SOAP Note 2 - The 26-year-old 10000m trail runner has height of 1.80m and weight 70kg. He PDF

Preview

Summary

The 26-year-old 10000m trail runner has height of 1.80m and weight 70kg. He had a knee ACL sprain back in 2008 but since then he doesn’t have any other injuries or any health issues. The athlete participate in a 5k trail run. At the last 1k-he misstep, fell on the ground and hit his left patella on ...

Description

ATTR 2100 Template Name:

Nick Cassata

Date of Injury:

17/9/2015

Sport:

Sprinter

Date of Evaluation:

18/9/2015

Body Part:

Left Knee

Primary Complaint:

Swollen and painful knee

Subjective: The 26-year-old 10000m trail runner has height of 1.80m and weight 70kg. He had a knee ACL sprain back in 2008 but since then he doesn’t have any other injuries or any health issues. The athlete participate in a 5k trail run. At the last 1k-he misstep, fell on the ground and hit his left patella on a rock. He states that immediately the knee started swelling and he had pain scale of 5/10 when he tried to weight bear on his left knee right after the incident. The day after the injury the knee appear to be much more swollen, red and tender with restriction of movement and much more painful with the pain scale be 8/10. He describes the pain as ”sharp” when he tries to extend or flex his leg and he cant bear weight at all on his injured leg.

Objective:

Assessment:

The athlete came inside the clinic with crouches and unable to bear weight on the affected leg and difficulty perform any range of motion. The knee appears to be swollen and tender with abrasions over the patellar area.  Through Palpation the pain is located on and around the patellar of the knee.  The swelling in the injured leg indicates 3 inches more circumference bilaterally.  Elevated temperature can be determined by palpating the injury site.  Decrease AROM. Pain starts at 40 degrees when the patient flexes the knee, and at 10 degrees when he tries to extent the knee.  Passive range of motion and manual muscle testing couldn’t perform by the athlete due excessive pain.  Neurovascular assessment: WNL  Sweep test (-)  Ballotable patella test (+)  Laucman test (-)  Varus-Valgus test (-)  Goadfrey’s test (-) IMP: Prepatellar Buristis DD: Fracture of the patella, rupture of the patellar tendon

Plan:

  

Rest Ice Elevation

Asses to a physician for MRI to check if there is fracture on the patella or if any other parts of the knee got injured. The physician can also help with the reduction of the swelling. The patient can get back in 1

to 2 weeks. Evaluator:

Michalis Aristodemou

Signature:

Michalis Aristodemou

Date:

18/9/2015...