Complains of dull pain
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SUBJECTIVE DATA:
CC: “Complains of dull pain in both of his knees”
HPI: The 15-year-old Caucasian male complains of dull pain in bilateral knees. Complains of catching under unilateral or both knees. Onset gradual but increasing over time, especially in last two weeks. Dull knee pain and catching sensation behind the right knee cap. Rarely, notices the clicking in the left knee but continues to have less pain. Pain is worse with exercise and activity. Pain eases with rest, elevation and ice. Patient rates the right knee at 8/10 and left knee 6/10
PMI: Tonsillectomy at 5-year-old, Flu vaccination 2019 season, HPV immunization completed 2019, Tetanus 2019, hospitalizations
CURRENT MEDICATIONS: None
SH: RR is a middle school student at Austin Middle School. He plays football and basketball with the school. He is a nonsmoker and his household members are nonsmoking. He does not use alcohol and his father drinks 1-2 drinks/monthly and his mother does not drink. He lives in the house with both his parents. He makes good grades.
ROS
GENERAL: no weight loss, no chills, no fever, no fatigue.
CV: Negative for palpitations or flutters, negative for hypertension. No edema noted to bilateral upper extremities. No edema to lower extremities.
GI: No nausea/ vomiting no diarrhea, no stomach pain.
PULMONARY: Denies cough, shortness of breath or labored breath.
MUSCULOSKELETAL: Normal gait, ambulates without assistance or limb.
NEUROLOGICAL: No headaches, dizziness, syncope, paralysis, ataxia, and denies numbness and tingling in the extremities. Denies seizures. Denies trauma.
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