Knee Injury SOAP Note Transcription Sample Report

SUBJECTIVE:  This is a very pleasant (XX)-year-old woman. She came in regarding a left knee injury. She was seen elsewhere with recommendation of anterior cruciate ligament reconstruction using bone-patellar tendon-bone autograft. She is here for a second opinion regarding her knee. She is very active with horses, gardening, and sports. She works with horses. She has 3/10 pain. She has had three foot surgeries in the past. She is married with one child. The patient smokes about a pack a day. She drinks socially. She has family history positive for hypertension, diabetes, stroke, and arthritis.

OBJECTIVE:  The patient is 5 feet 4 inches, 140 pounds. She is a well-nourished, well-developed woman, in no acute distress. She has normal affect. Skin is intact. She has very muscular legs. She lacks a few degrees of terminal extension and flexes to about 115 degrees, lacking about 20-30 degrees of terminal flexion secondary to pain. There is really no effusion today to speak of. She has a positive Lachman. She really guarded quite a bit with pivot maneuver, so we were unable to elicit that. Anterior drawer is less obvious on the opposite side. She is stable to varus/valgus testing at 0 and 20 degrees. Posterolateral drawer appears negative. She has both medial and lateral joint line tenderness, worse on the medial side. She is, otherwise, neurovascularly intact distally.

X-rays from the outside facility without a tangential view, nonweightbearing, are negative. MRI was performed, which shows an anterior cruciate ligament tear and a meniscal tear medially.

ASSESSMENT AND PLAN:  We had a lengthy discussion today regarding her knee. We talked about the diagnosis of anterior cruciate ligament tear and meniscal tear and went over options. We think, given the fact that she would like to get back to competitive level sports and that she does some outdoor activities, including pivoting activities, that it is reasonable for her to consider anterior cruciate ligament reconstruction for her knee. She has essentially decided she would like to go forward with an anterior cruciate ligament reconstruction. We had a long discussion regarding graft options, including bone-patellar tendon-bone autograft, hamstring autograft, allograft, and quad tendon autograft. She is hoping to avoid bone-patellar tendon-bone autograft. We think that it is very reasonable for her to choose between hamstring autograft and allograft for reconstruction. We went over the surgery and the recovery time. Additionally, we think that she should continue to work on her preoperative therapy to try to regain all motion. We talked about the risks of stiffness postoperatively with her knee being stiff preoperatively. All the questions were answered. She will consider her options and let us know.

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