Abdominal Pain Intake - Adult

Subjective:
Chief Complaint:
Knee injury from volleyball fall

History of Present Illness:
Michael is a [age not specified]-year-old male presenting with a 2-week hx of left knee injury after a fall while playing volleyball. Pt has prior hx of left knee subluxation and attended physiotherapy at Regional Therapy Center. Pt reports improvement after therapy and currently uses a knee brace. Pt was able to walk immediately after the injury. No other questions or concerns reported at this time.

Past Medical History:
History of left knee subluxation. No prior problems with the right knee.

Family History:
No significant findings.

Social History:
Plays volleyball for school and club. No other social history provided.

Current Medications:
No current medications reported.

Allergies:
No allergies reported.

Objective:
Physical Examination:
General Appearance: He is alert, cooperative, and appears comfortable at rest.
ENT Examination: 
Respiratory Examination: 
Neurological Examination: 

Assessment:
Problem:
Left knee injury (719.46) after volleyball fall.

Differential Diagnosis:
Recurrent left knee subluxation: History of prior subluxation, recent injury during volleyball, improved with physiotherapy and brace use.
Other internal derangement of knee: Noted improvement post-therapy, ambulatory after injury.

Plan:
Continue knee brace as suggested. Follow up in 4 weeks. Continue prescribed physiotherapy exercises.