🩺 Record Detail
Patient Info
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Clinical Notes
Patient Identifying Information - Patient Name: Not Provided - Date of Visit: Not Provided - Age: Not Provided - Sex: Not Provided
Chief Complaint - Patient complains of right knee pain for the past two weeks.
History of Presenting Illness - Onset: Two weeks ago - Location: Primarily in the right knee - Character: Dull, achy pain - Aggravating factors: Walking and going up stairs - Timing: Constant pain for the past two weeks - Associated symptoms: No swelling or redness reported
Past Medical History - No significant past medical history provided
Medications - No current medications mentioned
Allergies - No known allergies reported
Social History - Works as a construction worker - Denies smoking or alcohol use
Review of Systems - Musculoskeletal: Positive for right knee pain - Respiratory: Not discussed - Neurological: Not discussed - Constitutional: No fever or chills reported
Physical Exam - General: Not documented - Neurological: Not documented - Musculoskeletal: - Examination of right knee: Mild tenderness on palpation, full range of motion
Assessment - Right knee pain, cause undetermined
Plan - Recommend rest, ice, elevation, and over-the-counter pain relievers - Follow-up appointment in two weeks for reevaluation