rjenn86
Guru
Hi I have a chart note and doctor is dictating peroneal strain. To my understanding this can be from the knee all the way to the ankle. I am wondering does the doctor need to be more specific? The chart note isn't clear on what part he is talking about but the pt came in to be seen for the knee. Here is what it looks like...
Patient is here for first evaluation regarding left lower extremity.They report roughly 1 week of progressive left lower extremity pain. Pt denies any one event that has occurred. They do report that pt is extremely active participating in both soccer and basketball. Pt states the pain is worse activities and is planning to the lateral aspect of left knee. Pt denies any swelling or mechanical symptoms such as clicking or locking. Pt is currently taking 2 Advil twice a day. Pt does report that soccer has one more week left and activities will drastically diminished.
On exam today pt is alert and oriented x3 in no acute distress. Left lower extremity demonstrates mild internal rotation in comparison to right. Pt has generalized ligamentous laxity particularly in ankles with inversion. Pt also is able to touch thumb to forearm bilaterally. Pt is tender to palpation over the peroneal tendon at its origin is nontender over the insertion site. Pt has full range of motion of hip in internal and external rotation as well as hip flexion. There is no pain elicited with this motion. Pt also has full knee motion including extension and flexion. Pt is stable to varus and valgus stressing. Pt is nontender over the attachment site of the hamstring tendons on the fibular head.
2 views of left knee were obtained as well as one view of right knee. Sensory is normal x-rays. I see any signs of any bony lesions. Joint spaces are well maintained. I also obtain AP and pelvis weightbearing. This demonstrates that the hip joints are in good position. No signs of complications.
Left peroneal strain with ligamentous laxity
Patient is here for first evaluation regarding left lower extremity.They report roughly 1 week of progressive left lower extremity pain. Pt denies any one event that has occurred. They do report that pt is extremely active participating in both soccer and basketball. Pt states the pain is worse activities and is planning to the lateral aspect of left knee. Pt denies any swelling or mechanical symptoms such as clicking or locking. Pt is currently taking 2 Advil twice a day. Pt does report that soccer has one more week left and activities will drastically diminished.
On exam today pt is alert and oriented x3 in no acute distress. Left lower extremity demonstrates mild internal rotation in comparison to right. Pt has generalized ligamentous laxity particularly in ankles with inversion. Pt also is able to touch thumb to forearm bilaterally. Pt is tender to palpation over the peroneal tendon at its origin is nontender over the insertion site. Pt has full range of motion of hip in internal and external rotation as well as hip flexion. There is no pain elicited with this motion. Pt also has full knee motion including extension and flexion. Pt is stable to varus and valgus stressing. Pt is nontender over the attachment site of the hamstring tendons on the fibular head.
2 views of left knee were obtained as well as one view of right knee. Sensory is normal x-rays. I see any signs of any bony lesions. Joint spaces are well maintained. I also obtain AP and pelvis weightbearing. This demonstrates that the hip joints are in good position. No signs of complications.
Left peroneal strain with ligamentous laxity