Sports Injury Medical Report
Patient Information
Patient Name: | [Your Name] |
Patient ID: | 123456789 |
Date of Birth: | January 1, 2050 |
Gender: | Female |
Contact Information: | 123-456-7890 |
Injury Incident Details
Date of Injury: 09/25/2055
Time of Injury: 2:15 PM
Location of Incident: Riverside Stadium, Main Field
Mechanism of Injury:
During a high-speed sprint, the patient attempted to pivot sharply to avoid a defender. This sudden change of direction caused his right knee to twist awkwardly, followed by an immediate collapse to the ground. The patient reported hearing a “pop” in the knee at the time of injury.
Chief Complaints
Initial Physical Assessment
Injured Body Part: Right knee
Type of Injury Suspected: Anterior cruciate ligament (ACL) tear
Severity of Injury: Severe
Functional Limitations:
Objective Findings:
Visible Swelling: Present; significant swelling in the right knee joint.
Bruising/Discoloration: Mild discoloration observed laterally around the knee.
Range of Motion: Severely limited; unable to fully extend or flex the knee beyond 30 degrees.
Palpable Tenderness: Marked tenderness on the anterior knee and medial joint line.
Deformity or Misalignment: No visible deformity noted, though the knee is visibly swollen and feels unstable during movement.
Imaging & Diagnostic Results
Medical Diagnosis
Primary Diagnosis: Complete ACL tear in the right knee
Secondary Conditions: Mild meniscal tear, medial joint line
Treatment & Management Plan
Immediate Treatment Administered:
Application of ice to the knee to reduce swelling.
Compression with an elastic bandage.
Knee immobilizer applied to restrict movement.
Prescription of ibuprofen 400mg for pain relief, to be taken every 6 hours as needed.
Non-weight-bearing instructions were given, and crutches were provided.
Rehabilitation & Recovery Protocol:
Physical Therapy Referral: Yes; intensive physiotherapy to begin after 3 weeks of post-operative recovery. Initial exercises will focus on restoring range of motion, followed by strength training and stability exercises.
Medications Prescribed:
Ibuprofen 400mg for pain, 3 times daily.
Naproxen 250mg for inflammation, 2 times daily.
Rest and Recovery:
Strict non-weight-bearing on the right leg for the first two weeks, followed by gradual weight-bearing with crutches.
Post-surgery recovery is expected to last 6-9 months before returning to full athletic activity.
Activity Limitations:
No running, jumping, or high-impact activities for the first 6 months.
Avoid prolonged standing or walking during the initial recovery phase.
Projected Timeline for Return to Play: Estimated 9-12 months post-surgery, depending on the progression of rehabilitation and functional recovery.
Follow-Up Care
Scheduled Follow-Up Appointments:
Next appointment with the orthopedic surgeon on 10/10/2024 for post-surgical evaluation.
Additional Diagnostic Testing (if needed):
Follow-up MRI in 3 months to assess the progress of healing.
Physician's Signature:
Dr. Sarah Mitchell
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