Subjective

CC ” I feel off of sparkle two days ago, and my knee has been hurting since” Chelsea is an 11-y/o Caucasian female who presents to the clinic after falling off her adult horse from a height pof two feet two days ago. She is expereincing intermittent painbelow to her knee cap since the fall. The patent is present with the fatehr Ned who stated that the pain started a little beofre the afall.Pateient stated her pain is getting worse as she is unable to take of her panst and riding boots. Laying and sitting down provides her with relieve from it. Also patient was hospitalized sixy days ago with a diagnosis of DKA secodnary to Type 1 diabetets Chelsea Warren Musculoskeletal and Neurovascular Systems shadow health Documentation . She is following her reimen per her endocrinologist. Allergies: NKDA, no latex or enrionment allergies. Home MedicationsInsulin aspart, subq daily per sliding scale at meal time PMH DKA and was hospitalized Type 1 Diabetes Insulin Glargine, subq daly dose

CC: “I fell off of Sparkle two days ago, and my knee has been hurting since.” Chelsea presents to clinic ambulatory without the use of assistive devices. Chelsea states that she fell off of Sparkle, her adult horse from a height of two feet while the horse was stationary. This occurred two days ago, and she has been having intermittent pain inferior to her kneecap since the fall. Ned, her father, present for exam, provides context and further clarification. He xxxx  but it really hurts.” Chelsea’s pain began before the fall. She reports “Two weeks ago, I noticed that while jumping/running/riding my left knee would start to hurt. I didn’t really think about it because I’m getting taller. When I stopped to rest it would go away.” Her father reports that she is not taking acetaminophen, because the pain is relieved when she rests, and she is not using the ice packs that he recommended because she doesn’t like to touch her knee. She reports her pain as “really, really bad” with activity, but simply “uncomfortable” at other times. She didn’t report it because she was afraid her horse would get taken away. Chelsea Warren Musculoskeletal and Neurovascular Systems shadow health Documentation Ned affirms she uses helmets regularly but declines to use knee pads due to peer pressure regarding the way they make her look. Of particular importance, the patient was discharged from the hospital 60 days ago with a diagnosis of xxxxx  Home Medications •Insulin glargine, sub q daily, dose per endocrinology •Insulin aspart, sub q sliding scale at mealtime, dose per endocrinology Past Medical History •Hospitalization: DKA •Diagnoses: Type 1 diabetes mellitus Social History •Sexual History: has not started menstruating and is not sexually active. •Physical activity: Rides horses three times weekly for the last few years •Nutrition: healthy, carb-controlled diet •Social support: Splits time with each parent every two weeks. Support from parents, content to stay with either one. Has close group of friends, all girls. •Education: Attends school regularly 5th grade, on track academically Review of Systems • Cardiac: Denies swelling in the lower extremities. Denies ecchymosis in the lower extremities. • Neurologic: Denies any abnormal gait, Denies any numbness/tingling/weakness, Denies falls. • Musculoskeletal: Denies pain with ambulation, affirms pain with stairs/running/jumping/putting on pants, affirms pain with range of motion activities involving the knee. • Hematologic: denies recurrent bruising. • Dermatologic: Denies itching/rash/lesions.

Objective

VS: BP 114/76, O2 99% and posterior tibial pulse, HR 88%, Resp Rate 20, Temp. 36.5C, BMI 18.5, Height 145cm, Weight 39kg Physicial Exxam General Survey: alert and oriented, sitting comfortablyin NAD, well groomed and xxxxxx tested with both patellar and achilles at a +2 bilaterally. Musculoskeletal: Pt was able to ambulate across the room with steady gait, squat with facial grimace xxxx bilaterally without any abnormal findings noted. Msucle strenght was 5/5 on the hip and knees with pain observed on the left kneeas pt grimaced. Left tibial tuberosity was tender to palpation Right tibial tuberosity was non tender to palpation with no crepitus noted.

Vital Signs BP: 114/76, O2 Sat: 99%, HR: 88 BPM, Resp. Rate: 20, Temp: 36.5C, xxxxx  speech is clear, appropriate, and pleasant. Judgment and insight intact. •Cardiac: DP and PT and popliteal pulses 2+ on palpation bilaterally. No peripheral extremity edema on inspection. •Skin: Skin is warm, dry, intact throughout the body on inspection. Skin is appropriate color for ethnicity. Good skin turgor. No rashes or lesions present. •Neuro: Alert and oriented x xxxient is able to ambulate across the room with steady gait. She is able to sit upon and disembark exam table without difficulty. She performs a full squat completely with observed facial grimacing and verbalizing pain. Legs, hips, knees, ankles, and feet without edema or deformity bilaterally on inspection. ROM xxxx ted: hips 5/5 bilaterally; knees 5/5 bilaterally with observed facial grimacing and verbalizing pain when testing left knee; ankles 5/5 bilaterally. Patella non-tender to palpation without crepitation or patellar instability bilaterally. Knee joint stability assessed in supine position with stable knee joint bilaterally on palpation. Chelsea Warren Musculoskeletal and Neurovascular Systems shadow health Documentation No palpable adiposities in the popliteal fossa bilaterally. Left tibial tuberosity tender to palpation with a tibial prominence palpated and verbalization of pain without crepitation. Right tibial tuberosity non-tender to palpation without crepitation. Chelsea Warren Musculoskeletal and Neurovascular Systems shadow health Documentation