S – Subjective
Presenting complaint:
* Sharp pain in the right knee.
Mechanism of injury and date:
* Twisted knee while playing football, 28 October 2024.
Symptoms:
* Sharp pain on the inside of the right knee.
* Swelling around the knee joint.
* Difficulty weight-bearing.
Function (impact on life):
* Unable to walk without a limp and difficulty with daily activities.
Aggravating factors:
* Walking.
* Squatting.
* Twisting the knee.
Relieving factors:
* Rest.
* Ice.
* Elevation.
24-hour pattern:
* Pain is worse in the morning and after activity.
Activity:
- Regular activity:
* Plays football twice a week.
- Meeting guidelines (Y/N):
* N
- Training load (recent changes):
* Increased training load in the last month.
Health:
General health:
* Generally fit and healthy.
Past medical history, previous injuries and surgery:
* No significant past medical history.
* No previous injuries.
* No surgeries.
Family history:
* Father with osteoarthritis.
Usual GP:
* Dr. Smith.
Stress management:
* No specific stress management strategies.
Diet:
* Balanced diet.
Hours of sleep:
* 7-8 hours per night.
Imaging:
* No imaging performed yet.
Previous treatment:
* None.
Red flags:
* No red flags reported.
Social history:
* Lives with parents.
* Student.
Previous experiences with physiotherapy:
* None.
Patient goal for today:
* "To reduce pain and get back to playing football."
O – Objective
Observation:
* Swelling around the right knee.
* Mild bruising.
* Antalgic gait.
Palpation:
* Tenderness over the medial collateral ligament (MCL).
* No bony tenderness.
Range of motion (ROM):
* Reduced knee flexion (0-90 degrees).
* Painful knee extension.
Special tests:
* Positive valgus stress test at 30 degrees.
* Negative McMurray's test.
Strength and functional testing:
* Weakness with knee extension.
* Difficulty with single-leg stance.
A – Assessment
Impression:
Suspected Grade 2 MCL sprain.
Rx – Treatment
"Informed consent received from client for treatment."
"Discussed diagnosis, prognosis, contributing factors, and treatment plan."
Advice and education:
* RICE protocol (Rest, Ice, Compression, Elevation).
* Importance of early mobilisation.
* Gradual return to activity.
Activity recommendations:
* Avoid activities that aggravate pain.
* Progressive weight-bearing as tolerated.
Exercises prescribed:
* Quadriceps sets: 3 sets of 10 repetitions, 3 times a day.
* Hamstring curls: 3 sets of 10 repetitions, 3 times a day.
* Calf raises: 3 sets of 10 repetitions, 3 times a day.
* Straight leg raises: 3 sets of 10 repetitions, 3 times a day.
Manual therapy provided:
* Soft tissue massage to surrounding muscles.
Plan
* Review in one week.
* Provide home exercise program.
* Monitor progress and adjust treatment as needed.
S – Subjective
Presenting complaint:
[presenting complaint] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Mechanism of injury and date:
[mechanism of injury and date] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Symptoms:
[current symptoms] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Function (impact on life):
[functional impact] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Aggravating factors:
[aggravating factors] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Relieving factors:
[relieving factors] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
24-hour pattern:
[24-hour symptom behaviour] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Activity:
- Regular activity:
[usual physical activity] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
- Meeting guidelines (Y/N):
[guideline adherence] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
- Training load (recent changes):
[training load changes] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Health:
General health:
[general health status] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Past medical history, previous injuries and surgery:
[past medical history] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Family history:
[family medical history] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Usual GP:
[usual GP] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Stress management:
[stress management strategies] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Diet:
[dietary habits] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Hours of sleep:
[hours of sleep] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Imaging:
[imaging findings] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Previous treatment:
[previous treatment received] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Red flags:
[red flags reported or identified] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Social history:
[social background] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Previous experiences with physiotherapy:
[previous physiotherapy experience] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
Patient goal for today:
[patient’s desired outcome for session] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a direct quote or summarised bullet point.)
O – Objective
Observation:
[observation findings] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Palpation:
[palpation findings] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Range of motion (ROM):
[ROM findings] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Special tests:
[special test results] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Strength and functional testing:
[strength and function findings] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
A – Assessment
Impression:
[clinical impression or diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note. Write in paragraph format.)
Rx – Treatment
"Informed consent received from client for treatment."
"Discussed diagnosis, prognosis, contributing factors, and treatment plan."
Advice and education:
[advice or education provided] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Activity recommendations:
[activity recommendations] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Exercises prescribed:
[exercise prescription details] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points. Include what/where/when/how much/how often.)
Manual therapy provided:
[manual therapy performed] (Only include if explicitly mentioned in transcript, context or clinical note. Write as bullet points.)
Plan
[plan for follow-up or next session] (Only include if explicitly mentioned in transcript, context or clinical note. Write as a single bullet point.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care – use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output. Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)
