1.AMBULATORY CARE FACE SHEET
Admit Date: 7/8/20XX @ 20:22
Discharge Date/Time: 7/9/20XX @ 10:10
Sex: M Age: 47 Disposition: Home
Admitting Diagnosis: Possible torn meniscus of the left knee. Discharge Diagnosis: Left Knee meniscectomy.
Procedures: Laparoscopic Surgery to the Left Knee.
Date of Consultation: 7/8/20XX
This is a 47-year-old male who was in his usual state of health until today entered the Emergency Room with severe pain to his left knee and equal amount of edema within the patellar area. This occurred after the patient fell at an angle on the left knee during a game of football with friends. The patient was evaluated with L-Knee Radiograph and Magnetic Radiograph Imaging (MRI) for soft-tissue films. The L-Knee X-Ray revealed no fractures to the Femur, Patella, Tibia, or Fibula. The MRI revealed a large tear surrounding the meniscus of the left knee. The patient was treated with a left knee splint and crutches with a prescription for Mobic 15mg daily and Tramadol/APAP 37.5 mg every 4-6 hours for pain. The patient was referred to Orthopedics for surgical repair. He has no past history of tobacco abuse, previous fractures, or surgeries.
2.Past Medical History:
Allergies: No known drug allergies.
Medical History: History of Chronic Otitis Externa
Family History: Noncontributory.
Review of Systems: No medical abnormalities.
Vital Signs: BP 130/80, P 92, T 98.5
This is a well-developed and well-nourished anxious black male in mild distress. Head and neck are normocephalic and the oropharynx is clear. The left knee shows 5+ edema and patient is unable to bend at knee joint connection. The patient’s left leg is not weight bearing and the pain level continues to be a 6 to 7 on the pain scale. The patient is using crutches and wheelchair for mobility. All...