[##]-year-old [male/female] with [right/left] knee pain with history and
exam consistent with likely patellofemoral pain syndrome (“runner’s knee”).
Initial consideration in this patient included medial and lateral
meniscus injury, ligamentous injury to the medial collateral ligament (MCL),
lateral collateral ligament (LCL), anterior cruciate ligament (ACL), and posterior
cruciate ligament (PCL), knee dislocation, patellar and other knee fractures,
patellar and quadriceps tendon injury or rupture, arthritis, pes anserine and
prepatellar bursitis, and septic arthritis among others.
Patient present with [right/left] knee pain in the setting of [describe
injury] concerning for ligamentous and meniscal injury to the knee. Patient [reported/denied] episodes of locking
and clicking of the [right/left] knee. Patient
noted to have tenderness to palpation [over the medial/lateral joint line
concerning for ligamentous injury] on exam.
Specialized testing performed on the [right/left] knee as noted above
with [positive McMurray test suggestive of medial meniscus injury]. Imaging of the [right/left] knee [felt to not
be indicated in a patient meeting all Ottawa Knee Rules/with no evidence
suggestive of bony injury on exam/obtained with plain films noted to be
unremarkable/ findings]. The patient was
noted to have no evidence of associated [collateral/cruciate ligament/any
other] injuries. Patient provided with
[compression sleeve/knee immobilizer/crutches] in the ED prior to discharge
[and noted to have improved pain after treatment with Toradol/etc.].
Prior to discharge, we discussed return precautions, symptomatic
treatment with rest, ice, compression, and exercises as described in the
handout provided at time of discharge, and follow up with primary care doctor
within one week for further evaluation, and the patient demonstrated
understanding and agreement with this plan.
We specifically discussed that while additional imaging, including MRI,
may ultimately be a part of the management of this condition, it is not part of
the emergent management of this condition.
We recommended close follow up with their primary care provider for
further discussion of additional imaging, and the patient demonstrated
understanding and agreement.
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