🩺 Record Detail
Patient Info
Name: Unknown
Age: Unknown
Date: 2026-08-04 22:31:13
Transcript
Clinician: 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, a 61-year-old female, presents for a follow-up on hypertension and a new complaint of right knee pain persisting for two weeks.
History Summary
The patient has a history of hypertension and is experiencing new right knee pain without any trauma. Current blood pressure is 148/92 mmHg.
Examination Findings
The knee examination reveals mild swelling and tenderness along the medial joint line. The patient has a full range of motion with no instability noted.
Impression
The patient likely has osteoarthritis of the right knee. Hypertension management requires adjustment.
Recommendations
- Increase glystenopril from 10 mg to 20 mg daily for hypertension management.
- An x-ray of the right knee has been ordered to further evaluate the knee pain.