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Dear Sample Doctor:

The patient is an 18-year-old student football athlete presenting today for evaluation of left suprapatellar knee pain that has been present for approximately six weeks. Pain began after he sustained a direct blow onto the knee when being tackled. Position he was playing at that time was wide receiver. Pain is now aggravated with light touch. He did have some swelling early on, but that has since resolved. No true mechanical symptoms elicited. No mechanical symptoms of buckling, locking, or giving way. He denies any radiation of pain. No paresthesias in the distal extremity. No history of similar symptoms in the past.

PHYSICAL EXAMINATION:
On exam, he stands at 5 feet 9 inches and weighs 153 pounds. Left knee exam, normal appearing left knee. Full active range of motion. No patellar crepitus noted. No pain elicited with patellar apprehension or inhibition. There is some mild discomfort elicited to the distal femur/quadriceps tendon area. No effusion present. Muscle strength against resistance with knee extension is 5/5. No extensor lag noted. Negative Lachman. Normal Laxity with varus and valgus stress. Negative anterior and posterior drawer test. Negative McMurray's.

RADIOGRAPHS:
X-rays, left knee, well-maintained joint space. No fractures. No suspicious lesions.

ASSESSMENT:
Left knee distal femur contusion/low-grade distal quadriceps tendon strain.

PLAN:
I reviewed the diagnostic and exam findings with the patient and his father and reassured him that clinically I do not feel any instability in his knee. At this point, I do not feel as though any further diagnostic studies would be beneficial from an orthopedic standpoint. I feel as though he can proceed with any activity he is able to tolerate at this point. In the future if symptoms are continuing to give him problems, he will follow up with us. Prior to following with us, we should obtain an MRI of the knee. He agrees and understands and will follow up with us at that time.

Sincerely,

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