MUSCULOSKELETAL SYSTEM
Date of Exam: 3/29/22
Pt. Initials: H. L.
Age: 22
Gender: Female
Race: Caucasian
Religion: Christian
Marital Status: Single
Occupation: Dog groomer
S:
CC: “I hurt my knee and it is swollen”
HPI:
Pt present to office with CC of a R knee pain that began 3 days ago. Pt reports the pain
began several hours after falling off of her bicycle. Pt denies symptoms at the time of
injury. Pt reports initial symptoms began “several hours after the fall” and include pain,
swelling, warmth, and redness. Pt reports that walking provokes the pain. Pt reports the
pain is felt “in front part of my knee.” Pt describes the pain as “aching and lasts for
several hours after activity.” Pt reports the pain as 6/10. Pt reports associated symptoms
of swollen, warm, and red surrounding skin. Pt reports the swelling, warmth, and redness
began 2 days ago. Pt denies additional associated symptoms including stiffness, pain that
coincide with weather changes, weakness, fatigue, wasting, gait change, limping,
numbness, tingling, crepitus, recent fractures, locking episodes of the knee, and episodes
of the knee giving way. Pt reports improved pain, swelling, temperature, and redness with
elevation and ice of the R knee. Pt denies the use of any medications to aid in symptom
relief. Pt denies similar symptoms occurring previously. Pt reports she has sought medical
attention at this time d/t “I can’t work like this; the pain just gets worse the longer I work
and walk around.”
PMH:
Allergies:
Pt denies allergies to medications.
Pt denies allergy to animals including dogs and cats.
Pt denies environmental allergies including dust and grass.
Pt denies food allergies.
Medical/Chronic Illnesses:
Pt reports history of asthma. Dx at 10-years old. Pt denies hospitalization for asthma.
Pt denies additional medical dx.
Pt denies hx of Pneumonia, Tuberculosis, and Tonsillitis.
Surgical:
Pt reports dental surgery at age 17 to remove her molars.
Medications:
Pt reports using an albuterol inhaler 2-3 times per week. Pt reports 2 puffs with each
use. Pt reports 90 mcg per actuation.
, Pt reports taking a daily multivitamin for 2 years.
Pt denies additional OTC or prescription medications.
Pt denies herbal medications.
Last Exams:
Pt reports last PCP visit was in January 2019 for an annual check-up. Pt reports she
does not go to her PCP unless, “I am sick and need a prescription or something.”
Pt reports last Dentist appointment was in October 2021 for a six-month cleaning.
Pt reports last Eye exam was in April 2021 for a yearly checkup. Pt reports she wears
eyeglasses to as needed for distant vision.
Pt states last OBGYN appointment was June of 2021 for a yearly routine visit.
Vaccines:
Pt reports “all the normal childhood vaccines.”
Pt reports receiving 2 doses of the COVID-19 vaccine in September 2021 and
October 2021. Pt denies receiving a COVID-19 booster vaccine.
Pt reports receiving a flu vaccine in September 2021.
Pt denies receiving the pneumonia vaccine.
Psych Hx:
Pt denies psychiatric hx.
FH:
Paternal grandfather- Deceased, age 77, lung cancer. Pt reports dx of lung cancer. Pt
reports occupation of Firefighter for 30 years. Pt reports positive exposure to smoke.
Pt reports “regularly smoked until he got old.” Pt unable to report quantity. Pt denies
hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s
syndrome, and scoliosis.
Paternal grandmother- Deceased, age 67, stroke. Pt reports hx of strokes. Pt denies hx
of RA, osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s
syndrome, and scoliosis.
Maternal grandfather- Deceased, age 89, “old age and dementia.” Pt reports tobacco
smoker “most of his life.” Pt reports open heart surgery at age 65. Pt reports dx of
dementia at age 85. Pt denies hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s
contracture, SLE, Marfan’s syndrome, and scoliosis.
Maternal grandmother- Living, age 88. Pt denies smoking, COPD, emphysema, and
lung cancer. “As far as I know she is in perfect health.” Pt denies hx of RA,
osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s syndrome, and
scoliosis.
Mother- Living, age 57. Pt denies COPD, emphysema, and lung cancer. Pt reports
tobacco smoker for “off and on for 30 years.” Pt unable to report quantity. Pt reports
dx of asthma. Pt denies hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s
contracture, SLE, Marfan’s syndrome, and scoliosis.
Father- Living, age 63. Pt reports dx of COPD. Pt denies emphysema and lung cancer.
Pt reports tobacco smoker and chewing tobacco for “off and on for over 30 years.” Pt
unable to report quantity. Pt reports occupation of Firefighter for 27 years. Pt denies
hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s
syndrome, and scoliosis.
