[doctor] hey william so i see that you injured your knee could you tell me a bit about what happened
[patient] yeah i thought it was a good idea to go to the trampoline park with my wife and heard a snap and instant pain when i was on the trampoline
[doctor] okay alright and so do do you go to the trampoline park often
[patient] i do n't and i think that's the issue
[doctor] okay so this is the first time you'd ever done something like that
[patient] yes
[doctor] okay alright i just wan na get like a few more details do you like work out regularly was this for fun or for like an exercise class
[patient] no it's just for fun
[doctor] okay and do you have like a regular exercise regimen at all
[patient] try to not consistent with it
[doctor] okay no that's fine this is not a place of judgment i just i'm just trying to understand like if a little bit more of the background okay so we went to the trampoline park which knee where did you hurt
[patient] my right
[doctor] okay your right knee and so based on like your inside and outside which part hurts more
[patient] it's kind of the outside of the knee
[doctor] alright so the lateral aspect not a problem and you said that you heard a pop when you landed right
[patient] yeah
[doctor] okay have you taken anything for the pain
[patient] just tylenol
[doctor] alright so did the tylenol help
[patient] not really
[doctor] okay alright and so hmmm when does it have you tried anything else like did you ice it use heat anything like that
[patient] no i just kinda elevated it and that was about it
[doctor] okay that's fine and how long ago did this happen
[patient] a week ago
[doctor] okay alright so you put up with the pain for a week that's i'm proud of you for that
[patient] i do n't like to come to the doctors
[doctor] excuse me i feel rejected right now why why would you say something like that it's fine but you know i i like it when you're not here either because that means that you're doing a good job so let's see about like getting your knee fixed up but i want to talk about some of the other issues that you have first so we know that you have hypertension right and i discussed maybe you getting a blood pressure cuff because i needed you to measure those a bit more regularly did you get the cuff
[patient] what no
[doctor] no okay that's fine have you measured your blood pressure recently at all
[patient] no
[doctor] okay are you still taking your medication because i see you're on twenty milligrams of lisinopril
[patient] yeah most days i remember
[doctor] okay
[patient] ra i'm not suspicious but we're just gon na go with that okay because looking at your vitals it it is of still a bit high i'm not really comfortable i see like a hundred and eighty over you know eighty and
[doctor] that's not where we wan na be so i wonder if we might need to adjust your medication but let's talk about your diabetes how are your blood sugars
[patient] i think they're little bit better
[doctor] okay what makes you think that have you been taking them
[patient] yeah i check it you know most days again kinda when i remember
[doctor] okay how often are you checking it
[patient] i would say four five times a week
[doctor] okay you might wan na switch to maybe two or three times a day but you know that's something i'm glad that you are measuring are you taking your metformin
[patient] yes
[doctor] okay and then i think we have you on five hundred milligrams correct
[patient] yes
[doctor] alright how is your diet
[patient] kinda the same as my exercise decent could be better
[doctor] alright and okay not a problem so what is your do you are you measuring your calories at all looking at your macros are you just eating what you feel like
[patient] yeah just trying to watch what i eat more than anything but nothing specific
[doctor] okay and are you do you know if you're particularly focused on your salt like is it like a low salt diet
[patient] no just trying to watch my carbs a little bit more but not counting or anything
[doctor] alright so like is it a specific diet i just wan na make sure like are you on like the keto diet
[patient] no
[doctor] okay alright not a problem so if you do n't mind i'm gon na go ahead and do a quick physical exam as i mentioned before your blood pressure is a little high as i listen to your heart i do like it's got a nice regular rate and rhythm i do n't appreciate any murmur when i listen to your lungs they sound clear bilaterally i would like to look at your knee though so when i press here on the outside does it hurt
[patient] little bit
[doctor] okay and then when i press on the inside does it hurt
[patient] no
[doctor] alright can you bend your knee and straighten it
[patient] i can i think that's all i can i can bend
[doctor] mm-hmm alright so are you having problems walking can you bear weight
[patient] i can but i have a little bit of a limp
[doctor] okay so do you mind getting up and walking for me really quickly alright so i do notice that there is a slight gait like there is a small sorry you are correcting you do have a limp i i am a little worried about that but it's probably it's probably the superficial when i'm looking at your knee i do notice some like ecchymosis and edema that just means bruising and swelling along the lateral aspect of your knee i do n't notice any effusion and it looks like you have a decent range of motion but i do understand that you know you are experiencing pain with some movement okay i'm gon na go ahead and order an x-ray and when you come back we can have that discussion alright so i reviewed the results of your right knee x-ray which showed no evidence of fracture or bony abnormality so let's talk about my assessment and plan alright so for your first problem of right knee pain i think you have a lateral a lateral ligament strain i wan na prescribe some meloxicam which is gon na be fifteen milligrams daily for pain and swelling i'm gon na refer you to physical therapy to help strengthen the muscles around the area and to prevent further injury if you're still having pain we can do further imaging imaging but like this is a common injury that tends to heal on its own for your second problem with hypertension i wan na continue the lisinopril at twenty milligrams and order an echo i am concerned that we might not be getting your blood pressure to where we need it to be so we might have to do some medication modification for your third problem with diabetes i wan na order an a1c i know that you said you have been measuring your blood sugars but i think this would give us a better image of what's been happening long term and i also wan na order a lipid panel in case we need to make any adjustments to that medication as well do you have any questions
[patient] sounds good
[doctor] alright awesome
CHIEF COMPLAINT

