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Health History -- Case Study

Biographical Data: Fill in your own information

Chief Complaint: "I have a grating sensation in my knee"

Present Illness:

    Location-left knee
    Quality-grating sensation
    Quantity-it is difficult walking up stairs.
    Timing-It occurs all of the time. Sometimes my knee locks up on me when I am sleeping and I have to pop it to get it to unlock. It has been bothering me for 3-4 years now and it is progressively getting worse.

    Factors: It's worse at night when sleeping, after a long drive in the car and when climbing stairs or hiking up hills. Nothing helps the grating but the pain is improved with advil (2 tabs) and a warm bath.

    Associated Manifestations: I get a pain in my knee right below the kneecap where the tendon is. (no specific pattern to the pain)

Past History: Fill in your own data but mention an old sprain of the left ankle after jogging and wearing a cast for 2 months on the leg.

Current Health Status: Fill in your own data but add that your exercise history tends to fluctuate from no exercise to active walking or jogging. Frequent advil for stiffness and pain/discomfort in knee.

Family History: Fill in your own data

Psychosocial History: Fill in your own data

Review of Systems: Fill in your own data but mention some swelling of left knee on left side of knee cap, some stiffness after prolonged sitting, driving or sleeping, and difficulty climbing. Mention the grating is much worse when stepping up on an object.

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