Diagnosis:
- Right knee osteoarthritis
Plan:
- Physiotherapy referral for quadriceps strengthening and pain management.
- Prescription for Celecoxib 200mg daily as needed for pain.
- Review in 3 months with follow-up X-rays of the right knee.
Thank you for referring Mr. Arthur Pendelton who I reviewed today. Arthur is a 68 year old retired carpenter male who presents with chronic right knee pain.
Mr. Pendelton reports a gradual onset of right knee pain approximately 18 months ago, with no specific injury. The pain is described as a deep ache, rated 6/10 on a visual analogue scale, worse with weight-bearing activities, prolonged standing, and climbing stairs. He finds relief with rest and occasional paracetamol. He denies any locking, clicking, or instability. Previous treatments included over-the-counter pain relievers and a brief course of physiotherapy which provided minimal relief. He explicitly denied considering a knee brace.
Mr. Pendelton lives at home with his wife and is generally active, enjoying gardening and short walks. He has a history of controlled hypertension, managed with Amlodipine 5mg daily, and hypercholesterolaemia, managed with Atorvastatin 20mg daily. He underwent an appendectomy in 1985. He has no known allergies. He occasionally drinks alcohol and is a non-smoker.
On examination, there was a mild effusion of the right knee with palpable crepitus during flexion and extension. Range of motion was 0-110 degrees flexion, with pain at the extremes. Ligamentous stability was intact. Quadriceps strength was 4/5 bilaterally. X-rays of the right knee performed on October 2024 at i-Med demonstrated significant joint space narrowing, osteophyte formation, and subchondral sclerosis consistent with advanced osteoarthritis.
We discussed the diagnosis of right knee osteoarthritis, explaining the degenerative nature of the condition. Non-operative management options, including physiotherapy, weight management, and analgesia, were reviewed. Surgical options, specifically total knee arthroplasty, were also discussed, including potential risks such as infection, bleeding, and the need for rehabilitation. Mr. Pendelton was provided with information leaflets on knee osteoarthritis and total knee replacement surgery. He expressed concerns about the recovery period following surgery but was receptive to exploring conservative measures first.
Thank you for your ongoing care of Arthur. Please feel free to get in touch if you have any questions or require further information regarding the management plan.
Diagnosis:
- [primary_diagnosis] (List only the main diagnosis with affected side. If there are two distinct pathologies, include both, otherwise focus on the primary condition. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
- [management_plan_item_1] (Each management plan item should be on its own line with a dash. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [management_plan_item_2] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
-[management_plan_item_3] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you for referring [patient_full_name] who I reviewed today. [patient_first_name] is a [patient_age] year old [occupation] [sex] who presents with [chief_complaint]. (Include occupation only if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit this term without noting its absence. For all placeholders in this sentence, only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[detailed_history] (Include onset, duration, severity, aggravating/alleviating factors, associated symptoms, functional limitations, previous injuries, trauma, treatments tried and responses. If the patient has explicitly denied a therapy when asked about it, state this explicitly. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[combined_history_paragraph] (Create one cohesive paragraph that combines any explicitly mentioned social history (occupation, home supports, living situation, sports, physical activities, hobbies), followed by medical and surgical history, current medications and allergies in a single flowing paragraph with no separation. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[examination_and_investigations] (Physical examination findings including any explicitly mentioned inspection, palpation, range of motion, strength testing, joint stability, deformity, swelling or tenderness. Then summarise investigations performed, including type (X-ray, CT, US, MRI), when performed (month and year if mentioned), where performed (imaging provider name such as PRC, SKG, i-Med if mentioned), and results. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[treatment_discussion] (Summary of treatment discussion including diagnosis explanation, patient education, surgical and non-operative options, informed consent, potential risks, patient information resources provided, and specific concerns addressed, but only if these elements are explicitly mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Thank you for your ongoing care of [patient_name]. Please feel free to get in touch if you have any questions or require further information regarding the management plan.
Yours Sincerely,
(This is a clinical letter to the referring GP. Only include information explicitly mentioned in the consultation, transcript, contextual notes, or clinical note. For diagnosis, include only the primary diagnosis or at most two distinct pathologies - do not list multiple related diagnoses or symptoms. Write in full sentences with no section headings except for "Diagnosis:" and "Plan:" at the beginning. List each diagnosis and plan item on a separate line with a dash (-). If any information related to a placeholder has not been explicitly mentioned, omit the placeholder completely without noting its absence. For imaging providers (such as PRC, SKG, i-Med), include the name exactly as mentioned. For dates, format as month/year if mentioned. Do not quote text from the transcript.)