CHIEF COMPLAINT: Left knee pain.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old male who presents to the emergency department today with the above complaint. The patient states that two days ago he was walking. He states that afterwards he experienced pain to the left knee. The pain is mainly over the lateral aspect of the left knee. There was no trauma or injury, did not fall, nor did he twist the left knee that he is aware of. He has not noticed any swelling, redness or bruising. He declines pain to the left hip, left ankle, and phalanges of the left foot. He came to the emergency department with pain to the left knee for further evaluation. He rates his pain as an 8 on a pain scale of 1-10 with 10 being the most severe.
While here in the emergency department, the patient states that he developed pain to his chest. The pain is central in nature, and he describes it as a “heavy” sensation. The pain radiates to the left upper extremity, and he states that his left arm was “numb.” He also notes that he feels short of breath and has had some nausea, no diaphoresis, no vomiting.
PAST MEDICAL HISTORY: The patient has a prior history of sciatica. According to records, he has a prior history of kidney stones, hypertension, hepatitis C and a prior history of polysubstance abuse. He has hypertension as well as chronic back pain. It appears that the patient was hospitalized on MM/DD/YYYY secondary to chest pain. He had Lexiscan stress test without difficulty. EKG components were negative on post-exercise imaging.
PAST SURGICAL HISTORY: The patient states that he had abdominal surgery secondary to trauma. According to records, he had some type of a stab wound, which required exploratory laparoscopy. He has also had hernia repair x2, surgery for kidney stones, and also surgery secondary to testicular torsion.
MEDICATIONS: Neurontin, Motrin, and Xanax.
ALLERGIES: The patient is allergic to codeine.
SOCIAL HISTORY: The patient denies tobacco, ETOH or illicit drug use.
FAMILY HISTORY: The patient states that his father died of an MI at age 54.
REVIEW OF SYSTEMS:
GENERAL: No fever. No change in appetite or energy.
ENT: No congestion, runny nose, ear pain or sore throat.
EYES: No redness, swelling or drainage.
RESPIRATORY: No cough. The patient notes shortness of breath as per HPI.
CARDIOVASCULAR: Chest pain as per HPI. No palpitations.
GASTROINTESTINAL: Nausea, but no vomiting, diarrhea, no abdominal pain.
GENITOURINARY: No dysuria.
NEUROLOGIC: No headache.
MUSCULOSKELETAL: Left knee pain as per HPI.
SKIN: No rashes.
HEMATOLOGY: No history of abnormal bleeding.
ENDOCRINE: No polydipsia or polyuria.
PSYCHIATRIC: The patient denies depression.
PHYSICAL EXAMINATION:
VITAL SIGNS: Temperature is 36.2 tympanic, pulse 104, respirations 18, BP 148/102, O2 sats 99% on room air.
GENERAL: The patient is well developed, nontoxic, in no acute physical distress.
HEENT: Head: Atraumatic. No scalp lesions or masses: Eyes: Pupils are equal and reactive to light. Extraocular movements are intact. There is no conjunctival discharge or erythema. Ears: No erythema or exudate of the external canals. Both TMs are pearly gray with good light reflex. Nose: No mucosal congestion, discharge or lesions. Mouth: Mucous membranes are moist and pink. There is no pharyngeal erythema or exudate. Uvula is midline. Airway is patent.
NECK: Supple without meningismus. There is no cervical lymphadenopathy.
LUNGS: Equal breath sounds bilaterally. Clear to auscultation without crackles, wheezes or retractions.
HEART: Regular rate and rhythm. There are no murmurs, gallops or rubs.
ABDOMEN: Soft, positive bowel sounds. No organomegaly or masses. No CVA tenderness. Abdomen is nontender. No rebound or guarding. No peritoneal signs. No rigidity.
EXTERNAL GENITALIA: Deferred.
SKIN: No rashes, lesions or pigment changes.
CNS: The patient is alert and oriented x3. Cranial nerves II-XII are grossly intact. EXTREMITIES: No obvious joint deformity. No clubbing, cyanosis or edema. Left lower extremity: The patient lies on the exam bed with his left knee flexed secondary to pain. He does elicit pain with extension of the knee or with full flexion. He is point tender over the lateral aspect of the left knee, but there is no overlying erythema, no edema or ecchymosis. He has full range of motion of the left hip, left ankle, and phalanges of the left foot. Pulses are +2 bilaterally. Cap refill is less than 3 seconds. The patient has good strength and good sensation.
EMERGENCY DEPARTMENT TREATMENT AND COURSE: Left knee x-ray was obtained. Four views reviewed. It was read as no signs of acute fracture, dislocation or marked arthritic changes per radiologist. After coming to the emergency department and going through triage process, the patient developed chest pain. Further diagnostic studies have been ordered. The patient was placed on cardiac monitoring. IV access will be obtained. The patient will receive four baby aspirin p.o., morphine sulfate 4 mg IV, and Zofran 4 mg IV.
CBC, comprehensive metabolic panel, EKG, PT, PTT, urinalysis, cardiac panel at 0 hour and 90 minutes, BNP, ABG, D-dimer, chest x-ray PA and lateral have been ordered. All results are currently pending.
The patient will continue to be monitored. We will obtain all diagnostic results, reassess, and decide on further management/disposition. She has been evaluated and examined by Dr. John Doe, who agrees with this plan.
