History

Identifying Data:

Full Name: Mr F

Address: Not Disclosed

Age: 31 years

Date & time:6/15/2021 7:00 AM

Location: Woodhull Hospital

Religion: Not disclosed

Source of Information: Self

Reliability: Reliable

Source of Referral: Self

Mode of Transport: Self

Chief Complaint: “R knee injury” x2 hours

History of Present Illness:

31 year old M with no significant PMHx complains of R knee injury that occurred 2 hours ago. Patient fell off an electric bike when trying to avoid hitting a car. Bike fell on top of him injuring his R knee. R knee pain described as 9/10. Associated with tingling in toes. Patient was wearing helmet and denies head injury, LOC, neck pain. Denies any other injuries.

Denies fever, chills, SOB, CP, abdominal pain, N/V/D

Past Medical History:

Denies past medical history

Immunizations – UTD  

Past Surgical History:

Laparoscopic appendectomy 5/2/2018 no complications

Medications:

No vitamins, herbal teas or supplements

Allergies:

NKDA

No known environmental allergies

Family History:

No pertinent family history

Social History:

Mr F is an unmarried 31 year old male living in an apartment with his partner. Does not drink alcohol, smoke or vape. Currently employed as accountant

Travel-No recent travel

Sleep-Sleeps 7 hours per night

Review of Systems:

General-See HPI

Skin, hair, nails – Denies changes in texture, excessive dryness or sweating, discolorations, pigmentations, moles/rashes, pruritus or changes in hair distribution.

Head – Denies head trauma, LOC, fracture

Eyes – Denies lacrimation, erythema

Ears – Denies tinnitus, discharge, ear pain, hearing changes

Nose/sinuses – Denies discharge, epistaxis, obstruction

Mouth/throat – Denies bleeding gums, mouth ulcers, voice changes. Does not follow with dentist

Neck – Denies lumps, swelling, decreased ROM

Pulmonary system – See HPI

Cardiovascular system –See HPI

Gastrointestinal system-  See HPI

Genitourinary – Denies frequency, urgency, dysuria, hematuria, nocturia

Nervous –Denies seizures, loss of consciousness

Musculoskeletal– See HPI

Hematological system –Denies bleeding, easy bruising, lymph node enlargement, blood transfusions

Vital Signs

HR: 65 BPM, regular

BP 143/84 R arm lying

RR: 18 breaths/minute, unlabored

Temp: 97.9 degrees F oral

O2 Sat: 99% on room air

Ht 5’10’’

Wt 220 lbs

BMI 31.6

Physical Exam:

General: Uncomfortable appearing male, well groomed, non-toxic appearing, in no acute distress. Appears stated age.

Skin:   warm & moist, good turgor. capillary refill <2 seconds throughout. No jaundice or pallor. No petechiae or rash.

Hair:   average quantity and distribution

Head: normocephalic, atraumatic, no signs of injury

Eyes – symmetrical; sclera white; conjunctiva pink and moist, no discharge. PERRLA, EOMI

Nose –  Nasal mucosa moist. No rhinorrhea, congestion, masses, trauma, or deformities

Lips –  Pink, moist; no cyanosis or lesions.  

Oropharynx – Well hydrated; no injection; exudate; masses; lesions; foreign bodies. Tonsils present with no injection or exudate.  Uvula pink, no edema, lesions

Neck – FROM, supple, no rigidity. No midline tenderness. Trachea midline.   No masses; lesions; scars; pulsations noted. no stridor noted. no palpable adenopathy noted.

Chest – Symmetrical, no deformities, no evidence trauma. Respirations unlabored, no paradoxic respirations or use of accessory muscles noted. No nasal flaring or retractions

Lungs – Clear to auscultation bilaterally, no adventitious sounds, wheezes or rhonchi.

Heart:   RRR. S1 and S2 are distinct with no murmurs, S3 or S4. No friction rubs appreciated.

Abdomen: Flat and symmetrical without striae or pulsations noted. Bowel sounds normoactive in all four quadrants. Nontender to palpation and tympanic throughout, no guarding or rebound noted. No hepatosplenomegaly or CVA tenderness appreciated.

Musculoskeletal: R knee swollen and tender to palpation with limited ROM. Calf soft, DP/PT pulses 2+. Some altered sensation in superficial and deep peroneal regions. Sural, medial, and ventral sensation intact

Other extremities normal, FROM, no swelling or deformities

Neuro: Alert, no focal deficit noted.

Assessment:

31 year old M with no significant PMHx complains of R knee pain after bike injury 2 hours ago

Plan:

• R knee trauma
  • R knee x ray 3 views 
    • Moderate knee effusion. There is lateral tilting of the femur with impaction of the lateral tibial plateau and lateral tibial plateau lucencies suspicious for fractures correlate with CT scan of the right knee. Lateral view reveals displaced proximal tibial fractures with displacement of 2 cm posteriorly seen
    • Impression: Severely displaced R knee fracture
  • CT angiogram R lower extremity – r/o vascular injury
    • No evidence of vascular injury
    • Comminuted proximal tibial fracture
  • Book for OR today for ORIF
  • NPO
  • Admit to ortho
  • After surgery
    • 2 months non-weight bearing
    • Lovenox 40 mg once daily for 1 month
    • Percocet prn pain q4-6 hours
    • Morphine 2 mg prn breakthrough pain