Surgery improved functioning initially but trauma induced arthritis has progressed to the point patient can no longer walk more than a few feet with assistive devices. Both knees crushed in a car accident in 2009. Patient brought to exam in a wheelchair by daughter. Significant limits on basic work-related activities. States Orthopedist recommended another surgery. Knee exam significant for swelling, visible scars from prior surgery, lateral laxity, and significantly reduced ROM. Unable to get off exam table without assistance. Patient ambulates with cane prescribed by PCP prior to losing medical insurance. Recommend follow up treatment with Ortho. Limp observed, knee appears swollen, ROM achieved with audible clicking noise from joint. Has decreased physical activity over the last few months with no relief. Patient complains of chronic knee pain aggravated by climbing stairs, kneeling, walking. No significant effect on basic work-related activities. Patient complains of recurrent knee pain aggravated by running, persistent kneeling, or other prolonged physical activity. No effect on basic work-related activities. Patient complains of transient knee pain, negative for impact on ADLs, negative for redness, swelling, or signs of deformity.
Note that radiological findings are not requested or necessary in the scenarios describe below. The following tables contain examples of phrases found in chart notes and the corresponding rating:īob applies for ABD cash and states knee pain is keeping him from working.
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