Setting: Orthopedic Clinic
HPI: Timothy Powers is a 17-year-old male who comes to the orthopedic clinic after sustaining a knee injury the previous night.
He was playing in a high school football game and felt severe pain in his left knee after getting tackled.
He was taken to the ER where he was placed in a knee brace and instructed to follow up with the orthopedics clinic today.
Timothy describes how it was the fourth quarter of a close game when he got tackled from the side. He immediately felt a ‘pop’ in his knee and was unable to get up. His teammates had to help him off the field, where the team’s trainer then took a look.
He was unable to put any weight on the knee. The trainer applied ice, and Timothy watched the rest of the game from the sideline.
The trainer suggested he go see a doctor the next day.
Past Medical History: Otherwise healthy
Past Surgical History: None
Medications: Acetaminophen as needed for pain
Family History: His parents and siblings are alive and healthy.
Social history: He is in his junior year of high school. He plays football and basketball for his school’s varsity teams. No alcohol, tobacco or illicit drug use. He has a girlfriend but is not sexually active.
ROS: No fever or chills, shortness of air, numbness, tingling or weakness. No problems with his right leg.
General: Healthy appearing male; appears in pain and mildly anxious.
CV: 2+ posterior tibial and dorsal pedis pulses bilaterally
Abdomen: Soft, nontender, bowel sounds present, no masses, exam limited by body habitus. Unable to palpate bladder.
Musculoskeletal: The left knee is grossly swollen with a palpable effusion. The right knee is normal. Knee active ROM is reduced on the left and full on the right. The left knee’s medial joint line is tender to palpation, otherwise both knees are non-tender to palpation throughout the joint lines.
|Valgus stress||Increased laxity||Normal|
Neurologic: BUE and RLE strength 5/5
LLE 5/5 w/ exception of knee flexion and extension limited by pain
Sensation intact to light touch throughout bilateral lower limbs.
Reflexes: R patellar 2+; L patellar unable to assess due to pain/swelling; Achilles 2+ bilaterally. No ankle clonus on either side.
Gait: ambulated with axillary crutches, unable to bear full weight on the left lower limb.