Telehealth (Phone) Psychiatric

Subjective:
Chief Complaint:
Persistent knee pain and limited mobility following ACL reconstruction surgery.

History of Present Illness:
- Symptom Update: The patient reports ongoing discomfort and limited mobility following her knee surgery nine months ago. She continues to experience significant pain, particularly in the mornings, requiring the use of a crutch to move short distances. She expresses frustration with the lack of communication regarding her MRI results, which were conducted three to four weeks ago but have not yet been discussed by her surgeon. She is also disappointed to learn that her surgeon is leaving the practice and is uncertain about the transition to a new provider.
- Onset: Symptoms have persisted since her initial surgery nine months ago.
- Progression: The patient reports no significant improvement in her symptoms and describes her knee as feeling "full of concrete." She is concerned about the visible gap in her tendon and the potential need for further surgical intervention.
- Frequency: Pain and discomfort are described as daily occurrences, with mornings being particularly challenging.
- Modifying Factors: She has been engaging in physical therapy, acupuncture, and plans to begin chiropractic care, including active-release therapy and laser treatment for inflammation. She avoids NSAIDs due to a severe allergy and relies on Tylenol and ice for pain management.
- Associated Symptoms: Persistent pain, limited mobility, and visible tendon gap.
- Impact on Daily Life: The patient reports difficulty performing daily activities, such as walking short distances in her home. She has also experienced work-related stress, which she attributes to her physical limitations and perceived lack of recognition for her efforts.
- Medication Adherence: The patient adheres to her current pain management regimen, which includes Tylenol and ice, but expresses frustration with the limited options available due to her NSAID allergy.

Past Medical History:
The patient has undergone knee-related surgeries, including an anterior cruciate ligament (ACL) reconstruction using her own knee tendon. She reports persistent discomfort and limited mobility nine months post-surgery. She has no prior history of surgeries or being cut open before these recent procedures.

Social History:
The patient resides in a home environment and works from home. She engages in light physical activities, such as digging grass out of her roses, while ensuring she remains seated to avoid standing for prolonged periods. She has a supportive partner who assisted her in rebuilding a fence in her backyard. She also mentions her partner is making progress with his own therapist.

The Review of Systems:
The patient reports persistent knee pain and discomfort, particularly in the mornings, requiring the use of a crutch for mobility. She experiences significant scar tissue formation and a visible gap in the tendon used for the ACL graft. She denies any refusal to engage in physical therapy or alternative treatments such as acupuncture and chiropractic care.

Allergies:
The patient has a severe allergy to nonsteroidal anti-inflammatory drugs (NSAIDs), which precludes their use for pain management.

Current Medications:
The patient is currently using Tylenol as needed for pain management and applying ice to reduce inflammation. She does not use any other medications at this time.

Past Surgical History:
The patient underwent knee surgery nine months ago, during which her own knee tendon was used to create an ACL graft. She has not had any prior surgeries before this procedure.

Problem:
The primary issue is persistent pain and limited mobility following knee surgery nine months ago. The patient is also experiencing frustration with the lack of communication regarding her MRI results and concerns about the potential need for additional surgical intervention.

Substance Use History:
The patient denies any indication of substance use.

Objective:
Mental Health Examination:
- Appearance and Behavior: The patient appears engaged and communicative during the session.
- Speech: Normal rate, volume, and articulation.
- Mood: The patient reports feeling irritable and frustrated due to her ongoing physical challenges and work-related stress.
- Affect: Congruent with mood, displaying frustration and concern.
- Thought: Logical, coherent, and goal-directed. No evidence of delusions, obsessions, paranoia, suicidal ideation, or homicidal ideation.
- Perception: The patient denies experiencing hallucinations.
- Cognitive Functioning:
    - Orientation: Fully oriented to time, place, person, and situation.
    - Attention and Concentration: Adequate; the patient follows the conversation well.
    - Memory: Intact short-term and long-term memory.
- Insight: Good; the patient recognizes the impact of her physical condition on her mental health.

Test Results:
The patient underwent an MRI approximately three to four weeks ago, but the results have not yet been discussed with her.

Mental Status Examination:
The patient is alert and oriented, with a neat appearance and cooperative demeanor. Her speech is normal in rate and tone. She exhibits irritability, which is attributed to her ongoing pain and stress. Her thought processes are logical and coherent, with no evidence of psychosis or significant mood instability. Insight and judgment appear intact.

Assessment:
- Current Mental Status: The patient appears irritable and frustrated, which she attributes to ongoing pain, limited mobility, and work-related stress. She reports coping by engaging in activities such as reading and gardening while seated.
- Symptom Progress: Symptoms have not improved significantly since the initial surgery, and the patient continues to experience daily pain and discomfort.
- Medication Efficacy: Tylenol and ice provide limited relief for her symptoms.
- Medication Side Effects: The patient reports no side effects from her current pain management regimen.

Differential Diagnosis:
• Post-surgical complications of ACL reconstruction (T84.84XA): Persistent pain, scar tissue formation, and limited mobility suggest complications related to the surgery.
• Tendon rupture or incomplete healing (M66.89): The visible gap in the tendon and ongoing discomfort may indicate incomplete healing or rupture.
• Chronic pain syndrome (G89.4): The prolonged pain and functional limitations may be indicative of chronic pain syndrome.

Impression:

• The patient presents with ongoing post-surgical complications following ACL reconstruction, including persistent pain, limited mobility, and scar tissue formation. She also exhibits frustration and stress related to her prolonged recovery and dissatisfaction with her surgical outcomes. No acute psychiatric concerns are evident at this time.

Safety Assessment:
The patient denies any current suicidal or homicidal ideation, intent, or plan.

Plan:
• Medications: The patient will continue using Tylenol as needed for pain management. No changes were made to the current medication regimen. 
• Non-Pharmacological Interventions: The patient will continue physical therapy and acupuncture. Chiropractic care, including active-release therapy and laser treatment for inflammation, will be initiated. 
• Patient Education: The patient was advised to adhere to the current treatment plan and consider alternative therapies for symptom management. Lifestyle modifications, such as maintaining a balanced diet and engaging in seated activities to stay active, were discussed. 
• Follow-Up: A telehealth appointment is scheduled for June 4, 2025, to reassess progress and review the treatment plan. The patient will follow up with her new surgeon as needed.

Progress and Outcomes:
The patient continues to experience significant pain and functional limitations post-surgery. She is actively engaging in physical therapy and exploring alternative treatments such as acupuncture and chiropractic care. She has also advocated for herself in her professional environment, resulting in a promotion, despite ongoing work-related stress.