[doctor] hi , ms. thompson . i'm dr. moore . how are you ?
[patient] hi , dr. moore .
[doctor] hi .
[patient] i'm doing okay except for my knee .
[doctor] all right , hey , Sarah , ms. thompson is a 43 year old female here for right knee pain . so tell me what happened with your knee ?
[patient] well , i was , um , trying to change a light bulb , and i was up on a ladder and i kinda had a little bit of a stumble and kinda twisted my knee as i was trying to catch my fall .
[doctor] okay . and did you injure yourself any place else ?
[patient] no , no . it just seems to be the knee .
[doctor] all right . and when did this happen ?
[patient] it was yesterday .
[doctor] all right . and , uh , where does it hurt mostly ?
[patient] it hurts like in , in , in the inside of my knee .
[doctor] okay .
[patient] right here .
[doctor] all right . and anything make it better or worse ?
[patient] i have been putting ice on it , uh , and i've been taking ibuprofen , but it does n't seem to help much .
[doctor] okay . so it sounds like you fell a couple days ago , and you've hurt something inside of your right knee .
[patient] mm-hmm .
[doctor] and you've been taking a little bit of ice , uh , putting some ice on it , and has n't really helped and some ibuprofen . is that right ?
[patient] that's right . yeah .
[doctor] okay , let's review your past history for a second . it looks like , uh , do you have any other past medical history ?
[patient] uh , afib .
[doctor] okay , and are you taking any medications for that ?
[patient] yeah , i am . um , begins with a d.
[doctor] uh , digoxin ?
[patient] that's it . yeah , that's it .
[doctor] okay , all right . how about any surgeries in the past ?
[patient] i have had a nose job .
[doctor] all right . um , let's do your exam , okay ? so is it tender ... where is it mostly tender right now ?
[patient] right on the inside of my knee . right here .
[doctor] all right , so if i bend your knee forward , does that seem to hurt ?
[patient] yes , that hurts .
[doctor] all right , how about if i twist it a little bit that way .
[patient] that hurts a lot .
[doctor] okay , okay . and how about down here ? do you feel me touch you down here ?
[patient] yes .
[doctor] all right . any other pain down here in your calves ?
[patient] no .
[doctor] no , okay . so on exam you do have some tenderness over the medial portion of your knee over the medial meniscus area . uh , there is no , uh , there is a little bit of tenderness when i flex your , uh , when i , uh , uh , do some valgus stressing on your , on your leg . um , you have normal sensation . so let's take a look at your x-rays .
[patient] okay .
[doctor] okay . hey Sarah , show me the x-rays . so looking at the x-ray , um , of your left knee , uh , it appears to be there's no fractures there right now . i do n't see any , uh , there's a little bit of , uh , fluid , uh , but there is no , uh , there's no , um , fracture or there's no dislocation . everything else seems to be lined up properly , okay ?
[patient] okay .
[doctor] so in summary after my exam , uh , looking at your knee , uh , on the x-ray and your exam , you have some tenderness over the medial meniscus , so i think you have probably an acute medial meniscus sprain right now or strain . uh , at this point , my recommendation would be to put you in a knee brace , uh , and we'll go ahead and have you use some crutches temporarily for the next couple days . we'll have you come back in about a week and see how you're doing , and if it's not better , we'll get an mri at that time .
[patient] okay .
[doctor] i'm going to recommend we give you some motrin , 800 milligrams . uh , you can take it about every six hours , uh , with food . uh , and we'll give you about a two week supply .
[patient] okay .
[doctor] okay . uh , do you have any questions ?
[patient] no , i think i'm good .
[doctor] all right . hey , Sarah , order the medications and procedures discussed , and finalize the report . okay , come with me and we'll get you checked out .
CC:

Right knee pain.

HPI:

Ms. Thompson is a 43-year-old female who presents today for an evaluation of right knee pain. She states she was trying to change a lightbulb on a ladder, and she twisted her knee when she stumbled and caught herself from falling yesterday. She has been applying ice and taking Ibuprofen without relief.

CURRENT MEDICATIONS:

Ibuprofen, digoxin.

PAST MEDICAL HISTORY:

Atrial fibrillation.

PAST SURGICAL HISTORY:

Rhinoplasty.

EXAM

Examination of the right knee shows pain with flexion. Tenderness over the medial joint line. No pain in the calf. Pain with valgus stress. Sensation is intact.

RESULTS

X-rays of the right knee show no obvious signs of acute fracture or dislocation. Mild effusion is noted.

IMPRESSION

Right knee acute medial meniscus sprain.

PLAN

At this point, I discussed the diagnosis and treatment options with the patient. I have recommended a knee brace. She will take Motrin 800 mg, every 6 hours with food, for two weeks. She will use crutches for the next couple of days. She will follow up with me in 1 week for a repeat evaluation. If she is not better at that time, we will obtain an MRI. All questions were answered.
