[##]-year-old [male/female] with [right/left] knee pain [and injury] with history
and exam consistent with likely [medial/lateral anterior/posterior
collateral/cruciate] ligament injury.
Initial consideration in this patient included ligamentous injury to the
medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate
ligament (ACL), posterior cruciate ligament (PCL), and medial and lateral
meniscus, knee dislocation, patellar and other knee fractures, patellar and
quadriceps tendon injury or rupture, arthritis, pes anserine and prepatellar
bursitis, and septic arthritis amongst others.
Patient present with [right/left] knee pain in the setting of [describe
injury] concerning for ligamentous injury to the knee. Patient noted to have tenderness to palpation
[over the medial/lateral joint line concerning for MCL injury/LCL injury] on
exam. Specialized testing performed on
the [right/left] knee as noted above with [positive valgus (abduction) stress test
suggestive of MCL injury/positive varus (adduction) stress test suggestive of
LCL injury/positive anterior drawer test/Lachman’s test suggestive of ACL
injury/positive posterior drawer test suggestive of PCL 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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