[doctor] good morning rebecca , nice to see you .
[patient] nice to see you too .
[doctor] so , my nurse told you a little bit about dax , now i'm wondering if i can tell dax a little bit about you .
[patient] go for it .
[doctor] okay , so rebecca is a 27-year-old female patient . um , you have a history of carpal tunnel , um , uh , release done couple of years ago , you have some chronic back pain , some depression . why am i seeing you today ?
[patient] so last week , um , and over the course of the month , i have taken up swimming more regularly .
[doctor] okay .
[patient] i've been trying to get up and get active . and i've- ... all of a sudden i've been feeling some really bad , um , knee pain-
[doctor] okay .
[patient] . in my right knee .
[doctor] just in your right knee ?
[patient] yeah .
[doctor] okay . just when swimming ? are you swimming freestyle with your legs kicking straight or more like breaststroke where your legs kick out ?
[patient] yeah , it's only while swimming. i use the breaststroke so i guess where the legs are kicking out like a frog ... it kinda starts hurting a little bit after i swim a couple laps , which a month ago when i started i was able to do ten .
[doctor] okay .
[patient] but after a couple of laps it starts to hurt .
[doctor] and no injury ? like you did n't fall or twist it or anything like that that you remember ?
[patient] no , not that i can remember .
[doctor] okay . so just swimming a lot and you feeling more and more discomfort ?
[patient] yeah .
[doctor] okay , good . so , um ... i know my nurse did a review of systems before you came in . there were really no significant issues . you have a history of chronic back pain , that's been doing well ?
[patient] yeah , it comes and goes , but right now it's been doing really well .
[doctor] okay , no pain going down your legs or anything like that ?
[patient] no .
[doctor] okay . and i know you have some depression , you've been on medication . how's that been going ?
[patient] that's been going really well .
[doctor] okay .
[patient] with the medication and therapy and then trying to get outside more it's been really helping me .
[doctor] sleeping well ?
[patient] yeah .
[doctor] eating well ? okay . do n't feel any concerns about hurting yourself or others or anything like that ?
[patient] no .
[doctor] okay , good . um , and the , you had ca- carpal tunnel done a few years ago . how's that doing ?
[patient] that's doing-
[doctor] any flare up with that ?
[patient] . that's doing really well . i've been getting full range of motion and it's felt a lot better .
[doctor] okay , great . do you mind if i do a quick exam ?
[patient] yeah , go for it .
[doctor] squeeze my fingers for me . good . okay . is it painful if i move your patella like that ?
[patient] yeah , that hurts .
[doctor] okay . and i'm gon na hold your leg out , i'm gon na hold , i want you to stiffen your upper ... does that hurt when i do that ?
[patient] yeah , that hurts too .
[doctor] okay , good , all right . um , let's take a quick look at your x-ray , okay ?
[patient] okay .
[doctor] hey Sarah , show me the right knee x-ray . okay , so here's a picture of your right knee . actually normal x-ray , everything looks good , okay ? on my exam , um , you do n't really have any swelling in- in your joints , um , uh , of your knee . you have a little pain with , um , uh , range of motion of the knee . you have real pain when we do what we call patella in- ... patellar inhibition , okay ? so that's what caused most of that pain . so , um , your heart is regular , your lungs are clear , i do n't feel any adenopathy , your thyroid's , um , normal , your grips are equal , the rest of your exam is essentially normal , okay ? so my assessment is , you have what we call chondromalacia of the patella , okay ? it's just from the overuse and all- all the swimming you've been doing , okay ? so , um , to treat that we'll just use some anti-inflammatories , um , go ahead and take some ibuprofen , 600 milligrams four times a day with food . i do want you to do some straight leg raising exercises , that'll strengthen your quadriceps and that'll help with that pain , okay ?
[patient] okay .
[doctor] um , basically you want to avoid anything that puts extra pressure on your knees for a little while and it should be fine . if it's not getting any better in a couple weeks i wan na see you again , okay ? so no lunges , avoid the breaststroke . if you're comfortable, you can also do other swimming strokes where your knees are straight instead . or you can take the opportunity to have a little break .
[patient] all right .
[doctor] your second problem is your chronic back pain , that's been doing really well . um , keep swimming , that's okay after this gets better .
[patient] yeah .
[doctor] um , but i think , um , i think that's been under control . but if it flares up go ahead and , uh , give me a call , okay ?
[patient] mm-hmm .
[doctor] um , your third problem is your depression . that's been stable . we're gon na keep you on your current medication , not gon na change anything at this point , okay ? and as far as your carpal tunnel goes , that's relatively stable , so , um , uh , no changes there as well . okay ? so anything else i can do for you ?
[patient] no , that's it .
[doctor] okay , well we'll get you checked out .
[patient] all right .
[doctor] hey Sarah , finalize the report .

CHIEF COMPLAINT

Joint pain

HISTORY OF PRESENT ILLNESS

Ms. Thompson is a 27 y.o. female with a history of carpal tunnel release done a couple years ago, chronic back pain, and depression. She presents today for joint pain.

Ms. Thompson reports that over the course of the month she has begun swimming more regularly and trying to be more active. She has experienced bad right knee pain. The patient reports that her knee starts hurting after a couple of laps. She notes previously she could swim 10 laps. She denies injury or trauma to the knee.

The patient has a history of chronic back pain that has been intermittent, but right now it has been doing well. She denies pain radiating down her legs.

The patient has a history of depression, which has been going really well with medication and therapy. She is trying to get outside more and it has been helping her with her depression. She notes she is sleeping and eating well. She denies concerns about hurting herself or others.

The patient's carpal tunnel is doing really well. She has been getting full range of motion and it has felt a lot better.

REVIEW OF SYSTEMS

• Musculoskeletal: Endorses right knee joint pain. Endorses chronic back pain.
• Psychiatric: Endorses depression.

PHYSICAL EXAMINATION

• Neurological/Psychological: Appropriate mood and affect. Grips are equal bilaterally.
• Neck: Supple without thyromegaly or cervical lymphadenopathy.
• Respiratory: Lungs are clear to auscultation bilaterally. No wheezes, rales, or rhonchi.
• Cardiovascular: Regular rate and rhythm. No murmurs, gallops, or rubs. No extra heart sounds.
• Musculoskeletal: No lower extremity edema. Pain with patellar inhibition. Pain with range of motion of the right knee.

RESULTS

X-ray of the right knee is unremarkable.

ASSESSMENT AND PLAN

Ms. Thompson is a 27 y.o. female who presents today for evaluation of right knee pain.

Chondromalacia of right patella.
• Medical Reasoning: She has been more active lately but is unaware of any injury to the knee. Her recent x-rays were normal but she did have some discomfort on exam.
• Medical Treatment: Prescribed ibuprofen 600 mg 4 times a day with food. I do want her to do some straight leg raising exercises that will strengthen her quadriceps.
• Patient Education and Counseling: I encouraged her to participate in physical activity that is less straining on her joints , such as swimming freestyle laps, or to stop activity all together. If her pain does not improve in a couple of weeks, she will follow up.

Chronic back pain.
• Medical Reasoning: This is stable and well-controlled at this time.
• Medical Treatment: She should continue swimming regularly once her knee is feeling better.

Depression.
• Medical Reasoning: She is doing well with her current regimen.
• Medical Treatment: Continue current medications.

Carpal tunnel syndrome.
• Medical Reasoning: Relatively stable status post carpal tunnel release.
• Medical Treatment: Continue current regimen with no changes at this time.

Patient Agreements: The patient understands and agrees with the recommended medical treatment plan.
