The patient comes in today for an initial consultation for her left knee pain. She was walking down three stairs on 08/09/2012. She fell landing on her right side of her body. She is not sure exactly how she fell. The next day she woke up and began having pain in the left knee, which has become severe. She has been taking some anti-inflammatories for last couple of days and has gotten somewhat better. Pain is intermittent and associated with bending of the knee upon flexion and extension. The pain is sharp and stabbing in nature. She rates this 9/10 on a visual analog scale. Pain is better with rest. She has had no treatments for the pain other than taking anti-inflammatories.
Medial collateral ligament sprain.
I spent time going over clinical findings, assessment, diagnosis, and treatment recommendations. Given the equity of her pain has been seven days, I will recommend conservative approach. She is full weightbearing. So, we will recommend a knee support brace and continue with ice and rest. We will order the patient Naprosyn 500 mg one every 12 hours for pain and inflammation, #60 dispensed. We will also order Ultram 50 mg one every four to six hours as needed for pain, #30 dispensed. We will obtain x-ray of the left knee to rule out any bone injury. We will recommend physical therapy for palliative measures for her pain. If no improvement is seen in the next two weeks, we will consider an MRI. We will request authorization for knee brace for stabilization and support of the left knee.