左膝扭伤后疼痛一天,2个月前有类似病史。Presented with painfal left knee following a sprain for 1 day. Experienced similar episode 2 months previously.
PE:左髌周无明显压痛,麦氏症(+)。Upon physical examination, no tenderness is detected around left knee cap, however, McMurray's sign is detected positive.
1. 左膝MRI报告(临时):左膝骨质增生,半月板变性(以内侧为著),关节腔、髌上囊少-中等量积液,内侧侧副韧带损伤可能大。Informal MRI scan reports
steohyperplasia of left knee. degenerative change of meniscus (especially remarkable in medial side), mild to moderate hydrarthrosis in joint cavity and suprapatellar sac, indicating the possibility of injury of medial accessory ligament.
2. 左膝制动。Immobilization of left knee
3. 止痛片2盒;止痛喷剂3支。Anti-inflammatory tabletx 2 boxes, p.o.; painkiller spray 3 bottles
4. 随访。Followup.