Acute Care Visit Template

Acute Care Visit Template Chief Complaint: Right knee pain History of Present Illness: John Doe is a 28-year-old male presenting with right knee pain. Onset: 3 days ago Duration: Persistent Characteristics: Sharp pain, especially when bending the knee Aggravating factors: Running, climbing stairs Relieving factors: Rest, ice application Associated symptoms: Swelling, stiffness Current Medications: Ibuprofen 400 mg as needed for pain Past Medical History: Previous right knee sprain 2 years ago Social History: Non-smoker, occasional alcohol use, works as a software engineer, no recent travel Review of Systems: - Musculoskeletal: Positive for joint pain and swelling Physical Examination: Vitals: - Temperature: 98.6°F - Blood Pressure: 120/80 mmHg - Heart Rate: 72 bpm - Respiratory Rate: 16 breaths/min - Oxygen Saturation: 98% General: Appears in mild distress due to pain - Musculoskeletal: Right knee shows swelling, tenderness on palpation, limited range of motion, no redness Assessment: Right knee sprain Plan: 1. Diagnostic Studies: MRI of the right knee 2. Treatment: Prescribed physical therapy, continue ibuprofen as needed 3. Patient Education: Advise on RICE (Rest, Ice, Compression, Elevation) protocol 4. Follow-up: Re-evaluate in 2 weeks 5. Return precautions: Seek immediate care if pain worsens or if unable to bear weight on the knee Additional notes or comments: Consider referral to orthopedic specialist if no improvement.