Medial meniscus tear

The patient is a 63-year-old male who was a restrained passenger of a vehicle involved in a motor vehicle accident on May 27, 2013. He reports that his left knee hit the dashboard during this injury and now he reports significant knee pain. He denies any prior history of similar symptoms in the past. He has had an MRI scan, which was performed on 06/24/13 in addition to tissue swelling and a Baker’s cyst. It revealed medial meniscal tears as well as a grade I popliteus and soleus muscle strains. The patient has been receiving physical therapy with positive results. He denies any other injuries from this motor vehicle accident.

IMPRESSION:
1. Medial meniscus tear.
2. Popliteus/soleus muscle strains.

PLAN:
The patient and I did have a nice talk today regarding his pain and overall plan of care. He is doing well with physical therapy and has been seeing a chiropractic physician with positive results. He will continue to do both of this. We discussed possible treatment options, which do include referral to an orthopedic surgeon for cervical options as well as injection procedures. I discussed with the patient that I would like to get pre-approval for an injection to the left knee. We will get pre-approval for an injection to the left knee and at the same time the patient will see his orthopedic surgeon who he has been seeing for a number of years due to other injuries. We did discuss the medication options that the patient prefers to be off of medications. He was taking over-the-counter anti-inflammatory medications as needed. The patient will follow up with me in one week’s time and call me with any questions or concerns prior to this.

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