Summary:
- 45 year old female presents with chronic right knee pain, worsened by activity.
- Diagnosis: Osteoarthritis, right knee (medial compartment dominant).
- Plan: Commence physiotherapy, trial NSAIDs, and consider corticosteroid injection if conservative measures fail. Follow-up in 6 weeks.
HOPC:
- Patient reports chronic right knee pain for approximately 18 months, insidious onset. Pain is described as a dull ache, 6/10 at worst, exacerbated by climbing stairs, prolonged standing, and squatting. Some morning stiffness lasting less than 30 minutes. No locking or giving way reported.
- Specific musculoskeletal concerns: Right knee pain and stiffness.
- Detailed history: Pain began gradually without a specific injury. It has progressively worsened over time, impacting daily activities and recreational walking. Alleviated temporarily by rest and over-the-counter paracetamol. Associated symptoms include occasional crepitus.
- Previous treatments: Has tried paracetamol with minimal relief. No previous physiotherapy or orthopaedic surgeries for this complaint.
- Patient goals: Hopes to reduce pain and improve mobility to resume her regular walking routine without discomfort.
- Patient's Ideas, Concerns, and Expectations: Concerned about potential progression of arthritis and keen to explore non-surgical options first. Hopes to avoid surgery if possible.
Past medical and surgical Hx:
- Past medical history: Hypertension, well-controlled with medication.
- Previous surgeries: Appendectomy (20 years ago).
Medications:
- Current medications: Lisinopril 10mg once daily.
Allergies:
- Allergies: Penicillin (hives).
Social history:
- Social history: Right-handed. Works as an accountant, largely sedentary. Enjoys walking and gardening in her spare time. Non-smoker, occasional alcohol use (1-2 units per week). Lives with her partner, good home support.
Examination and Investigations:
- Examination findings: Right knee: Mild valgus deformity. Palpable crepitus with flexion/extension. Tenderness over medial joint line. Full extension, flexion to 120 degrees with pain at end range. Mild effusion. Ligaments stable. Strength 5/5 throughout. Gait antalgic on the right. Left knee: Unremarkable.
- Investigations: X-ray right knee (standing views) - September 2024 (i-Med): Moderate joint space narrowing in the medial compartment, osteophytes, and subchondral sclerosis. MRI right knee - October 2024 (PRC): Confirms medial compartment osteoarthritis with meniscal degeneration and mild bone marrow oedema.
Discussion and Plan:
- Management plan: Discussed the diagnosis of medial compartment osteoarthritis of the right knee and available treatment options, both conservative and surgical. Patient consented to a trial of conservative management. Non-surgical treatment options include regular physiotherapy focusing on strengthening quadriceps and hamstrings, improving range of motion, and activity modification. Prescribed Celecoxib 200mg daily as a trial of NSAIDs. Educated patient on potential side effects of NSAIDs and importance of taking with food. Patient advised to use ice packs for acute pain and continue with paracetamol as needed. If conservative measures prove insufficient after 4-6 weeks, a corticosteroid injection into the knee joint will be considered. Pre-operative care and surgical options (e.g., knee arthroplasty) were briefly discussed as future considerations if conservative treatment fails. Patient to follow up in 6 weeks or sooner if symptoms worsen significantly. Activity restrictions include avoiding high-impact activities for the next few weeks. Patient's concerns regarding surgical intervention were addressed.
Summary:
- [age] [sex] presents with [symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Diagnosis: [diagnoses] (Include all explicitly mentioned diagnoses. Only include this line if at least one diagnosis is explicitly mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- Plan: [plan_summary] (Briefly summarise the management plan explicitly stated below; only include if a plan is mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
HOPC:
- [history_of_presenting_complaints] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [consultation_reasons] (Specific musculoskeletal concerns such as joint pain, stiffness, swelling, injuries, fractures, deformities. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [detailed_history] (Including onset, duration, severity, aggravating/alleviating factors, associated symptoms, previous injuries, trauma. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [previous_treatments] (Such as physiotherapy, medications, orthopaedic surgeries and responses. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [patient_goals] (Goals for this visit if mentioned. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [patient_ice] (Patient's Ideas, Concerns, and Expectations. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Past medical and surgical Hx:] (Include this section heading only if any past medical history is explicitly mentioned)
- [past_medical_history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [previous_surgeries] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Medications:] (Include this section heading only if medications are explicitly mentioned. If "nil medications" or similar is stated, omit this entire section)
- [current_medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Allergies:] (Include this section heading only if allergies are explicitly mentioned. If "NKDA" or "no known allergies" or similar is stated, omit this entire section)
- [allergies] (Including reaction type if mentioned, allergies to medications, metals important for implants, or other materials relevant to orthopedic procedures. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Social history:] (Include this section heading only if any social history is explicitly mentioned)
- [social_history] (Such as handedness, employment, sports and physical activities, smoking status, alcohol use, recreational drug use, supports at home, hobbies. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Examination and Investigations:] (Include this section heading only if any examination or investigation details are explicitly mentioned)
- [examination_findings] (Musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, deformity, swelling, tenderness. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [investigations] (Include study date in month/year format if mentioned (e.g., "January 2023" or "Jan 2023"); study type (X-ray, CT, MRI); the imaging provider name exactly as mentioned in the transcript; and findings. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Discussion and Plan:] (Include this section heading only if any discussion or plan details are explicitly mentioned)
[management_plan] (Include discussion/consent, non-surgical treatment options, non-operative or operative plan, patient education, pre/post-operative care, activity restrictions, wound care (briefly), complications to watch for, patient/family concerns addressed, rehabilitation plan, and relevant referrals. Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(Never create patient details, assessment, plan, interventions, evaluation, or continuing care not explicitly mentioned in the transcript, contextual notes or clinical note. If information related to a placeholder is not explicitly mentioned, omit the placeholder completely without stating that information is missing. For imaging providers, include the exact name of any imaging provider mentioned in the transcript - common examples include PRC, SKG, and i-Med, but document whatever provider is specifically mentioned. For dates, format as month/year (e.g., "January 2023" or "Jan 2023"). For wound care, state briefly if mentioned. Do not quote patient or audio recording directly.)