Right Knee Injury Report

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Reason for Visit: Contusion of the Right Knee
S: TM states, as she was walking out of the break room, she thinks, the door caught her Left heel causing her to trip and falling on her right knee. This injury occurred on Wednesday, 2/3/2017, but the pain and the bruising was minimal, and so she didn’t report it. Today, her pain is up and bruising is worse.
O: Right Knee: no malalignment, no atrophy, mild swelling and bruising in the anterior knee; no effusion, palpated. Tenderness with palpation to anterior knee; Full active and passive ROM; Knee joint stable, without locking, and catching; X-ray was negative for abnormality, or fractures.
A: Right Knee Contusion
P: Ice X 20 minutes NOW
Soft Knee Brace: Right Knee
Ibuprofen 200 mg tab 2 tabs

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