DIALOGUE

[doctor] hi abigail how are you today
[patient] hello hi nice to meet you i'm i'm doing okay
[doctor] good i'm doctor sanchez and i'm gon na go ahead and take a look i saw with your notes that you've been having some knee pain yes that's that's true you know it's been going on for a while i like to run i do jogs i sign up for the 5k tack you know sometimes the marathon and i have n't been doing longer distances because
[patient] when i'm running i my right knee here it just starts to ache and it's it's just to the point where i need your opinion
[doctor] okay okay what have you done for it so far what makes it better what makes it worse
[patient] well it used to be that when i run it ache and then i put ice on it and then it would be okay so i do ice and ibuprofen
[doctor] okay okay and did you see anybody for this before coming into the office here
[patient] yeah i doctor wood is my primary care provider and i talked to him about it actually over the years and this last visit he said he referred me to you
[doctor] okay okay good so ice and rest makes it feel better running and and activity makes it hurt a little bit more is that correct
[patient] yeah that's right
[doctor] okay do you have any family history of arthritis or any of those type of immune diseases
[patient] i'm trying to think no i do n't think so no
[doctor] okay and do you get is it is this primarily worse in the morning or does it is it just there all the time when it comes on
[patient] it actually is worse towards the end of the day
[doctor] okay
[patient] once i'm on my feet all day it starts to ache towards the afternoon
[doctor] okay so let's go ahead and i want to do a quick examination here your blood pressure and was one twenty over sixty that's phenomenal your heart rate was fifty eight and you can tell that you're a runner with that that level of a heart rate and your respirations were fourteen so all of that looked very good there was no fever when you came in when i'm gon na just quickly listen to your heart and lungs okay those those sound good but let me get let's focus here on your lower extremities i'm i'm gon na look at your your left knee first when i move your left knee do you get any type of pain or is it just feel like normal and it's always your pain's always isolated to the right
[patient] that feels that feels normal
[doctor] okay okay so let me i just want you to back up here in the stretcher a little bit more and i'm just gon na do some movement of your knee any okay so i want you to push your leg out against my hand does that hurt
[patient] no
[doctor] okay and if you pull back does that hurt a little bit
[patient] no
[doctor] okay and i'm gon na move it around so when i look at the knee there is no redness there's no swelling i can appreciate a a small amount of effusion and that means that there's a little bit of fluid under the knee or in that knee's joint space and there is there is several reasons that could be now when i push on your knee does it hurt more on the inside or does it hurt more on the outside here
[patient] the the right knee here hurts on the outside
[doctor] okay okay and you've got a good pedal pulse so you know you can feel that and when i touch your feet you do n't have any numbness or tingling or anything like that
[patient] no uh uh
[doctor] okay well so what i want to tell you is that i think you have a knee sprain from overuse and we see that sometimes in runners now unfortunately you're gon na have to take some a little bit of time off of of active running but i do n't think it will be that long until we can get you up and running again now i reviewed the x-rays that we did when you first came into the office here this morning and the joint spaces of that right knee are are well maintained i do n't see any evidence of any fracture and when compared to the left knee everything looks good so i do n't even see any signs of any arthritis that i would've been suspecting i would like you to stay on two tylenol five hundred milligrams and two ibuprofen two hundred milligram tablets and i want you to take that three times a day and that's gon na help with both the pain and the inflammation i'm also gon na order some physical therapy for your your right knee and that physical therapy will help strengthen the lower extremities and make it give you a little bit of a balance and some they'll be able to recommend good running exercises for you i do wan na follow up with you in two weeks and see if we're getting better so let's no running for two weeks and if we're we're improving then we'll move on and probably start adding some additional activity does that sound like a plan
[patient] yeah that does i i was curious so i will lay off the running for now can i you know lift weights and do like my squats and and those type of exercises at the gym
[doctor] yeah absolutely and and those are good exercises but i'd like you to get that first physical therapy appointment in and they'll be able to talk with you on what the best exercises are for you to do
[patient] okay got it
[doctor] any questions
[patient] hmmm no i do n't think so
[doctor] okay thank you abigail and i'd like i said stop out at the desk and we'll make an appointment for two weeks
[patient] okay thanks doctor
[doctor] thank you

CLINICAL NOTE

CHIEF COMPLAINT

Right knee pain.

SOCIAL HISTORY

Patient reports she is an avid runner who enjoys participating in marathons.

FAMILY HISTORY

Patient denies any known family history of arthritis or other immune disease.

REVIEW OF SYSTEMS

Constitutional: Denies fever.
Musculoskeletal: Reports right knee pain.

VITALS

Blood pressure: 120/60 mmHg
Heart rate: 58 bpm
Respiration: 14
No fever.

PHYSICAL EXAM

Respiratory
- Assessment of Respiratory Effort: Normal respiratory effort.

Cardiovascular
- Examination: Normal pedal pulses in right knee.
- Auscultation of Heart: Regular rate and rhythm. No murmurs, gallops or rubs.

Musculoskeletal
- Examination: No clubbing, cyanosis, or edema.
- Right knee: No pain with movement. No pain with strength testing. No erythema or edema. Small effusion. Tender to palpation over the lateral aspect of the knee.

RESULTS

X-rays of the right knee were obtained and reviewed in office today. These reveal well-maintained joint spaces. There is no evidence of any fracture or arthritis.

ASSESSMENT AND PLAN

1. Right knee sprain.
- Medical Reasoning: The patient is an avid runner and her symptoms appear to be the result of overuse.
- Patient Education and Counseling: We discussed the nature of her diagnosis, as well as her x-ray results, in detail. I advised her that this is a common issue for runners and encouraged her to continue her strength training exercises.
- Medical Treatment: She will take Tylenol 500 mg, 2 tablets, and ibuprofen 200 mg, 2 tablets, 3 times daily to reduce her pain and inflammation. We will also refer her to physical therapy to help strengthen her lower extremities, work on her balance, and demonstrate proper running exercises. She should avoid running for the next 2 weeks until her follow up visit, at which point we can consider adding some additional activity.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.

INSTRUCTIONS

The patient will follow up in 2 weeks.