CC
Simon is a 13-year-old male here today with his mother to establish care. They recently relocated to the area from Cane. Simon has been complaining of some bilateral, though left greater than right, knee pain.
HPI
The patient has had knee pain on and off now for at least several months. They did have this evaluated with his prior doctor. Reportedly a left knee x-ray was done. It was normal. The doctor there recommended that they just monitor it. He has the pain only when he runs and mom reports that he has even given up cross-country because he did not want to run because of the pain. He, however, still continues to play baseball and basketball, both of which do not seem to cause him to have knee pain. There has not been any …show more content…
No wheeze or rhonchi.
Abdomen
Soft and nontender. No masses or discomfort.
Extremities
Bilateral knee exam was performed. No obvious signs of swelling. There is no redness. There is no tenderness over the tibial tuberosity or along the patellar tendon. No pain with patellar grind. Full range of motion of the knee without pain. No pain with varus and valgus strain. Other provocative testing all normal or negative. He is asymptomatic here in the office. His gait is normal.
Skin
There are no rashes on the visible skin.
A/P
Simon Pierce is a 13-year-old male here today to establish care.
Intermittent complaints of bilateral though left greater than right knee pain. Currently, he is not having symptoms. I did talk with mom that I am concerned about the fact that he is giving up activities because this knee pain has been bothering him. I have recommended a sports medicine or orthopedic evaluation. She declines that today. She would like to see how he feels over the course of the next couple of weeks. She is going to have him start running again and see if he develops symptoms. If so, she will contact me and let me know that she would like to do that referral then. Otherwise, if not having symptoms, will touch base with me for routine care. They will contact me if they change their mind regarding
Simon is a 13-year-old male here today with his mother to establish care. They recently relocated to the area from Cane. Simon has been complaining of some bilateral, though left greater than right, knee pain.
HPI
The patient has had knee pain on and off now for at least several months. They did have this evaluated with his prior doctor. Reportedly a left knee x-ray was done. It was normal. The doctor there recommended that they just monitor it. He has the pain only when he runs and mom reports that he has even given up cross-country because he did not want to run because of the pain. He, however, still continues to play baseball and basketball, both of which do not seem to cause him to have knee pain. There has not been any …show more content…
No wheeze or rhonchi.
Abdomen
Soft and nontender. No masses or discomfort.
Extremities
Bilateral knee exam was performed. No obvious signs of swelling. There is no redness. There is no tenderness over the tibial tuberosity or along the patellar tendon. No pain with patellar grind. Full range of motion of the knee without pain. No pain with varus and valgus strain. Other provocative testing all normal or negative. He is asymptomatic here in the office. His gait is normal.
Skin
There are no rashes on the visible skin.
A/P
Simon Pierce is a 13-year-old male here today to establish care.
Intermittent complaints of bilateral though left greater than right knee pain. Currently, he is not having symptoms. I did talk with mom that I am concerned about the fact that he is giving up activities because this knee pain has been bothering him. I have recommended a sports medicine or orthopedic evaluation. She declines that today. She would like to see how he feels over the course of the next couple of weeks. She is going to have him start running again and see if he develops symptoms. If so, she will contact me and let me know that she would like to do that referral then. Otherwise, if not having symptoms, will touch base with me for routine care. They will contact me if they change their mind regarding