JB, 15years old, Caucasian, Male Subjective Data Chief Complaint:The patient presents to the clinic with the complaints of dull pain in both knees for past five days and sometimes one or both knees click with the catching sensation under the patella. History of Present Illness: JB is a 15-year-old Caucasian male who presents to the clinic for bilateral anterior knee pain described as dull, accompanied by “clicking” and a “catching” sensation under the patella. He reports the pain started 5 days ago while playing soccer and “gets worse” while running. He states mild relief with rest, ice and use of ibuprofen. Patient states pain level of 7/10 when engaging in activity Current Medications: Ibuprofen 400mg every eight hours as needed. Allergies:No known allergy to medication, food, and environment
Past Medical History: Social History: JB is a sophomore in local public school where he is in honors classes and plays soccer and baseball. Lives with married parents and two younger siblings, sister age 8, and brother age 6. Denies alcohol, tobacco and illicit drug use. Always wears a seat belt and he has working smoke detectors in the house. He says living environment is safe and, supportive family member. Family History: No history of illnesses with possible genetic predisposition, no contagious or chronic illnesses. No history provided about the family member. Review of System: GENERAL: No weight loss, fever, chills, weakness or fatigue. HEENT: Head: no head injury. Eyes: No visual loss, blurred vision, double vision or yellow sclera. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose or sore throat
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