| { | |
| "Basic Information": [ | |
| "Age: 59 years", | |
| "Sex: Male", | |
| "Height: 181 cm", | |
| "Weight: 78.1 kg", | |
| "BMI: 23.8 (normal range)", | |
| "Occupation: Delivery driver (on feet most of the day)" | |
| ], | |
| "Chief Complaint and Present Illness": [ | |
| "Primary complaint: Right knee pain despite less severe radiographic findings", | |
| "Symptoms: Aching pain after walking, difficulty with stairs, occasional locking/catching", | |
| "Pain characteristics: Mild pain with walking and standing, moderate pain with stairs", | |
| "Functional limitations: Avoids kneeling, squatting, jumping, and pivoting" | |
| ], | |
| "Radiographic Findings": [ | |
| "Right Knee", | |
| "Overall Classification: Mild osteoarthritis", | |
| "Joint Space: Grade 0 (Normal width, no narrowing) in both compartments", | |
| "Osteophytes: Present (internal femoral, internal tibial, external tibial)", | |
| "Subchondral Cysts: None detected", | |
| "", | |
| "Left Knee", | |
| "Overall Classification: Moderate osteoarthritis", | |
| "Joint Space: Grade 2 (Moderate narrowing) in lateral compartment; Grade 0 in medial", | |
| "Osteophytes: Present (internal femoral, internal tibial)", | |
| "Subchondral Cysts: Grade 2 (Moderate) in internal femoral and tibial regions" | |
| ], | |
| "Range of Motion": [ | |
| "Right Knee: Flexion 105°, Extension lag of 6° (cannot fully extend)", | |
| "Left Knee: Normal range of motion (presumed)" | |
| ], | |
| "Muscle Strength": [ | |
| "Right Quadriceps: 4/5 (good but not normal)", | |
| "Right Hamstrings: 4/5", | |
| "Left Leg: Normal strength (5/5)" | |
| ], | |
| "Past Medical History": [ | |
| "Right knee injury 15 years ago (twisted playing soccer, never properly evaluated)", | |
| "Hypertension diagnosed 5 years ago, controlled with medication", | |
| "No previous knee surgeries" | |
| ], | |
| "Family History": [ | |
| "Father had knee problems in his 60s", | |
| "Mother has rheumatoid arthritis" | |
| ], | |
| "Current Treatment": [ | |
| "Medications", | |
| "Lisinopril 10mg daily for hypertension", | |
| "Ibuprofen 400mg PRN for knee pain (3-4 times weekly)", | |
| "No known medication allergies", | |
| "Physical Therapy", | |
| "No previous physical therapy or rehabilitation", | |
| "Self-treatment with ice for swelling", | |
| "Tried over-the-counter knee brace without significant benefit" | |
| ], | |
| "Current Psychological Status": [ | |
| "Frustrated and worried about knee condition", | |
| "Concerned about potential impact on employment", | |
| "Motivated to improve function" | |
| ], | |
| "Current Nutritional Status": [ | |
| "Generally balanced diet", | |
| "Regular consumption of desserts", | |
| "No specific dietary restrictions noted" | |
| ], | |
| "Treatment Goals": [ | |
| "Reduce pain to maintain current employment", | |
| "Improve walking comfort", | |
| "Return to light hiking activities" | |
| ], | |
| "Treatment Preferences": [ | |
| "Prefers to avoid surgery if possible", | |
| "Open to conservative approaches", | |
| "Willing to consider most non-surgical interventions" | |
| ], | |
| "Available Medical/Rehabilitation Resources": [ | |
| "Good health insurance through employer", | |
| "Coverage for specialist visits and physical therapy with small copay", | |
| "Lives near major medical center with good access to care", | |
| "Can commit to 20–30 minutes of daily home exercises", | |
| "Schedule allows for weekly therapy appointments" | |
| ], | |
| "KOOS Assessment Scores": [ | |
| "Right Knee Pain: 77.8/100", | |
| "Right Knee Symptoms: 67.9/100", | |
| "Left Knee Pain & Symptoms: 100/100", | |
| "Sport/Recreation Function: 40/100", | |
| "Quality of Life: 25/100" | |
| ] | |
| } | |