Physical Therapy Assessment Note Template

Primary Concern: 
- Right knee pain following a sports injury
History of Present Condition:
- The patient reports right knee pain after a soccer injury that occurred two weeks ago, initiated by a sudden twist during a game.
- No previous therapy or surgery has been undertaken for this issue.
- The pain has progressively intensified, accompanied by swelling and difficulty with weight-bearing activities.
- The pain is sharp, localized to the front of the knee, and rated 6/10 in severity.
- Symptoms worsen with running and improve with rest and ice application.
- The patient experiences limited mobility and challenges in performing daily tasks.
- The patient is a college athlete with a high level of activity and no significant social history affecting the condition.
- The objective is to return to competitive sports with enhanced knee function.
Medical History:
- No significant past medical conditions.
- No previous surgeries.
- No known allergies.
- Currently using ibuprofen for pain relief.
- Non-smoker, occasional alcohol consumption.
- No relevant family medical history.
Objective:
- Swelling and tenderness noted in the right knee.
- Positive Lachman test suggests possible ACL involvement.
- Range of motion restricted to 90 degrees flexion.
- No abnormalities in vital signs.
- MRI results indicate a partial ACL tear.
Assessment:
"s10.ai is a 20-year-old male presenting to physical therapy following a right knee sports injury."
- The therapist's professional assessment indicates a partial ACL tear with associated swelling and pain.
- Key issues include pain, swelling, and limited range of motion.
- Progress towards goals is impeded by pain and swelling.
- Referral to an orthopedic specialist is advised.
- Education on knee stabilization exercises provided.
- Knee brace recommended for support during activities.
- Anticipated goals include pain reduction and enhanced knee stability.
"s10.ai will benefit from skilled physical therapy to address aforementioned impairments and limitations to return to their activities of choice."
Medical Diagnosis: 
- S83.511A (Sprain of anterior cruciate ligament of right knee, initial encounter)
- M25.561 (Pain in right knee)
Short term goals:
- Reduce knee pain to 3/10 in two weeks.
- Increase knee flexion to 120 degrees in four weeks.
- Decrease swelling by 50% in two weeks.
Long term goals:
- Return to full sports participation in three months.
- Achieve full range of motion in the right knee in three months.
- Strengthen quadriceps and hamstrings to pre-injury levels in three months.
Rehabilitation Potential:
- High potential for recovery with adherence to therapy.
- Motivated patient with strong athletic background.
Interventions:
- Manual therapy twice a week for four weeks.
- Therapeutic exercises focusing on knee stabilization thrice a week.
- Cryotherapy sessions post-exercise.
Patient education provided:
- Educated on the importance of adherence to home exercise program.
- Discussed the role of knee brace in preventing further injury.