Subjective:
Patient presents with a primary complaint of right knee pain, which began approximately 2 weeks ago following a fall while running. The pain is located primarily in the anterior aspect of the knee, described as a sharp, stabbing sensation that worsens with weight-bearing and activity. It is partially relieved by rest and ice. There is no radiation of pain. Associated symptoms include occasional clicking and a feeling of instability.
Patient reports no prior injuries to the right knee. No previous treatments have been attempted. Medical history is unremarkable, with no known allergies.
Patient reports difficulty with walking, squatting, and climbing stairs. These limitations impact her ability to perform her job as a teacher and participate in her usual recreational activities, such as running and hiking.
Patient's goals include reducing pain, restoring full range of motion, and returning to her pre-injury level of activity, including running.
Objective:
Observation:
Mild swelling is noted around the right knee joint, particularly in the suprapatellar region. No bruising or skin changes are observed. There is no muscle atrophy.
Gait analysis reveals a slight limp on the right leg. Weight-bearing is guarded.
Patient's posture is normal, with no obvious malalignment of the lower extremities.
Palpation:
Tenderness is elicited upon palpation of the medial joint line and the patellar tendon. No warmth or crepitus is noted. There is a small amount of effusion.
Range of Motion (ROM):
Active ROM:
Flexion: 110 degrees (limited by pain)
Extension: 0 degrees
Passive ROM:
Flexion: 120 degrees
Extension: 0 degrees
Strength:
Knee flexors: 4/5
Knee extensors: 4/5
Hip abductors: 5/5
Hip adductors: 5/5
Special Tests:
Anterior Drawer Test: Negative
Lachman Test: Negative
Posterior Drawer Test: Negative
Valgus Stress Test: Negative at 0 and 30 degrees of flexion
Varus Stress Test: Negative at 0 and 30 degrees of flexion
McMurray Test: Positive for medial meniscus
Apley's Compression/Distraction Test: Negative
Patellar Apprehension Test: Negative
Ballotable Patella Test (Patellar Tap Test): Positive for effusion
Quadriceps Active Test: Negative
Pivot Shift Test: Negative
Neurological:
Sensation is intact throughout the lower extremity. Patellar reflex is 2+ and symmetrical. Motor function is intact.
Vascular:
Peripheral pulses are palpable and equal bilaterally. Capillary refill is less than 2 seconds.
Assessment:
Key findings include right knee pain, swelling, limited range of motion, and a positive McMurray test. Provisional diagnosis: Medial meniscus tear.
Rationale: The patient's symptoms, including pain on the medial joint line, clicking, and a positive McMurray test, strongly suggest a meniscal tear. The mechanism of injury (fall) is also consistent with this diagnosis.
Prognosis is good with appropriate treatment, including physical therapy and possible surgical intervention. Contributing factors include the patient's activity level and age.
Plan:
Treatment plan includes: therapeutic exercises to improve range of motion and strength, manual therapy to address joint restrictions, and patient education on activity modification. Modalities such as ice and heat will be used for pain management.
Goals:
Reduce pain to a level of 2/10 within 2 weeks.
Increase knee flexion to 130 degrees within 4 weeks.
Improve quadriceps strength to 5/5 within 6 weeks.
Referral to an orthopaedic surgeon for further evaluation and possible MRI.
Physical therapy sessions will be scheduled twice a week for the first 4 weeks, then as needed.
Patient is instructed to avoid activities that aggravate the knee pain. Home exercise program will include range of motion exercises, quadriceps sets, and hamstring curls.
Subjective:
[describe the patient's primary complaint, including onset, duration, location, character of pain, aggravating and relieving factors, and any associated symptoms] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[document the history of the presenting complaint, including any prior injuries, treatments, or relevant medical history related to the knee] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[detail the patient's current functional limitations and how the knee condition impacts their daily activities, work, and recreational pursuits] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[inquire about the patient's goals for rehabilitation and expectations from physical therapy] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Objective:
Observation:
[document any visible signs of swelling, bruising, deformity, muscle atrophy, or skin changes around the knee joint and surrounding areas] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[describe the patient's gait pattern, weight-bearing status, and any compensatory movements or limping] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[note the patient's posture and alignment of the lower extremities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Palpation:
[identify and describe any areas of tenderness, warmth, crepitus, or effusion around the knee joint, including specific anatomical landmarks] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Range of Motion (ROM):
[measure and record active and passive range of motion for knee flexion, extension, and any other relevant movements, noting any limitations, pain, or compensatory patterns] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Strength:
[assess and grade the strength of knee flexors, extensors, hip abductors, adductors, and other relevant lower extremity muscles using manual muscle testing] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Special Tests:
[document the performance and findings of specific orthopedic special tests for the knee to assess ligamentous integrity (e.g., ACL, PCL, MCL, LCL), meniscal pathology, patellofemoral dysfunction, or other conditions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Anterior Drawer Test: [result and interpretation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Lachman Test: [result and interpretation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Posterior Drawer Test: [result and interpretation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Valgus Stress Test: [result and interpretation at 0 and 30 degrees of flexion] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Varus Stress Test: [result and interpretation at 0 and 30 degrees of flexion] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- McMurray Test: [result and interpretation for medial and lateral meniscus] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Apley's Compression/Distraction Test: [result and interpretation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Patellar Apprehension Test: [result and interpretation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Ballotable Patella Test (Patellar Tap Test): [result and interpretation for effusion] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Quadriceps Active Test: [result and interpretation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
- Pivot Shift Test: [result and interpretation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Neurological:
[assess sensation, reflexes (e.g., patellar reflex), and motor function of the lower extremity to rule out neurological involvement] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Vascular:
[assess peripheral pulses and capillary refill in the affected limb] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Assessment:
[summarize the key findings from the subjective and objective examination] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[provide a provisional diagnosis or differential diagnoses based on the assessment findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[explain the rationale for the diagnosis, linking it to the patient's symptoms and examination findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[discuss the patient's prognosis and potential contributing factors to their condition] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Plan:
[outline the proposed treatment plan, including specific interventions such as therapeutic exercises, manual therapy, modalities, and patient education] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[set specific, measurable, achievable, relevant, and time-bound (SMART) goals for the patient's rehabilitation] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[recommend any necessary referrals to other healthcare professionals or imaging studies] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[specify the frequency and duration of future physical therapy sessions] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[provide instructions for home exercise program or activity modifications] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
