NHS GP Ultimate Consult

GP Consultation Note Template "Patient has been consented to use AI scribe." F2F: Right knee pain Seen with Daughter Presenting Complaint and History: 68y/o female c/o R knee pain x 3/12. Gradual onset, worse with walking/stairs. No specific injury. Pain 6/10, aching. Stiffness in AM for ~15 mins. Denies swelling, redness, fever. No hx trauma. Self-medicating with OTC paracetamol, mild relief. Risk Factors: Obesity (BMI 32), sedentary lifestyle, family hx OA. ICE: Ideas: thinks it's 'wear and tear' due to age. Concerns: worried about needing surgery, limited mobility impacting independence. Expectations: wants pain relief, something to stop it getting worse. Alcohol and smoking history: Alcohol: 10 units/week. Occasional binge drinking. Smoking: Ex-smoker, quit 5 years ago (previously 20/day x 40 yrs). Allergy: NKDA Red Flags: None identified (no night pain, weight loss, fever, constitutional symptoms). Negative Symptoms: No numbness, tingling, weakness in leg. No locking or giving way. Examinations and Vitals Signs: Obs: BP 130/80, HR 78, Temp 36.8C, SpO2 98% RA. BMI 32. R knee: Mild crepitus on movement. Full ROM, slight pain at end range flexion. No effusion, warmth, or erythema. Good patellar tracking. Stable MCL/LCL. No meniscal signs. Working Diagnosis: Primary: Osteoarthritis, right knee. Differentials: Meniscal injury, Patellofemoral pain syndrome. Share Management Plan: 1. Medication: Paracetamol 1g QDS PRN, topical NSAID gel (e.g., Voltarol Emulgel) TDS for 2/52. 2. Investigation: X-ray R knee (AP/Lateral/Skyline views) to assess OA severity. 3. Follow up: Review in 4 weeks with X-ray results. Discuss physiotherapy referral if pain persists. 4. Referral: None at present. 5. Reassurance: Explained OA is common, management focuses on pain control & improving function. Not all cases require surgery. Safety Netting Advice: Advised to return if pain significantly worsens, develops swelling/redness, fever, or new neurological symptoms (numbness, weakness). Continue gentle exercise (walking, swimming) within pain limits. Weight loss encouraged.