Right knee injury.

HISTORY OF PRESENT ILLNESS

William Russell is a pleasant 57-year-old male who presents to the clinic today for the evaluation of a right knee injury. He has a past medical history significant for hypertension and type 2 diabetes.

Approximately 1 week ago, the patient sustained an injury to his right knee while at a trampoline park. He explains that he was jumping on a trampoline when he heard a snap, followed by instant pain in the lateral aspect of his knee. This is not a common activity for him, and he admits that he is inconsistent with exercise. As far as treatment, he has been elevating his knee and taking Tylenol without significant relief of his pain. He has not tried applying heat or ice to the area.

In terms of his hypertension, the patient admits that he did not purchase a blood pressure cuff as previously recommended. While he does not monitor his blood pressures at home, he has been compliant with lisinopril 20 mg.

His diabetes appears to be stable based on home monitoring, although he is only checking his blood glucose levels 4 to 5 times per week. He does not follow any specific diet plan, but he does try to make healthier choices such as limiting his carbohydrate intake. He has also been taking his metformin 500 mg as prescribed.

REVIEW OF SYSTEMS

Musculoskeletal: Reports right knee pain.

VITALS

Blood pressure: 180/80 mmHg

PHYSICAL EXAM

CV: Regular rate and rhythm. No murmurs.
RESPIRATORY:
Lungs are clear bilaterally.
MSK: Examination of the right knee: Mild tenderness to palpation at the lateral aspect. Ecchymosis and edema along the lateral aspect. No effusion. Decent range of motion. Pain with movement.

RESULTS

X-rays of the right knee were obtained and reviewed. These reveal no evidence of fracture or bony abnormality.

ASSESSMENT

1. Right knee pain, lateral ligament strain.
2. Hypertension.
3. Diabetes type 2.

PLAN

After reviewing the patient's examination and radiographic findings today, his symptoms appear to be consistent with a lateral ligament strain of the right knee. I am going to prescribe meloxicam 15 mg once daily for pain and swelling. I also put in a referral for physical therapy so he can work on strengthening the muscles around the area and prevent any further injury. We can consider further imaging if he continues to have pain, but I explained that this is a common injury that typically heals on it's own.

For his hypertension, I'm concerned that his blood pressure is not well controlled at this time, so we may need to modify his medication. I'm going to order an echocardiogram for further evaluation, but I want him to continue taking his lisinopril 20 mg for now.

For his diabetes, he stated that he has been measuring his blood glucose levels 4 to 5 times per week, but I want him to start measuring them 2 to 3 times per day. His hemoglobin A1c levels should provide more detail as far as his long-term progress so we will order that today. I'm also going to order a lipid panel and we can determine if any adjustments need to be made to his medication. In the meantime, he should continue taking metformin 500 mg.
