AI Scribe for Orthopedic Surgeons

CHIEF COMPLAINT:
65-year-old female, right knee pain, evaluation for total knee arthroplasty.

HPI:
Right knee pain x 4 years, progressive. Started medial, now diffuse with mechanical symptoms (catching with stair descent). Pain 7/10 at rest, 9/10 with stairs. Morning stiffness ~20 minutes. Failed conservative management:
- NSAIDs (meloxicam 15 mg daily) x 18 months — partial relief, GI upset
- Physical therapy x 12 visits over 4 months — no durable benefit
- Three intra-articular corticosteroid injections (most recent triamcinolone 40 mg, 4 months ago) — relief lasted ~6 weeks each
- One hyaluronic acid series (Synvisc-One) — no relief
Walks with antalgic gait, uses cane in left hand. Limited to 1 block before pain stops her. Sleep disturbed 3–4 nights/week from pain.

PMH: HTN (lisinopril 20 mg), hyperlipidemia (atorvastatin 20 mg), DM2 well controlled (A1c 6.7, on metformin 1000 BID), BMI 31.4
PSH: Right knee scope 2014 (medial meniscectomy)
Allergies: NKDA
Social: Non-smoker, retired teacher, lives with husband, 2-story home

EXAMINATION OF RIGHT KNEE:
Inspection: Mild varus alignment ~5°, small effusion, well-healed scope portals
Palpation: Tender medial joint line, no patellar grind tenderness
Range of Motion: 5–105° (vs left 0–135°)
Strength: Quad 4/5, hamstring 5/5
Stability: Stable to varus/valgus stress at 0° and 30°. Lachman negative. McMurray negative (consistent with end-stage OA, not new tear).
Special: Mild quad lag. Patellar tracking acceptable.
Gait: Antalgic with right-sided shortened stance phase.

IMAGING:
Standing AP, lateral, and Merchant view right knee (today, ortho clinic):
- Severe medial compartment joint space narrowing, bone-on-bone with subchondral sclerosis and osteophytes
- Mild lateral compartment narrowing
- Patellofemoral OA, Iwano grade 2
- Mechanical alignment: 5° varus, no significant deformity
- No fracture, no loose body

ASSESSMENT:
1. Severe right knee tricompartmental osteoarthritis, primarily medial — M17.11
2. Failed conservative management (NSAIDs, PT, three injections, HA) — appropriate surgical candidate per CMS criteria
3. Comorbidities controlled, BMI 31 (acceptable for primary TKA), ASA class II
4. Patient highly motivated, realistic expectations after counseling

PLAN:
1. Right total knee arthroplasty (CPT 27447) scheduled for 2026-06-15.
2. Implant plan: posterior-stabilized cemented TKA, surgeon's preferred system. Expect medial release, possible posterior osteophyte clearance.
3. Pre-op clearance: medical clearance with PCP, EKG, CBC, CMP, type and screen, urinalysis. A1c trending — recheck within 30 days, target <7.5.
4. Anticoagulation plan: aspirin 81 mg BID x 35 days post-op (low VTE risk profile).
5. Pre-op pain plan reviewed: acetaminophen 1 g Q8H scheduled, meloxicam 15 mg daily, gabapentin 300 mg TID starting day of surgery, oxycodone 5 mg Q6H PRN with strict 3-day taper goal.
6. Pre-op antibiotics: cefazolin 2 g IV within 60 min of incision.
7. Risks discussed in detail: bleeding, infection (~1%), VTE, stiffness requiring MUA, periprosthetic fracture, neurovascular injury, persistent pain, revision. Patient consented.
8. Optimization: continue metformin to day before surgery, hold the day of surgery; lisinopril hold morning of surgery; weight-bearing PT clearance noted; pre-hab PT starts in 2 weeks.
9. Follow-up: 2-week post-op for staple removal and wound check, 6-week for ROM benchmark (target 0–110°), 3-month, 1-year.
10. Diagnoses for billing: M17.11 (primary, right). E&M: 99214 (established, moderate complexity, prolonged decision-making and counseling documented).