Visit summary
Patient intake
Intake summary From patient
- Reason
- Right knee pain after a fall while hiking three weeks ago.
- Pain pattern
- Worst on stairs and after sitting · no swelling or locking
- Medications
- Atorvastatin 20mg · daily multivitamin
- Allergies
- Penicillin (hives)
- Goals
- Return to evening walk routine · avoid imaging if possible
What we talked about
Reason for visit From dictation
Right knee pain after a fall while hiking three weeks ago. Pain mostly with stairs and after sitting. No swelling, no locking. Hugo notes it's affecting his evening walk routine.
Assessment
What I found From dictation
On exam: mild tenderness over the medial joint line, full range of motion, no effusion, ligament tests negative. Most likely a soft-tissue strain from the fall, settling on its own. No red flags for fracture or meniscal tear at this time.
Plan — what we'll do
Instructions for you
- Keep walking as tolerated; avoid running and deep squats for two more weeks.
- Ice 15 minutes after any longer walk for the next week.
- Try the four stretches in the attached handout, twice daily.
- If pain wakes you at night, locks the knee, or the joint swells visibly, book sooner.
Stretch handout (PDF)
+ Attach file
Medications
No changes today. Continue atorvastatin 20mg at bedtime.
Atorvastatin 20mg · continue
+ Add medication
Follow-up
Recheck in 3 weeks if not better. Sooner if the pain worsens or new symptoms appear.
Auto-suggest follow-up · 3 weeks
Add booking link