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Original Question

MEDICAL RECORD Family Practice USA New Patient Dr. John Jones SEX: Female AGE: 20 DOS: 1/1/20XX CC: Pain in left knee Impression: Possible Medial meniscal tear of left knee Plan: MRI of left knee and follow up again after the scan, then refer to Orthopedist if necessary Patient is a 20-year-old-girl who says that she was doing some leg presses yesterday when she felt a sudden pop in the knee. After this, she has been unable to walk and unable to extend the knee completely. Her ability to walk returned after a while, but her knee still hurts if she extends fully. She is able to flex it with some pain. All of her pain is felt on the front and medial side of the knee. There is no history of any swelling or bruising around the knee. There is no history of any previous symptoms of that knee. There is no history of any obvious giving away or locking when she walks. Past Medical History: No chronic illnesses Past Surgical History: No previous operations Allergies: None Medications: Birth control pills and phentermine Social History: The patient does not smoke, drink alcohol, or use illegal drugs. Family History: COPD and coronary artery disease Review of Systems: HEENT, GI, GU, cardiorespiratory, neurological, endocrine, and constitutional symptoms were reviewed, and these are negative. Vital Signs: Pulse: 82; Respirations: 19; Blood Pressure: 120/78; Temperature: 99; Weight: 157 lbs; Height: 5’8. General: She is a well-nourished teenaged female sitting on the couch in no acute distress, well oriented to time, place, and person; HEENT EXAM: Head is atraumatic and normocephalic. Mucous membranes moist; NECK EXAM: Supple and nontender; HEART EXAM: S1 and S2; LUNG EXAM: Clear; ABDOMEN EXAM: Soft and nontender; EXTREMITY EXAM: Left knee examination shows no obvious swelling in the knee. The patient prefers to keep the knee flexed by about 15 degrees or so. There is significant point tenderness along the medial joint line. Range of motion is -10 to +90 degrees. Stability examination was difficult to perform given her pain levels. Her hip exam did not provoke any pain. No gross neurocirculatory problems were detected. I discussed with this patient about her diagnosis, suggesting an MRI would help clarify the diagnosis further. She agreed with the plan. An MRI scan was requested. I will see her again for follow up after the scan. In the meantime, I have asked her to perform range of motion exercises as tolerated and weight bearing as tolerated. After MRI refer to Orthopedic surgeon. John Jones, MD Electronically signed by JOHN JONES, MD 1/1/20XX

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