Download Case 4-1

History and Physical and Labs
CC: Right knee effusion and instability
HPI: MA, a promising 17 year-old male varsity basketball player presents with a swollen
right knee. The patient reports that he felt a “pop” when he attempted to quickly stop and
pivot with his knee in a flexed position. The knee quickly swelled. The patient is also
reports pain on the medial aspect of the joint line and a feeling of “unsteadiness” when he
walks.
PMHx/PSHx: None
MEDS: None
Physical Exam:
VS: stable
HEENT: unremarkable
Cardiac: unremarkable
Lung: unremarkable
Abdomen: unremarkable
RIGHT LOWER EXTREMITY:
Vascular: femoral, popliteal, and dorsalis pedis pulses intact and 2+. Normal capillary
refill at toes. Right knee intraarticular effusion (hemarthrosis).
Neuro: Sensation intact in anterior, posterior, lateral, and medial aspects of thigh, knee,
lower leg and foot. 2+ reflexes at patella and achilles tendon.
Musculo/Skeletal: Full range of motion in all joints. 5/5 muscle strength in all muscles
except right knee (untested because of pain).
Valgus Stress Test (at 30 degrees flexion try to abduct the knee): 7 mm of medial
joint opening.
Varus Stress Test (at 30 degrees flexion try to abduct the knee): No lateral joint
opening.
Lachman’s Test (anterior force applied to back of calf with knee at 30 degrees
flexion): 6 mm of anterior displacement of tibia from femur. (normal < 5 mm)
Posterior Drawer Test (posterior force applied to front of leg with knee at 90
degrees flexion): no movement (normal)
Labs: Unremarkable