CHIEF COMPLAINT: Left thigh pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Hispanic gentleman who comes to the emergency department today after injuring his left leg during a football game. The patient relates a history of tripping while running across the field and injuring the leg slightly. He states that he then sprinted later in the game and felt a tearing pain, which brought him to the ground and was extremely painful. He rates the pain as a 10/10 in severity. It is relieved by sitting, provoked by moving. It is constant and sharp in quality. The patient denies any other complaints associated with this current condition.
PAST MEDICAL HISTORY: None.
ALLERGIES: None.
MEDICATIONS: None.
FAMILY HISTORY: Positive for hypertension.
SOCIAL HISTORY: The patient smokes tobacco. Denies drinking alcohol and denies taking recreational drugs.
REVIEW OF SYSTEMS: Negative for fever or weight loss, no visual changes, no sore throat, no chest pain, no shortness of breath, no abdominal pain, no weakness or numbness, no rash or pruritus, no dysuria or frequency, and all other systems reviewed were negative.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature 98.6, blood pressure 148/80, pulse 94, respiratory rate 18, and oxygen saturation 97% on room air.
GENERAL: This is a well-appearing, well-developed Hispanic gentleman who is alert and oriented x3, in no apparent distress.
HEENT: Normocephalic and atraumatic. Pupils are equal, round, and reactive to light. Extraocular movements are intact. Tympanic membranes are clear, and oropharynx is pink and moist.
NECK: Supple without lymphadenopathy. No JVD or tracheal shift visualized.
LUNGS: Clear to auscultation bilaterally without wheezes, rhonchi or rales.
HEART: Regular rate and rhythm. No murmurs, rubs or gallops.
ABDOMEN: Soft, nontender, and nondistended with bowel sounds present in four quadrants.
MUSCULOSKELETAL: Reveals some tenderness to palpation over the left anterior thigh. The patient is able to flex and extend the leg, but there is pain associated with this movement. Strength exam on the left leg is limited by pain as well.
SKIN: Reveals no lesions or rashes.
NEUROLOGIC: Intact with no focal deficits. Specifically, the patient’s sensation and position sense are intact distally in the left leg, and there are good pulses in the distribution of the dorsalis pedis and posterior tibialis.
PSYCHIATRIC: Appropriate affect.
RADIOLOGY: X-ray of the pelvis revealed no acute radiographic abnormalities. X-ray of the femur revealed triangular-shaped lucency to the distal femoral metastasis. This is seen on a single image, likely represents artifact, as per Radiology.
EMERGENCY DEPARTMENT COURSE/MEDICAL DECISION MAKING: The patient was seen and evaluated. After thorough physical examination, reviewed the patient’s history of present illness and past medical history. It was determined that the next appropriate step was to perform the diagnostic tests as dictated above. After finding the patient to have no acute fracture or avulsion of his femur or pelvis, it was felt that the patient most likely had a sprain or tear of the quadriceps muscle. For this reason, the patient was given an Ace wrap, crutches, and pain medication in the form of Percocet #30 in order to treat an obviously painful condition. The patient will follow up with Orthopedics, was given an urgent orthopedics appointment so that they may further assess his condition at that time and evaluate him for any need for further definitive treatment. The patient was given instructions to rest, ice, and elevate his left extremity and was encouraged to return to the emergency department for worsening of symptoms.
DIAGNOSIS: Left quadriceps injury.
PLAN:
1. The patient will be discharged home in good condition with the above-dictated instructions.
2. The patient will follow up with Orthopedics.
3. The patient is to return to the emergency department for worsening of symptoms.
