Knee Note

Occupation:
Sport:
Chief Complaint:
Involved Side:
Injury:
HPI: 50y/o female with gradually worsening right knee pain over several years. 3-7/10 medial joint line knee pain. Worse with activity.
Quality: 9/10 worse with activity.
Associated Symptoms: Occasional popping, rare locking.
Severity/Timing: worse with activity.
Duration: gradually worsening over several months.
Context:
Modifying factors: Improved with rest
Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Family History: none
Medications: none
Allergies: none
SH: no tob, no ETOH
ROS: Patient questionnaire reviewed. Pertinent findings: none
PHYSICAL EXAM
HT: Wt: Pulse:
General Appearance: well-nourished, well-developed
Orientation: AO x 3
Mood / Affect: calm
Gait: normal
Skin: normal, no scars
Lymph: no edema, no lymphadenopathy
Inspection/Palpation: medial joint line tenderness.
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): - / -
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: Posterior horn medial meniscal tear
ASSESSMENT: Right Posterior Horn Medial Meniscal Tear (717.2)
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy
NSAIDS
Information sheet given
Follow-up 6-8 weeks