Patient Information:
Initials: P.A. Age: 15 years Sex: Male Race: White
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CC (chief complaint): “I have a dull pain in both knees. Sometimes one or both knees click. I feel a catching sensation under the patella.”
HPI: P.A. is a 15-year-old male who has reported to the clinic unaccompanied. His chief complaint is a dull pain in both knees. As reported by P.A., sometimes one or both knees click, and he feels a catching sensation under the patella. The pain started 4 days ago after completing an athletics competition. It increases during activity and subsides during rest. P.A. denies using any medications to manage the pain.
Location: both knees
Onset: 4 days ago
Character: dull
Associated signs and symptoms: fever
Timing: after sitting down for a long time
Exacerbating/ relieving factors: aggravated by physical activity and subsides with rest
Severity: 5/10 pain scale
Current Medications: None
Allergies: No known drug or food allergies reported.
PMHx: Received all childhood immunizations as scheduled. Last tetanus vaccine was on 02/08/2022. Denies a history of hospitalization.
Soc Hx: P.A. is a high school student. He does no consume alcohol or cigarettes. P.A. is an aspiring athlete and like to train everyday with his colleagues.
Fam Hx: No family member has recently been diagnosed with a serious medical condition.
ROS:
GENERAL: Reports fever. Denies abnormal changes in weight. Does not report chills or fatigue. Reports weakness in the knee joints.
HEENT:
Eyes: Denies visual loss or blurred vision
Ears: Denies ear pain
Nose: Denies nasal congestion or stuffiness
Throat: Denies a sore throat
SKIN: Denies itchiness, rashes, or lesions. rash or itching.
CARDIOVASCULAR: Denies chest discomfort or pain.
RESPIRATORY: Denies shortness of cough, sputum, or shortness of breath.
GASTROINTESTINAL: No abdominal pain or discomfort reported.
GENITOURINARY: Does not report a burning sensation during urination.
NEUROLOGICAL: Denies headache or dizziness. Does not report numbness or tingling of the extremities.
MUSCULOSKELETAL: Reports a dull pain on both knees. One or both knees sometimes click. P.A. reports a catching sensation under the patella.
HEMATOLOGIC: Does not report anemia or uncontrolled bleeding.
LYMPHATICS: Does not report enlarged nodes.
PSYCHIATRIC: Denies depression or anxiety.
ENDOCRINOLOGIC: Denies abnormal night sweats. Denies polyuria or nocturia.
ALLERGIES: Denies food or drug allergies.
O.
Vital signs: Temperature: 36.5 degree Celcius, blood pressure: 118/76, respiratory rate: 20 breaths per minute, weight: 124.4 lb, height: 68.2 inches.
General appearance: P.A.is attentive. He is well groomed. He is also properly oriented to time, place, and person.
Skin: No lesions or sores. The skin is warm and hairy.
HEENT:
Head: Normocephalic. No masses. No sign of physical injury.
Eyes: Clear conjunctivae. Visual acuity is 20/20.
Ears: No discharge. No signs of blockage.
Nose: Absence of nasal tenderness. The nasal mucosa is moist and hairy.
Throat: Non-erythematous. No edema or exudates.
Neck: No signs of swelling or pain.
Chest: Rhonchi rubs or wheezes absent
Heart: No gallop. No murmur. Capillary refill less than 3 seconds.
Abdomen: No evidence of abdominal tenderness. Absence of bowel sounds.
Back/spine: No evidence of deformities.
Extremities: Mild pain in the knee joints.
Genitalia/Rectal: Male genital organs present.
Neurologic: Abnormal gait.
Diagnostic results: No tests have been conducted so far.