Right knee osteoarthritis, injection

Clinical note

Right knee osteoarthritis, injection

CC: Right knee pain, established patient.
HPI: 67 y/o with known osteoarthritis of the right knee, worse over 6 weeks, pain with stairs, no locking, no trauma. Tried acetaminophen with partial relief. Also here for hypertension follow-up, BP log at home 128-138 systolic, tolerating amlodipine.
Exam: Right knee mild effusion, crepitus, ROM 0-120, stable ligaments. BP 136/84.
Procedure: After verbal consent, sterile prep, 40 mg triamcinolone with 4 mL lidocaine injected into the right knee via anterolateral approach. Tolerated well.
A/P: 1. Osteoarthritis of the right knee, injected today, PT referral. 2. Hypertension, continue amlodipine, recheck 3 months.
MDM: low. Separately identifiable E/M for the hypertension management.