Mr X a 15-year-old, black male who came in for a dull pain in the knee.

Mr X a 15-year-old, black male who came in for a dull pain in the knee.

Mr X a 15-year-old, black male who came in for a dull pain in the knee. 150 150 Peter

Patient Information:

Patient: X, Age: 15 years old, Sex: Male, Race: Black

S.

CC (chief complaint): patient came for a dull pain in both knees.

HPI: Mr X a 15-year-old, black male who came in for a dull pain in the knee. He said sometimes one or both knees click, with a catching sensation under the patella. I will if the pain is limiting joint movement, the onset of the pain, is the pain intermittent or constant. The pain started having the pain a month ago while he climbed the stairs at home. Slight swelling no redness which sometimes affects both knees which has interrupted with his daily activities. The joint looks good. The patient said pain is experienced with movement and worse with climbing or ascending a flight of stairs as such it most felt during the day while he is active and relieved with rest. His mom applied ice to the knees and gave 500mg of Tylenol which relieved the pain. Mom also applied icy hot rub to help with the pain. The cause is unknown to the patient, but he says he is soccer player and has had contacts with friends in the field while playing so he feels it could be from the trauma in contact sports.

Location: knee- bilateral at times

Onset: insidious

Duration: started a month ago

Character: dull knee pain with one or both knees having a click sensation, with a catching sensation under the patella

Associated signs and symptoms: no fever, no nausea, no vomiting, limited movement, swelling of the knee

Timing: while climbing a flight of stairs or with strenuous activity, or movement.

Exacerbating/ relieving factors: pain is worse with climbing and movement, relieved with rest. Mom applied an ice pack to the knees, used icy hot rub and gave him 500 mg of Tylenol which he said helped. He has been using them for a week now.

Severity: 8/10 pain scale with movement, 3/10 while at rest

Current Medications:

Tylenol 500 mg 1 tab x 2/ day

Ice packs were used as needed

Icy hot- twice daily

Allergies: patient’s mom said he had no food of drug allergies and that he has never had an allergic reaction. The patient also confirmed he has no allergies.

PMHx: up to date with all immunizations. He has never been hospitalized and has had no surgeries. He was born at term with no abnormalities or deformities, patient denies any autoimmune condition.

Soc Hx: Patient is in high school and plays soccer but has been remote leaning and so has not played in about 3 months buts jogs daily around the neighborhood. He lives with his mom and dad and has 2 siblings in their single-family home. Patient has health insurance through his parents and good access to healthcare. His hobby is doing sports; running sprinting and soccer which have been limited with the pain in his knee. He can perform his activities of daily living but unable to complete activities like climbing and bending while performing house chores. He says he gained some weight from staying more at home lately but weight but normal for his age. He eats a balanced diet with fruits and vegetable and Powerade while exercising especially with the morning sun for vitamin D. He rarely drinks sodas. He says he never smoked and does not drink alcohol. He is to club activities in school to keep focused and out of bad companionship. His parents are involved in life to make he succeeds.

Fam Hx: Mom has osteoporosis and has had a knee replacement surgery, Dad is healthy. No medical problems with siblings. Maternal died at 75years from stroke, maternal grand mom is still living. She is 77years and takes just vitamins. Both paternal grandparents are of late, not sure of the cause of death.

ROS:

GENERAL:  no fever, no chills, knee pain, no weight loss.

HEENT:  Eyes:  patient has impaired vision and wear glasses. Hearing is intact, patent nostrils and mouth is pink and moist. No sores in the throat.

SKIN:  No rash or itching, skin is intact

CARDIOVASCULAR:  patient denies chest pain, no palpitation, he has strong pulses on all extremities.

RESPIRATORY:  No shortness of breath, no cough

GASTROINTESTINAL:  denies nausea, vomiting and diarrhea. No pain in the stomach

GENITOURINARY: he voids normally and able to control stream

NEUROLOGICAL:  No headache, dizziness, syncope, paralysis, ataxia, numbness or tingling in the extremities. No change in bowel or bladder control.

MUSCULOSKELETAL:  pain in the joint and muscles of the knee, no stiffness, click sound heard with movement, swelling

HEMATOLOGIC:  No anemia, bleeding or bruising.

LYMPHATICS:  No enlarged nodes.

PSYCHIATRIC:  patient says he has never been depressed but he is anxious about what is going on with his knee.

ENDOCRINOLOGIC:  No reports of sweating, cold or heat intolerance. No polyuria or polydipsia.

ALLERGIES:  no known allergies