Subjective Assessment:
Patient presents today with a 6-week history of left knee pain following a fall during a football match. The patient reports the pain is gradually improving with rest and ice. The mechanism of injury was a direct blow to the lateral aspect of the knee. The patient is currently able to weight bear but experiences pain with twisting movements.
HPC:
The patient reports a gradual onset of left knee pain following a fall. Initially, the pain was severe, but it has gradually improved over the past six weeks. The patient denies any specific incident that worsened the pain recently.
VAS:
4/10 at rest, 6/10 with activity.
Aggravated by:
Twisting movements, prolonged standing, and squatting.
Eased by:
Rest, ice, and elevation.
Mandatory questions:
Night/Constant/Bilateral Pain/Weight Loss: No night pain, no constant pain, no bilateral pain, no weight loss.
Increased sweating/Night sweats: Denies increased sweating or night sweats.
Power loss/Numbness/Pins & needles: No power loss, numbness, or pins and needles.
Prolonged steroids/Osteoporosis: Denies prolonged steroid use or history of osteoporosis.
Anti-coagulants: Not on any anti-coagulants.
Sleep Disturbance: Sleep is not disturbed.
Metal Implants: No metal implants.
Relevant Medical History:
Nil.
PMH:
Nil.
Patient valued outcomes (PVOs):
Patient aims to return to playing football and be able to squat pain-free.
Objective Assessment:
Posture: Normal alignment.
Gait: Antalgic gait on the left leg.
Back - Movements: Within normal limits.
Back - Palpation: No tenderness.
Quadrant: Negative.
SI Joints - Stork: Negative.
SI Joints - Squish: Negative.
Hip Joints: Within normal limits.
Flexibility: Reduced knee flexion.
Strength: Reduced quadriceps strength.
ASIS Fixed: Negative.
SLR (Straight Leg Raise): Negative.
Palpation: Tenderness over the lateral joint line.
Functional: Squatting limited by pain.
Alignment: Normal.
Knees: Mild effusion.
Feet: Normal.
Other:
No other findings.
IMPRESSION:
Suspected meniscal injury.
PLAN:
Advise on RICE protocol. Provide education on activity modification. Commence quadriceps strengthening exercises. Review in 2 weeks.
TREATMENT:
Manual therapy to reduce swelling. Education on correct squatting technique.
HEP (Home Exercise Programme):
Quadriceps strengthening exercises, hamstring stretches, and gentle range of motion exercises.
ADVICE:
Advised to avoid activities that aggravate the pain. Advised to use ice after activity. Advised to follow the home exercise program.
Next Day Plan:
Review the patient's progress and adjust the treatment plan as needed. Continue with the current treatment plan.
Subjective Assessment:
[Include how the patient is presenting today, the mechanism of injury, how their treatment is progressing, and timeline of injury] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
HPC:
[Describe history of presenting complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
VAS:
[Record VAS score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Aggravated by:
[Describe aggravating factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Eased by:
[Describe easing factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Mandatory questions:
Night/Constant/Bilateral Pain/Weight Loss: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Increased sweating/Night sweats: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Power loss/Numbness/Pins & needles: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Prolonged steroids/Osteoporosis: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Anti-coagulants: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Sleep Disturbance: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Metal Implants: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Relevant Medical History:
[Describe relevant medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
PMH:
[Describe past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Patient valued outcomes (PVOs):
[Include patient’s goals for physiotherapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Objective Assessment:
Posture: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Gait: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Back - Movements: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Back - Palpation: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Quadrant: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
SI Joints - Stork: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
SI Joints - Squish: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Hip Joints: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Flexibility: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Strength: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ASIS Fixed: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
SLR (Straight Leg Raise): [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Palpation: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Functional: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Alignment: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Knees: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Feet: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Other:
[Describe other findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
IMPRESSION:
[Describe clinical impression] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
PLAN:
[Describe management plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
TREATMENT:
[Describe treatment provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
HEP (Home Exercise Programme):
[Describe prescribed home exercise programme] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ADVICE:
[Describe advice given to patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Next Day Plan:
[Describe plan for next day] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