Date of Exam: 3/29/22
Pt. Initials: H. L.
Age: 22
Gender: Female
Race: Caucasian
Religion: Christian
Marital Status: Single
Occupation: Dog groomer
S:
CC: “I hurt my knee and it is swollen”
HPI:
Pt present to office with CC of a R knee pain that began 3 days ago. Pt reports the pain
began several hours after falling off of her bicycle. Pt denies symptoms at the time of
injury. Pt reports initial symptoms began “several hours after the fall” and include pain,
swelling, warmth, and redness. Pt reports that walking provokes the pain. Pt reports the
pain is felt “in front part of my knee.” Pt describes the pain as “aching and lasts for
several hours after activity.” Pt reports the pain as 6/10. Pt reports associated symptoms
of swollen, warm, and red surrounding skin. Pt reports the swelling, warmth, and redness
began 2 days ago. Pt denies additional associated symptoms including stiffness, pain that
coincide with weather changes, weakness, fatigue, wasting, gait change, limping,
numbness, tingling, crepitus, recent fractures, locking episodes of the knee, and episodes
of the knee giving way. Pt reports improved pain, swelling, temperature, and redness with
elevation and ice of the R knee. Pt denies the use of any medications to aid in symptom
relief. Pt denies similar symptoms occurring previously. Pt reports she has sought medical
attention at this time d/t “I can’t work like this; the pain just gets worse the longer I work
and walk around.”
PMH:
Allergies:
Pt denies allergies to medications.
Pt denies allergy to animals including dogs and cats.
Pt denies environmental allergies including dust and grass.
Pt denies food allergies.
Medical/Chronic Illnesses:
Pt reports history of asthma. Dx at 10-years old. Pt denies hospitalization for asthma.
Pt denies additional medical dx.
Pt denies hx of Pneumonia, Tuberculosis, and Tonsillitis.
Surgical:
Pt reports dental surgery at age 17 to remove her molars.
Medications:
Pt reports using an albuterol inhaler 2-3 times per week. Pt reports 2 puffs with each
use. Pt reports 90 mcg per actuation.
, Pt reports taking a daily multivitamin for 2 years.
Pt denies additional OTC or prescription medications.
Pt denies herbal medications.
Last Exams:
Pt reports last PCP visit was in January 2019 for an annual check-up. Pt reports she
does not go to her PCP unless, “I am sick and need a prescription or something.”
Pt reports last Dentist appointment was in October 2021 for a six-month cleaning.
Pt reports last Eye exam was in April 2021 for a yearly checkup. Pt reports she wears
eyeglasses to as needed for distant vision.
Pt states last OBGYN appointment was June of 2021 for a yearly routine visit.
Vaccines:
Pt reports “all the normal childhood vaccines.”
Pt reports receiving 2 doses of the COVID-19 vaccine in September 2021 and
October 2021. Pt denies receiving a COVID-19 booster vaccine.
Pt reports receiving a flu vaccine in September 2021.
Pt denies receiving the pneumonia vaccine.
Psych Hx:
Pt denies psychiatric hx.
FH:
Paternal grandfather- Deceased, age 77, lung cancer. Pt reports dx of lung cancer. Pt
reports occupation of Firefighter for 30 years. Pt reports positive exposure to smoke.
Pt reports “regularly smoked until he got old.” Pt unable to report quantity. Pt denies
hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s
syndrome, and scoliosis.
Paternal grandmother- Deceased, age 67, stroke. Pt reports hx of strokes. Pt denies hx
of RA, osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s
syndrome, and scoliosis.
Maternal grandfather- Deceased, age 89, “old age and dementia.” Pt reports tobacco
smoker “most of his life.” Pt reports open heart surgery at age 65. Pt reports dx of
dementia at age 85. Pt denies hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s
contracture, SLE, Marfan’s syndrome, and scoliosis.
Maternal grandmother- Living, age 88. Pt denies smoking, COPD, emphysema, and
lung cancer. “As far as I know she is in perfect health.” Pt denies hx of RA,
osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s syndrome, and
scoliosis.
Mother- Living, age 57. Pt denies COPD, emphysema, and lung cancer. Pt reports
tobacco smoker for “off and on for 30 years.” Pt unable to report quantity. Pt reports
dx of asthma. Pt denies hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s
contracture, SLE, Marfan’s syndrome, and scoliosis.
Father- Living, age 63. Pt reports dx of COPD. Pt denies emphysema and lung cancer.
Pt reports tobacco smoker and chewing tobacco for “off and on for over 30 years.” Pt
unable to report quantity. Pt reports occupation of Firefighter for 27 years. Pt denies
hx of RA, osteoporosis, gout, Paget’s, Dupuytren’s contracture, SLE, Marfan’s
syndrome, and scoliosis.
