Ortho Office Note

HISTORY OF PRESENT ILLNESS: Patient presents today with right knee pain following a fall while playing football. Reports immediate pain and swelling after the injury. The pain is described as a sharp, throbbing pain, rated 7/10, and is exacerbated by weight-bearing and twisting movements. The patient reports a popping sensation at the time of injury. No previous knee injuries or surgeries. Patient has tried over-the-counter pain medication with minimal relief. Patient goals include pain relief and return to sport. PHYSICAL EXAM: "Well-appearing" 28-year-old man "in no apparent distress. Alert and oriented x 3. Normocephalic. Non-labored respirations on room air. Extremities are warm and well-perfused. Good peripheral pulses. Sensation intact in non-affected extremities." Right knee. Skin findings: Mild swelling and bruising noted around the knee. No open wounds or deformities. Gait is antalgic, favoring the right leg. Specific physical examination findings: Positive McMurray's test, positive Lachman's test, and moderate effusion. Areas of pain to palpation or with movement: Tenderness to palpation along the medial joint line and with full range of motion. Pain is rated as moderate to exquisite. Strength testing results: Quadriceps strength 4/5 due to pain. Range of motion: Flexion 90 degrees, extension limited to 0 degrees due to pain and swelling. Crepitus noted with movement. Special test results: Positive McMurray's test, positive Lachman's test, negative valgus/varus stress testing. Neurovascular findings: Capillary refill < 2 seconds, good pulses, intact sensation. "Patient otherwise NVI." IMAGING INTERPRETATION: AP, lateral, and sunrise views of the right knee obtained. "Independently reviewed by myself today demonstrating a possible displaced bucket-handle tear of the medial meniscus and a possible ACL tear." ASSESSMENT: Right knee: Suspected medial meniscus tear and ACL tear. - Possible ACL tear. PLAN: Discussed the diagnosis of a possible medial meniscus tear and ACL tear with the patient. Explained the need for further imaging, specifically an MRI, to confirm the diagnosis and assess the extent of the injuries. Discussed treatment options, including conservative management with physical therapy, bracing, and activity modification, as well as surgical options, including arthroscopic meniscal repair and ACL reconstruction. Patient has tried activity modification and pain medication without significant relief. Patient was counselled on the risks and benefits of each treatment option. MRI ordered. Referral to orthopaedic surgeon for further evaluation and potential surgical intervention. Patient instructed to follow up in two weeks or sooner if symptoms worsen. Patient provided with instructions on RICE (Rest, Ice, Compression, Elevation) and pain management. Date: 1 November 2024