HISTORY AND PHYSICAL EXAMINATION
The patient was seen by me with complaints of a painful right knee after a recurrent injury. The patient had been seen in this office in the past for problems referable to the right knee. At that time, findings were consistent with right lateral patellar chondromalacia secondary to patellar malalignment syndrome. At that time, she demonstrated a positive inhibition and apprehension test. She was placed in immobilization at that time, then started on quad-strengthening exercise program.
She showed improvement in a physical therapy program. She was placed in an open patellar, standard U patellar knee support. She did very well but returned following an injury, at which time she reported that she had had an arthroscopy and lateral retinacular release, but it was unsuccessful, and it did not afford her any relief as far as her complaints were concerned. She had some episodes of subluxation by history; at least she describes these episodes. Apparently she sustained a re-injury when she slipped and fell and landed on her knee, and the knee dislocated laterally. She noted the acute onset of pain at that time.
Examination revealed a genu valgum of 9 degrees, Q angle of 16 to 17 degrees with slight patellar tilt, but positive patellar inhibition with any lateral movements of the patella. There was no significant definite end point with lateral maneuver, indicating that we could have dislocated the patella had we desired. It was felt that she had sustained injury to the medial retinaculum. Examination, therefore, was consistent as well for VMO (vastus medialis obliquus) instability or inadequate VMO (vastus medialis obliquus) function to maintain good patellar position.
We then started her on an electrical stimulation program and therapy, and this proved to be successful in the short term, but she continues to have discomfort of the knee with a positive apprehension test.
We outlined surgery and the hopeful gains thereof, and she opted for surgery, namely, lateral retinacular release and VMO (vastus medialis obliquus) advancement. If sufficient, then we would not continue with any additional surgery. This will be determined at the time of surgery. However, she was advised that if the knee continued to subluxate following this, then she would be a candidate for extensor mechanism realignment.
PAST HISTORY
Medical history is not remarkable. No surgeries of note other than described above.
ALLERGIES
None.
MEDICATIONS
None.
REVIEW OF SYSTEMS
Review of systems is not remarkable.
PHYSICAL EXAMINATION
GENERAL: On physical examination, she was a well-developed female.
VITAL SIGNS: Blood pressure 102/70, pulse rate 80 and regular, respiratory rate 20, temperature afebrile.
SKIN: Clear without rashes.
HEENT: Normocephalic. Nose and throat clear. Mucosa pink and moist.
NECK: Supple. Trachea midline.
CHEST: Chest was clear without rales, wheezes, or rhonchi.
HEART: Regular sinus rhythm without murmurs.
ABDOMEN: Abdomen was scaphoid and soft.
NEUROLOGIC: Oriented x4.
EXTREMITIES: The extremities show 2+ pulses which are equal bilaterally, without clubbing, cyanosis, or edema. Examination of the right knee reveals the following: Genu valgum 7 degrees, Q angle 19 degrees, anterior drawer sign negative, posterior drawer sign negative, Slocum maneuver negative. Medial collateral ligament is intact. Lateral collateral ligament is intact. Patellar apprehension test is positive. Patellar inhibition test is positive.
IMPRESSION
Patellar malalignment syndrome with patellar tilt.
PLAN
The patient is now admitted for lateral retinacular release and probable VMO (vastus medialis obliquus) advancement.
FOOTNOTE
Line 11 (Page 1). Malignment (meaning libel) was edited to malalignment (meaning out of alignment). The physician pronounces it correctly in the Impression.
Line 14 (Page 1). The term quad-strengthening refers to
quadriceps-strengthening exercises.
quadriceps-strengthening exercises.
Lines 28, 29 (Page 1). Alternative: 16-17.
Lines 35, 36 (Page 1). VMO (not a common abbreviation) was translated for clarity.
Line 50 (Page 1). The physician misspoke; extensor realignment mechanism was edited to extensor mechanism realignment.
Line 15 (Page 2). The heading Physical Examination was added for clarity.
Lines 16-35 (Page 2). The subheadings were added for clarity.
Lines 30, 31 (Page 2). Degrees was provided and spelled out for values 7 and 19.
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