CC: Left knee pain x 2 day

Subjective:

45 years old male with no significant PMHx presents to clinic for left knee pain with injury that happened on two days ago (08/28/2020). Patient was supporting the patient who was about to fall and bent his left knee on the floor. Patient was then brought to Harlem ER by ambulance, prescribed walking cane and Ibuprofen 600 mg, but medication not received yet due to resting himself at home. Patient took Tylenol 2 tabs in the ER with some relief. X-ray done in ER with result of no deformity. He describes the pain as sharp, no radiation, and rates the pain 7/10 with movement, 3/10 with rest. No medication taken since Friday, applied ice pack with some help. Noted unable to move the affected area due to pain. Patient denies fever, chill, headache, N/V/D, or any sick contacts at this time.

Objectives:

Allergies: NKDA

Current Medication: Patient denies pre-existing medications

Vitals:

• BP: 138/79, sitting, left arm
• HR: 83 bpm, regular
• RR: 18 breaths per minute, regular
• O2 Sat: 98%, RA
• T: 98.4 oral
• Ht: 73 in Wt: 312 lbs     BMI: 41.2 kg/m2

Physical Exam

• Gen – Well nourished, well developed female resting in chair, no apparent distress
• ENT – NC/AT, no JVD noted
• Thorax – Symmetric, no retractions
• Lung – CTA b/l, no rhonchi, rales or wheezes noted
• CV – S1S2 distinct, no M/R/G, RRR. No carotid bruits
• Abdomen – Soft, non-tender, non-distended. Bowel sounds normoactive in all four quadrants, no masses to palp, no hepatosplenomegaly.
• Extremities – Mild edema in left knee. No clubbing, cyanosis, radial/DP pulses +2 bilaterally
• MS – Limited ROM noted in left knee. Full range of motion in the rest of the joints, strength 5/5 bilaterally throughout
• Neuro – A&O x 3, no gross motor or sensory deficits, CN II-XII grossly intact

Assessment

45 years old male with no significant PMHx presents to clinic for left knee pain with injury. History and limited ROM of affect area most consistent with left knee sprain.

Plan

• Refer to physical therapy
• Ibuprofen PRN to relieve knee pain
• Rest and avoid heavy lifting
• Apply ice or heat pack to affected area