Chapter 4: The Musculoskeletal System | Bill Jesmann's Chart Note

CHART NOTE

Patient Name: Jesmann, William
ID Number: 42645
Examination Date: October 26, 20xx

SUBJECTIVE
This 16-year-old male was tackled during a football game, twisting his left knee. The pain is worse on the lateral and inferior aspect of the left knee. It's worse if he pivots. He states that he has sometimes noticed a "catch" in his knee after practice. It has responded well to ice and ibuprofen.

OBJECTIVE
There is slight tenderness with active and passive ROM (range of motion) of the knee. The knee is not erythematous or warm. There is no crepitus (crackling or grating sound) or edema. There is tenderness with palpation of the left medial collateral ligament. There is a lateral collateral ligament laxity (looseness, slackness, or displacement) but no medical collateral laxity. McMurray test is negative.

ASSESSMENT
Left lateral collateral ligament sprain.

PLAN
He will be sent to an orthopedist for consultation and possible MRI and/or arthroscopy. Follow-up PT is recommended.