Bilateral Injury

Reason for Visit: s/p Contusion of Bilateral Knees
S: Aerotek TM was waking in to the front sliding doors when she slipped and fall from the puddle of water from the rain water from the other TMs tracking them in. At the time no one was around her, she was more concerned with embarrassment so she simply got up and walked away from the injury site fast as she could. But one of the folk lift driver show her and founder in a sitting area and asked her if she was ok and informed her that she had left her umbrella where she had fall. Also her Tea Leader was informed and was told to go to the HMA Medical Clinic. One of the reason she didn’t come to the medical clinic was she knew she wasn’t hurt. The fall wasn’t that hard and she doesn’t have any pain, 0/10. TM also reports she has effusion in her right leg and mild edema in her left leg related her osteoarthritis, and this is a chronic issue for her. She is managing her current condition with Advair OCT PRN and Epson Salt bath to manage the pain. TM denies any other issues. TM denies previous injury to her bilateral Knee joints. TM reports cervical DJ.
O: normal gait, effusion right knee, mild edema of left knee joint; right knee joint larger than the left knee joint; no warmth palpated to bilateral knee joints; no discoloration to bilateral knee joints; Full ROM with some discomfort; pedal pulses +3 bilaterally. Negative x-ray finding.
A:
Bilateral Knee Contusion
Osteoarthritis of bilateral knees – this is personal condition per patient report; chronic condition her current condition with Advair OCT PRN and Epson Salt bath to manage the pain.
P:
Ice X 20 minutes NOW
X- Ray: Bilateral Knees
Naproxen 220 mg tab 1 tab by mouth BID
Acetaminophen 500 mg tab 2 tabs by mouth every 8 hours as needed for pain
Biofreeze 1 packet 1 application every 4 to 6 hours to bilateral knees as needed for pain
Soft Knee Brace to bilateral Knees
Ice at home tonight
Disposition: Full Duty; Follow up tomorrow prior to next
shift