Virtual Consult (Semble)

Orthopaedic Surgeon **Virtual consultation summary** **Re: Right Knee Pain** **Summary of Consultation:** - You reported experiencing persistent pain in your right knee, particularly when walking upstairs or standing for long periods. You mentioned the pain started approximately three months ago after a minor fall, and has progressively worsened. - Your medical history includes well-controlled hypertension and no prior significant knee injuries or surgeries. You are currently taking a daily aspirin and occasional paracetamol for pain relief. **Self-reported examination findings:** - You described tenderness over the medial aspect of your right knee. You noted some stiffness, especially in the mornings, and a sensation of grinding or clicking with movement. Your range of motion appears somewhat limited on self-assessment due to pain, particularly with full flexion and extension. **Test Results Discussed:** - We discussed the results of your recent X-ray of the right knee, which showed mild to moderate degenerative changes, particularly in the medial compartment, consistent with osteoarthritis. There was no evidence of fracture or acute injury. **Diagnosis:** - Based on your symptoms, history, and X-ray findings, your diagnosis is early-stage osteoarthritis of the right knee. **Treatment Plan:** - We've discussed a treatment plan that includes regular low-impact exercises, such as swimming or cycling, to strengthen the muscles around your knee. We recommend starting with over-the-counter anti-inflammatory medication (ibuprofen) as needed for pain and swelling, provided you have no contraindications. We also reviewed the benefits of weight management to reduce stress on your knee joint. - We have scheduled a follow-up virtual consultation for 1 November 2024 to review your progress and discuss further options if your symptoms do not improve. We may consider a referral for physiotherapy at that time. **Important Information:** - It's important to continue monitoring your pain levels and any changes in your knee function. If you experience sudden severe pain, swelling, or instability, please contact us immediately. Thank you for attending this virtual consultation. We hope to see an improvement in your symptoms with the outlined plan.