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[Verified Answer]: Medical Record Excerpt: Patient: Robert…

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Medical Record Excerpt: Patient: Robert Smith, 54 y/o male. Date: 11/02/2023 Chief Complaint: Left knee pain and swelling. History of Present Illness (HPI): Patient presents to the clinic today with left knee pain and swelling that began approximately 3 days ago. He reports the pain is sharp and worsens with weight-bearing. He denies any recent trauma or injury. He has noticed increased swelling and stiffness in the knee. Past Medical History (PMH): Hypertension, well-controlled with Lisinopril 20mg daily. Hyperlipidemia, managed with Atorvastatin 40mg daily. Medications: Lisinopril 20mg daily, Atorvastatin 40mg daily, Ibuprofen 600mg PRN for pain. Allergies: NKDA (No Known Drug Allergies). Physical Examination: Vital Signs: BP 130/80, HR 78, RR 18, Temp 98.6°F. Left Knee: Significant swelling, tenderness to palpation along the medial joint line, decreased range of motion, positive McMurray’s test. No erythema or warmth noted. Right Knee: Normal range of motion, no swelling or tenderness. Assessment: Left knee effusion, unspecified. Possible medial meniscus tear. Plan: Left knee X-ray, AP and lateral views. Prescribed Naprosyn 500mg BID for pain and inflammation. Instructed to apply ice to the knee for 20 minutes at a time, several times a day. Follow-up appointment scheduled for one week, or sooner if pain worsens. Radiology Report (Attached Summary): Left knee X-ray: Mild joint effusion noted. No evidence of fracture or dislocation. Follow-Up Note (One Week Later): Patient reports slight improvement in pain and swelling. Naprosyn tolerated well. Continued ice therapy recommended. MRI of the left knee ordered to further evaluate possible meniscus tear. Identify and list at least 10 key data elements that would be important to extract during a medical record audit’

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