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Machine-generated draft from a research prototype. Not for clinical use. Green means the clause's words were found in the transcript, not that the clause is correct.

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CHIEF COMPLAINT

Right knee pain.

HISTORY OF PRESENT ILLNESS

Elizabeth Ross is a pleasant 38-year-old female who presents to the clinic today for the evaluation of right knee pain. The onset of her pain began 2 weeks ago, when she was playing basketball and another player ran into her. She states that she fell and landed on her side. She denies hearing a pop at the time of the injury. The patient localizes her pain to the medial aspect of her knee. She used ice and an ACE wrap right after the injury. Today, she notes that she has been doing exercises, hiking, camping, fishing.

PAST MEDICAL HISTORY

The patient reports that she has been in a walking boot. She denies any numbness or tingling in her toes.

ALLERGIES

The patient reports that she has been wearing a right knee for the past 2 weeks. She denies any numbness or tingling.

PHYSICAL EXAM

Respiratory Clear bilaterally. No wheezes, rales, or rhonchi. Cardiovascular No murmurs, gallops, or rubs. Musculoskeletal Some edema and an occasional positive Lachman sign. Decreased flexion and extension. Positive straight leg raise. Strength is 4/5.

ASSESSMENT

Right knee pain, the patient to undergo physical therapy.

PLAN

Ibuprofen PRN. Referral to physical therapy.

Transcript

1. doctor: hi michelle what's been going on the medical assistant told me that you injured your knee
2. patient: yeah i'm gon na have to keep this my favorite story is that i had a sandra who injured her knee cold dancing so that would immediately came up to mine but let's try skiing so i was skiing in vermont last weekend and i caught my ski when i was coming off the lift and i fell and my knee popped and it's hurt ever since
3. doctor: okay and were you able to ski down the hill or did you have to be taken down by the ski patrol
4. patient: i had to be taken down by the ski patrol i was unable to bear weight
5. doctor: okay is n't that slightly terrifying they had to do the same thing for me and you're just kind of sitting there watching all of the trees go by so anyway so what part of your knee is bothering you the most is it the inside the outside
6. patient: it hurts on the outside but it also feels like it wo n't hold my weight
7. doctor: okay so it feels like it's gon na buckle
8. patient: hmmm yes
9. doctor: okay alright and are you able to bend it
10. patient: i was immediately after the injury but not really now
11. doctor: okay and how about straightening it are you able to straighten it at all
12. patient: somewhat but it really hurts when i try to straighten all the way
13. doctor: okay alright now do you have any numbing or tingling in your toes
14. patient: no
15. doctor: okay and can you feel your toes okay
16. patient: i think so
17. doctor: okay alright now are you a pretty active person you said you were skiing do you do what kind of other activities do you do
18. patient: i chase my two four -year-old
19. doctor: okay do you have twins
20. patient: i do
21. doctor: nice that's great
22. patient: yeah
23. doctor: so okay and what's your support like at home who is who is able to help out are you still doing that kind of hobbling around on crutches or
24. patient: yeah now my husband is home with me but he also works a job where he is gone quite a bit so it's just me and the kids
25. doctor: okay alright and did the ski patrol give you crutches i i see you have them here with you okay alright great and are you otherwise generally healthy
26. patient: yes
27. doctor: okay and no high blood pressure diabetes anything like that
28. patient: mm-hmm
29. doctor: no okay alright and well i i wan na go ahead let me just do a quick physical exam i'm gon na be calling out some of my exam findings and i'll let you know what that means when i'm done okay alright so on your heart exam your heart sounds in a nice regular rate and rhythm i do n't appreciate any murmur on your lung exam your lungs are nice and clear to auscultation and remind me what knee did you injure again
30. patient: my right knee
31. doctor: your right knee okay so on your right knee examination i do appreciate some edema and an effusion over the right knee does it hurt when i press
32. patient: yes
33. doctor: okay there is pain to palpation of the right lateral knee there is decreased flexion and extension there is a positive lachman sign there is a palpable palpable dorsalis pedis and posterior tibial pulse there is no leg edema in the ankle okay well let's just talk a little bit about you know my assessment and you know my plan for you so you know i know that you had the x-ray done of your of your right knee that did n't show any bony abnormality but i i'm concerned that you have ruptured your your acl or your anterior cruciate ligament that's like a major ligament that helps connect and helps your knee move back and forth so i wan na go ahead and order a knee mri just so that we can get a a a good look and just you know confirm that physical exam okay now some people can have a normal physical exam and their acl can still be torn but you do have a lot of pain on the lateral aspect of your knee so i wan na make sure if there make sure that there is not any other structures that have been damaged by this accident okay i wan na go ahead and you know are you what are you taking for the pain
34. patient: ibuprofen
35. doctor: is that helping
36. patient: somewhat yes
37. doctor: okay alright do you want something stronger
38. patient: no i'm okay
39. doctor: alright so let's just continue with ibuprofen you can take you know six hundred to eight hundred milligrams every eight hours as needed i wan na go ahead and put you in a brace that's gon na help your knee feel a bit more supported okay and let's go ahead and i'm hoping that we can get this mri done in you know the next couple days and then we can have a conversation about what needs to be done now you said that you are are are you know obviously a very active active mom any other exercise or anything else that that i should be aware of that you do just wondering in terms of which kind of graft we would use to fix this with your with your acl being injured
40. patient: hmmm no i not i i would like to get back to the running but currently not that active
41. doctor: okay alright alright do you have any questions about anything
42. patient: i think you've explained it well
43. doctor: okay alright so i'll see you again soon okay
44. patient: okay thank you
45. doctor: alright take care bye