DIALOGUE

[doctor] so sophia i see that you you hurt your knee tell me about what happened
[patient] yeah i was jumping on my kid's trampoline and i could just slipped out from under me
[doctor] my gosh one of those big trampolines in your back yard
[patient] yeah a pretty big one
[doctor] okay which knee was it
[patient] my right knee
[doctor] right knee okay and when did this happen
[patient] about four days ago
[doctor] great the weather was perfect this weekend so i'm glad you at least got outside sorry to hear you got hurt okay so your right knee did you did you feel it like pop or or snap or anything when you hurt it
[patient] yeah i felt a little pop and then it swelled up really big afterward
[doctor] okay did you try anything for the pain
[patient] i took some ibuprofen and i put some ice on it
[doctor] okay did that help
[patient] a little bit but it's still really hard to get around
[doctor] alright and have you have you been able to stand on it or does that hurt too much
[patient] it hurts quite a bit to stand but i am able to put weight on it
[doctor] okay alright and what part of the knee is it inside outside middle
[patient] kind of that inside part of my kneecap
[doctor] okay alright and okay so as long as you're here and then your primary care physician i'm looking through your chart and it looks like we're treating your diabetes so how you've been doing with your your diet overall are you are you keeping your sugars low
[patient] it's going okay i i forget to check quite a bit though
[doctor] sure
[patient] on it
[doctor] yeah i understand how has your diet been lately
[patient] it's been pretty good
[doctor] okay okay good good you know it's hard to stay away from the sugary foods sometimes i i enjoy ice cream regularly okay so let's do physical exam as long as you are here so i'm just gon na listen to your heart your heart sounds normal no murmurs or gallops listen to your lungs quick if you can take a deep breath lungs are clear that's good news let's take a look at that knee right knee looks like it definitely has some swelling i'm gon na do some maneuvers here does it hurt when i push you on the inside of the knee
[patient] yeah that hurts
[doctor] okay how about the outside
[patient] a little bit but not as much
[doctor] okay so some pain on palpation on the inside little bit of pain on the outside of the knee if i bend the knee back does that hurt
[patient] yeah
[doctor] how about when i extend it
[patient] yeah that hurts
[doctor] okay so little bit of limited range of motion as well as pain on both flexion and extension on the knee i'm gon na push on this a little bit looks like your mcmurray's test is negative just checking for a meniscus tear okay so let's talk a little bit about your plan what i am concerned about for your knee is it sounds like you have a torn or injured mcl i it's that inside tendon in your knee so i'm concerned about that since you're having trouble with weightbearing and you heard that pop so what i'm gon na do is i'm gon na put you in a straight leg brace and i'll prescribe some mobic you can start taking that as a a pain reliever and to try to get some of the swelling down i want you to ice your knee once an hour for about fifteen minutes but i'm also gon na send you out for an mri because we wan na make sure this is what happens see if there's any other damage to the knee does that sound good
[patient] yeah that sounds great thank you
[doctor] yeah and then for your diabetes as long as you're here it sounds like you're managing that pretty well but i do wan na get a recheck on your hemoglobin a1c and then i'm also i'm going to get a refill on the metformin that you have been taking five hundred milligrams so you can keep taking that as well so do you have any other questions for me
[patient] no that's it thanks
[doctor] alright well thank you hope that you feel better

CLINICAL NOTE

CHIEF COMPLAINT

Right knee pain.

MEDICAL HISTORY

The patient has a history of diabetes. She has been doing pretty good with her diet. She states that she forgets to check her sugars quite a bit.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain and swelling.

PHYSICAL EXAM

Respiratory
- Auscultation of Lungs: Clear bilaterally.

Cardiovascular
No murmurs, gallops.

Musculoskeletal
- Examination of the right knee: Some swelling present.
- Palpation: Some pain to palpation on the medial aspect of the right knee, and a little bit of pain on the lateral aspect of the right knee.
- Range of Motion: Limited range of motion as well as pain on both flexion and extension of the knee.
- Special Testing:
McMurray's Test: Negative.

ASSESSMENT AND PLAN

1. Right knee pain.
- Medical Reasoning: I am concerned about a torn MCL due to pain on ambulation and trouble with weightbearing, as well as the pop she heard.
- Patient Education and Counseling: We discussed treatment options today including bracing, anti-inflammatories, and icing. - Medical Treatment: I am going to put her in a straight leg brace and I will prescribe some Mobic. She can start taking that as a pain reliever and to try to get some of the swelling down. I want her to ice her knee once an hour for about 15 minutes.
- Additional Testing: I am also going to send her out for an MRI.

2. Type 2 diabetes.
- Medical Reasoning: The patient states that her type 2 diabetes are well-managed.
- Medical Treatment: I am also going to get a refill on the metformin that she has been taking 500 mg.
- Additional Testing: We are going to recheck her hemoglobin A1c.

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