consultation
The patient is a 61-year-old female presenting for a follow-up on hypertension and a new complaint of right knee pain for two weeks.
History Summary
The patient reports experiencing right knee pain for the past two weeks without any history of trauma. She has a history of hypertension.
Examination Findings
Blood pressure is recorded at 148/92 mmHg. The knee examination reveals mild swelling and tenderness along the medial joint line. The patient has a full range of motion in the knee with no instability noted.
Impression
- Hypertension - Blood pressure is above the target range.
- Right knee pain, likely osteoarthritis.
Recommendations
- Increase glystenopril from 10 mg to 20 mg daily for hypertension management.
- Ordered an x-ray of the right knee to further evaluate the cause of pain.
- Follow-up visit to assess the effectiveness of the increased medication dosage and review x-ray results.