Orthopaedics Consultation Note

Orthopaedics Consultation Note **Diagnosis/ Presenting Complaint** 45-year-old male presenting with a 3-month history of progressive right knee pain, exacerbated by activity and stairs. He reports occasional locking and a feeling of instability. Initial onset was gradual with no specific injury, but pain has worsened significantly in the past month, impacting daily activities. **Outcome** Diagnosed with medial meniscus tear and early osteoarthritis of the right knee. Recommended initial conservative management including physiotherapy, anti-inflammatory medication, and a knee brace. Discussed surgical options (arthroscopy for meniscectomy/repair) if conservative measures fail. Patient is agreeable to starting conservative treatment. **Age** 45 **Occupation** Construction Site Manager. His role involves frequent standing, walking on uneven surfaces, and occasional lifting, which significantly aggravates his right knee pain. He reports difficulty climbing scaffolding and inspecting sites due to his symptoms. **Past Medical History** No significant past medical history. No previous knee injuries or surgeries. Denies any chronic conditions such as diabetes or rheumatoid arthritis. No known allergies. **Discussion/ Outcome** The consultation involved a thorough review of the patient's symptoms, physical examination findings (tenderness over medial joint line, positive McMurray's test), and review of recent MRI imaging confirming a medial meniscus tear and mild chondral changes. Treatment options discussed included conservative management (physiotherapy focusing on strengthening and range of motion, NSAIDs, knee brace for support) and surgical intervention (arthroscopic meniscectomy or repair). The risks and benefits of both approaches were explained in detail. Patient expressed a preference to exhaust non-surgical options first. He demonstrated good understanding of the plan and potential need for future surgical assessment if symptoms persist or worsen. Agreed to start physiotherapy next week and follow up in 6 weeks with progress.