DATE OF ADMISSION: MM/DD/YYYY
CHIEF COMPLAINT: Bilateral knee pain.
HISTORY OF PRESENT ILLNESS: This is an (XX)-year-old Hispanic female patient, who was brought in by her father this evening with a complaint of bilateral knee pain secondary to a fall while playing soccer. The patient states that she just remembers hitting the ground hard with her knees. She did not feel anything pop or hear anything. She says that the crowd was too loud, and she could not hear anything. The patient has been unable to bear weight on the left leg since the injury. She states that this is the worse of the two. She complains of swelling and also some abrasions on both knees. No numbness or tingling or decrease in sensation. The patient has increased pain with range of motion. The patient states there was no loss of consciousness with the fall.
PAST MEDICAL HISTORY: Asthma.
ALLERGIES: NKDA.
CURRENT MEDICATIONS: Albuterol and St. John’s wort.
SOCIAL HISTORY: The patient is a nonsmoker.
REVIEW OF SYSTEMS: The patient has had no fever or chills, no loss of consciousness, no numbness or tingling. Review of systems is otherwise negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.2 degrees, pulse 84, respirations 18, blood pressure 122/76, and pulse oximetry is 100% on room air.
GENERAL: This is an (XX)-year-old Hispanic female patient, who is awake and alert. The patient is semi-reclined on the gurney, appears to be resting comfortably, nontoxic.
EXTREMITIES: Upon examination of the right knee, there is some mild edema. No ecchymosis or erythema. Small abrasions over the patellar region. She has some small amount of edema over the anterior portion of the knee. She has pain and tenderness with palpation and increased pain with range of motion. She had a negative anterior and posterior drawer test. Negative Lachman. She had good pedal pulse, brisk capillary refill. The Achilles tendon is intact. Skin is warm, dry, and intact. On examination of the left knee, there are multiple small abrasions over the anterior knee, edema over the anterior knee, with exquisite tenderness with palpation, all of the surrounding area of the knee. She had a negative anterior and posterior drawer test. Negative Lachman. She had increased pain with Apley’s test with downward pressure and rotation of the foot. The patient has a good pedal pulse and brisk capillary refill. Skin is warm, dry, and intact. Achilles tendon is intact. She has increased pain with attempts of range of motion.
DIAGNOSTIC TESTS: X-rays were done of both knees, four views each. Interpreted by Dr. Jane Doe, in the absence of Radiology, as negative for fracture or dislocation.
PROCEDURES: Knee immobilizer was applied to the left knee. It was re-examined by Dr. Jane Doe. It was well placed. The extremity was neurovascularly intact. She was also given crutches and one Tylenol No. 3 here in the ER.
CONSULTATIONS: None.
IMPRESSION:
1. Right knee pain.
2. Left knee pain, rule out cartilage tear.
DISCHARGE INSTRUCTIONS:
1. RICE.
2. Prescription for Tylenol No. 3, one to two p.o. every four hours p.r.n., #20 given.
3. Follow up with Dr. John Doe in two to three days.
4. Return for increased pain, fever, redness, swelling, decreased sensation or other concerns.
DISPOSITION: The patient was released in good condition.
