Sports Injury Medical Report

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Patient Information

Patient Name:	[Your Name]
Patient ID:	123456789
Date of Birth:	January 1, 2050
Gender:	Female
Contact Information:	123-456-7890

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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

• Primary Symptoms Experienced:

  • Severe pain localized to the right knee.

  • Immediate swelling around the knee joint.

  • Inability to bear weight or walk without assistance.

  • Limited range of motion with difficulty bending or straightening the knee.

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Initial Physical Assessment

• Injured Body Part: Right knee

• Type of Injury Suspected: Anterior cruciate ligament (ACL) tear

• Severity of Injury: Severe

• Functional Limitations:

  • Complete inability to bear weight on the right leg.

  • Difficulty moving the knee without extreme pain.

• 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.

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Imaging & Diagnostic Results

• Diagnostic Imaging Performed:
  MRI of the right knee confirmed a complete rupture of the anterior cruciate ligament (ACL), with associated mild meniscal damage on the medial side. No fractures were identified.

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Medical Diagnosis

• Primary Diagnosis: Complete ACL tear in the right knee

• Secondary Conditions: Mild meniscal tear, medial joint line

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Treatment & Management Plan

1. 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.

2. 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.

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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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