MADIGAN ARMY MEDICAL CENTER OUTPATIENT ENCOUNTER 9600 Veterans Drive TACOMA WASHINGTON 98493 USA ZZTEST VADOD TWO Madigan Army Medical Center 9040 Fitzsimmons Ave Tacoma WA 98431 USA Madigan Army Medical Center 9040 Fitzsimmons Ave Tacoma WA 98431 USA
Appointment Walk-in Appointment on 2/15/2008 20080215000000-08
Reason for Visit/Chief Complaint Knee Injury
Encounter Entries
Note 1
Reason for Visit/Chief Complaint Knee Injury
Date 20080215113716-08
Provider
Provider Id Name Clinic Name
999999-PROVIDER-ID LAST, FIRST M
Subjective Patient twisted knee walking down steps at his house. He iced it and elevated it for two days, but it continued to swell.
Objective Swelling in knee is visible. Vitals Date: 2/15/2008 11:33:00 AM SYS: 130 DIAS: 80 Pulse: 70 Resp: 20 Weight(KG/LBS): 180/81.647 Height(CM/IN)180.34/71 BMI:25.1 Temp(C/F): 36.778/98.2 O2: 98 Pain Level: 3
Assessment Definite knee sttrain, but no permanent tissue damage.
Plan Take ant-inflamitories, continue to ice and elevate. If problem does not go away in 1 week, return to the clinic.
Multi Problem
Vital Signs
Date / Time
20080215113300-08
Height 180.34 cm (71 in)
Weight 180 lbs (81.647 kg)
BMI 25.1 kg/m2
BSA 0 m2
Temperature 36.778 C (36.778 F)
Pulse 0 / minute
Respirations 20 / minute, unlabored
Systolic 130 mmHg
Diastolic 80 mmHg
Problem List
ICD TEXT DX SOURCE
453.9 VENOUS THROMBOSIS NOS ICDB