Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with right knee swelling, reported onset [Date/Time]. Patient describes a sensation of tightness and pressure within the joint, exacerbated by weight-bearing and prolonged activity. Denies history of recent trauma, fever, or chills. Reports associated stiffness and limited range of motion.
Clinical Examination Findings
Right knee examination reveals visible suprapatellar fullness and obliteration of the parapatellar gutters. Positive patellar ballottement test and fluid wave/bulge sign present, consistent with moderate joint effusion. Range of motion is limited to [Degrees] due to mechanical obstruction from fluid. No erythema or warmth noted. Neurovascular status intact distally.
Treatment Protocol
Plan: 1. Rest, Ice, Compression, and Elevation (RICE protocol). 2. Non-steroidal anti-inflammatory drugs (NSAIDs) as directed. 3. Activity modification to avoid high-impact loading. 4. Consider diagnostic/therapeutic arthrocentesis if symptoms persist. 5. Follow-up in [Timeframe] to monitor resolution.