Sports Medicine Specialist Review Letter to referrer and interested parties

[Patient’s title (Mr or Ms followed by patient’s surname)] returns for review today for assessment of [provisional diagnosis of injury] (Only include if explicitly mentioned in transcript, note or context). This review was performed in co-consultation with Dr. Thomas Kelly, Specialist Sport and Exercise Physician. HISTORY Mr. Smith reports a significant improvement in his knee pain since his initial consultation. He states that the pain has reduced from a 7/10 to a 2/10 on the pain scale. He is now able to walk for 30 minutes without any pain, and his ability to participate in recreational activities has improved. He reports that he is now able to cycle for 1 hour without any pain. He is still experiencing some stiffness in the morning, but this resolves within 15 minutes. He is now able to return to work full time. INVESTIGATIONS Mr. Smith underwent further investigations with a MRI of the left knee. MRI of left knee performed on 20 October 2024 at City Imaging demonstrated the following findings: - Moderate-sized joint effusion. - Mild chondral injury to the medial femoral condyle. CURRENT THERAPIES/TREATMENTS Mr. Smith has been undergoing physiotherapy, including exercises to strengthen the quadriceps and hamstrings. He has been taking ibuprofen 400mg twice daily for pain relief. He has also been advised to use ice packs after exercise. EXAMINATION On examination, Mr. Smith’s knee range of motion has improved. There is no effusion present. The McMurray test is negative. The patient is able to perform a single leg squat without pain. DIAGNOSIS Mr. Smith presents with clinical and radiological features consistent with a meniscal tear. Differential diagnoses include: - Osteoarthritis: This is less likely given the patient's age and the acute onset of symptoms. - Ligamentous injury: This is less likely given the negative findings on examination. MANAGEMENT I have discussed Mr. Smith's condition with them today and recommended the following management plan: - Continue with physiotherapy, including exercises to strengthen the quadriceps and hamstrings. - Continue with ibuprofen 400mg twice daily for pain relief. - Advise the patient to avoid activities that aggravate his symptoms. Further treatment options were discussed including optimization of non-operative management with ultrasound-guided injections, and referral to an Orthopaedic Specialist for consideration of operative management of this injury. I would appreciate the opportunity to review Mr. Smith in 4 weeks to assess their response to the recommended treatment plan and to assess their progress with the physiotherapy-based rehabilitation program. Once again, many thanks for giving me the opportunity to assist with management of your patient. If you have any further questions, please do not hesitate to reach out to me. Warm Regards, Dr. Jane Doe General Practitioner Co-Consulted with Dr. Thomas Kelly, Specialist Sport and Exercise Physician Provider No. 1234567 City Medical Clinic, 123 Main Street, Anytown, AB, 12345 cc: Dr. John Smith, Orthopaedic Surgeon and City Orthopaedics cc: Jane Brown, Physiotherapist and City Physiotherapy cc: David Green, Exercise Physiologist and City Exercise Physiology