Mrs. Garcia Case Summary

Mrs. Garcia is a 45-year-old patient who came to the office with a complaint of left knee pain of one-day duration. Mrs. Garcia was in her usual state of health until yesterday when she developed a left knee pain while playing kickball. Complaints of sudden onset of pain and swelling over the left knee joint as well as locking and painful popping. The onset of pain was secondary to a twisting injury and followed by a give away weakness. Upon awaking this morning her left knee was swollen, stiff and tender with a mild amount of redness. The knee started to hurt her, which is worse while climbing the stairs; she rates the pain as 8/10 with 10 being the worst pain. The knee pain is slightly relieved by keeping the leg elevated and applying ice …show more content…
Problems at birth: No reported problems
Adult illnesses (physical, emotional, mental): No history of rheumatoid arthritis, cerebral palsy, muscular dystrophy, diabetes, hypertension, asthma, HIV. Surgeries: No surgeries, especially surgeries involving muscles, bones, or joints. Ob/ Gyn: No children, never married not been into any relationship. Menarche age 13, last menses was last month 12th. No interest in sex, and not sexually active. No concerns about HIV infection. Hospitalizations: No hospitalizations
Health maintenance. Immunizations: Oral polio vaccine at the age of 6months, tetanus shots × 2, 2012, followed with a booster dose one year later, flu vaccine, 2016, no reaction. Last Examination: Last routine physical exam was in 2015 everything gone well. Screening tests: Last Pap smear, March 2016, nothing significant found. The last mammogram was in December 2015, with some calcifications. Cholesterol screening done in 2015, total cholesterol level was 198, dental exams every year for cleaning, last in November 2015. Eye exam January this year for his farsightedness received new eyeglasses, complete eye exam was done including tonometry, was negative for