Knee Note

Occupation:
Sport:
Chief Complaint:
Involved Side:
Injury:
HPI: 25y/o female with gradually worsening right knee pain over several years. 3-7/10 anterior knee pain. Worse with prolonged sitting and climbing stairs. Increased pain after prolonged running.
Quality:
Associated Symptoms:
Severity/Timing:
Duration:
Context:
Modifying factors:
Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries, does not use any assistive devices. .
PMH:none
PSH:none
Family History: patient questionaire was reviewed in the chart and was signed and dated and is noncontributory.
Medications: none
Allergies: none
SH: no tob, no ETOH, married.
ROS: Patient questionnaire was reviewed, signed and dated. Pertinent findings: no fevers, no chills, no drastic changes in weight, no metal known metal allergies.
PHYSICAL EXAM
HT: Wt: Pulse:
General Appearance: well-nourished, well-developed, no acute distress. Appears stated age.
Orientation: AO x 3
Mood / Affect: calm
Gait: normal
Skin: normal, no scars
Lymph: no edema, no lymphadenopathy
Inspection/Palpation: non tender
Alignment (R/L): 4 valgus / 4 Valgus
Effusion (R/L): none / none
ROM (R/L): 0-130 / 0-130
Varus laxity (R/L): 0+ / 0+
Valgus laxity (R/L): 0+ / 0+
Posterior Drawer (R/L): 0+ / 0+
Lachman (R/L): 0+ / 0+
Pivot shift (R/L): 0+ / 0+
McMurray (R/L): - / -
No quad tightness
Lateral patellar tracking with deep knee bend. Notes anterior knee pain at 45-90 degrees of deep knee bend.
no apprehension
no generalized ligamentous laxity
subjective normal distal sensation bilaterally
5/5 EHL, TA, PF bilaterally
Dorsalis pedis (R/L): 2+/2+
DTR (R/L): Biceps (2+/2+); Triceps (2+/2+) Patellar (2+/2+); Achilles (2+/2+)
Xray: Mild lateral patella tilt. The osseous structures are otherwise intact without fracture, dislocation or evidence of arthritis.
MRI: none
ASSESSMENT:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy
Patellofemoral Brace
NSAIDS
Information sheet given
Follow-up 6-8 weeks