Orthopaedic Follow Up

(Write all content in paragraphs using complete sentences.) [date of input] (Insert the full date of the clinical encounter in DD/MM/YYYY or standardised clinical format. Only include if explicitly mentioned in transcript or context, else omit section entirely.) "It was a pleasure to review you today. Below is a letter detailing our consultation:" _Review_: - [Reason(s) for consultation, including specific musculoskeletal concerns or symptoms such as joint pain, stiffness, swelling, injuries, fractures, deformities, etc.] (Document the patient’s reported reason for the consultation or follow-up, specifically highlighting musculoskeletal complaints. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [History of the presenting complaint(s), including onset, duration, severity, aggravating/alleviating factors, associated symptoms such as limitation of movement, previous injuries, trauma, any previous treatments and responses, etc.] (Summarise the full narrative history of the presenting issue(s), covering all key dimensions: timeline, pain characteristics, associated trauma, previous investigations, treatments, and the clinical context. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [If doing physiotherapy, whether things are progressing well or poorly] (Document current physiotherapy involvement, patient-reported progress or lack thereof, and any relevant commentary on goals and functional improvement. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [How the symptoms have evolved since the last visit and generally how the patient is progressing] (Describe any changes, improvement or deterioration in symptoms since the last encounter, including patient’s perception of their overall progress. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) _Assessment & Investigations:_ - [Vitals] (Include relevant vital signs such as blood pressure, heart rate, temperature or respiratory rate if assessed. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Physical examination findings, with emphasis on musculoskeletal examination including inspection, palpation, range of motion, strength testing, joint stability, presence of deformity, swelling, or tenderness, etc.] (Detail all musculoskeletal physical exam findings. Include specific joints or areas assessed, presence of pain, effusion, abnormal alignment, deformity, swelling, or tenderness. Include functional tests if applicable. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Appearance of the surgical wound] (Comment on the state of any post-operative wound, including healing status, erythema, discharge, approximation, or signs of infection. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant] (Include findings on distal sensation, pulses, capillary refill, motor function and temperature if assessed. State explicitly if neurovascularly intact. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Investigations with results, including imaging and laboratory tests, etc.] (List imaging results such as X-rays, MRIs, CTs, or lab tests with relevant findings. Include dates and interpret key abnormalities if mentioned. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) _Management plan_: 1. [Orthopaedic Issue or Condition] (State the orthopaedic issue or condition being addressed. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Assessment, including the clinician's likely diagnosis and rationale based on subjective and objective findings] (State the working or confirmed diagnosis, supported by clinical reasoning drawn from subjective history and objective findings. Include differential diagnosis if relevant. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences. Do not invent or infer a diagnosis.) - [Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning] (Detail any upcoming diagnostic tests or imaging ordered to support diagnosis or guide management. Include rationale if provided. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Non-surgical treatment options, including physiotherapy, casting or bracing, medications, lifestyle modifications, etc.] (List all conservative treatments recommended including exercise programs, bracing, analgesia, or referrals to allied health professionals. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Surgical treatment options, detailing the type of surgery, the nature of the surgery, and any techniques mentioned] (Document specific surgical procedures being planned, including whether open or arthroscopic, joint involved, technique, and any device or implant mentioned. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Post-operative care plan, covering expected hospital stay, rehabilitation, physiotherapy, pain management, and follow-up appointments] (Describe care plans following surgery, including expected recovery timeline, medication plan, referrals to rehab services and scheduled follow-up. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc.] (Note any referrals made to other departments or external specialists for collaborative management. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - [Document any counselling or education provided to the patient regarding diagnosis, surgical or non-surgical options, prognosis, and importance of adherence to the management plan. ] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences) - [Summarise any questions raised by the patient or family and the responses provided by the clinician] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) - "Informed consent was obtained after a discussion of the nature of the treatment proposed, the nature of the condition, the treatment alternatives, the expected postoperative course, and material risks. The patient gave informed and signed consent for the discussed procedure." (Use this statement only if informed consent was explicitly documented as obtained during the consultation. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) (Follow the same structure as above for each additional issue or condition identified. Repeat the full assessment and plan structure listed above for any secondary or tertiary orthopaedic issues addressed in the consultation. Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs using complete sentences.) Kind regards,