Chief Complaint (CC)

Chief Complaint (CC): A dull pain in both knees with occasional clicking in one or both knees and the sensation of the patella catching.

History of Present Illness (HPI): RF is a 15-year-old male who reports dull pain in both knees. Sometimes one or both knees click, and the patient describes a catching sensation under the patella. He states that the pain has been on and off for the last four months and initially only present after intense activity but has gotten worse since starting track this summer and seems to be present more often than before.

The patient states that the clicking comes and goes and isn’t always present in both knees at the same time. The catching sensation under the patella is more pronounced since he started doing the long jump in track. The patient states that he is able to bear weight as the pain is a dull ache. Icing his knees after sports and taking ibuprofen help to reduce the pain and swelling but both occur more frequently now making it difficult to participate in sports. The patient feels that he may be overdoing it with all of the sports he participates in and is worried about not being able to play soccer if it continues to get worse. The patient rates the pain 7/10 after intense activity.

Medications: Ibuprofen 200 mg oral tab, two tabs every 6 hours as needed for pain.

Allergies: No known drug, food, or environmental allergies.

Past Medical History (PMH): None

Past Surgical History (PSH): None

Sexual/Reproductive History: Patient is not sexually active at this time.

Personal/Social History: Patient denies smoking, alcohol use, and illicit drug use. The patient is very active with sports playing soccer, basketball, baseball, and track. He states that he tries to eat well mainly because of sports but doesn’t always make the best choices for snacks. He tries to avoid soda most of the time and reports drinking a lot of water.

Immunization History: Immunizations are up to date. Gets influenza vaccine annually.

Significant Family History:

Paternal grandfather has hypertension, and father has borderline hypertension. Maternal grandfather has type II diabetes.

Lifestyle: RF is a freshman in high school who lives with both of his parents and older sister. RF plays soccer, basketball, baseball and participates in track for high school. RF also plays club soccer playing and traveling most of the year. RF is a good student, athletic, and enjoys being active. He also participates in winter sports and skis during winter break.  RF works part-time as a referee during the summers due to his commitment to school and sports.

Review of Systems:

General: No recent weight gain or loss of significance. Patient denies fatigue, fever, or chills.

HEENT: No headaches or dizziness. No changes in vision. He does not wear glasses, and his last eye exam was just under a year ago. Denies eye drainage, pain, or double vision. No changes in hearing. Has had no recent ear infections, tinnitus or ringing in the ears. Denies sinus infections, congestion, and epistaxis. He reports his sense of small is intact. Last dental exam was four months ago for regular cleaning. Denies bleeding gums or a toothache. Denies dysphagia or throat pain.

Neck: No history of trauma, denies recent injury or pain. He denies neck stiffness.

Breasts: Denies any breast changes. Denies history rashes. Denies history of masses or pain.

Respiratory: Denies a cough, hemoptysis, and sputum production. Patient denies any shortness of breath with resting or with exertion. Patient reports no pain with inspiration or expiration.

Cardiovascular/Peripheral Vascular: No history of murmur or chest palpitations. No edema or claudication. Denies chest pain. No history of arrhythmias.

Gastrointestinal: Denies nausea or vomiting. Patient reports no abdominal pain, diarrhea, or constipation. Last bowel movement was this morning. Denies rectal pain or bleeding. Denies changes in bowel habits. Denies history of dyspepsia.

Genitourinary: Denies changes in urinary pattern. No incontinence, no history of STDs or HPV, the patient is heterosexual and not sexually active. Denies hematuria. Denies urgency, frequency, and dysuria.

Musculoskeletal: No limitation in range of motion for all limbs though patient reports difficulty moving knees after excessive strain from sports.  No history of trauma or fractures. Patient reports dull pain in both knees. The patient states occasional swelling in knee joints after participating in sports. Patient reports clicking in one knee and sometimes both. The patient states that the pain is worse after participating in the long jump or running long distances. Patient denies history or presence of misalignment of either knee.

Psychiatric: Denies suicidal or homicidal history. No mental health history. Denies anxiety and depression.

Neurological: No dizziness. No problems with coordination. Denies falls or seizures. Denies numbness or tingling. Denies changes in memory or thinking patterns.

Skin: No history of skin cancer. Denies any new rashes or sores. Patient reports many blisters from sports which are treated with Neosporin, band-aids, and NewSkin spray. Denies eczema and psoriasis. Denies itching or swelling.

Hematologic: No bleeding disorders or history of blood transfusion. Denies excessive bruising.

Endocrine: Patient reports no endocrine symptoms. Denies polyuria, polydipsia. Patient denies no intolerance to heat or cold.

Allergic/Immunologic: Denies environmental, food, or drug allergies. No known immune deficiencies.