Subjective:
* Patient reports overall improvement in symptoms since last session, with a noticeable reduction in pain levels during daily activities. Attended a work event last week, which slightly aggravated symptoms.
* Current pain experience: 3/10 at rest, 5/10 during activity.
* Symptoms: Sharp pain in the right knee, located at the patellar tendon, aggravated by squatting and running. Occasional clicking sensation.
Aggs:
* Squatting: Pain onset after 3 reps, intensity 6/10, sharp pain in patellar tendon.
* Running: Pain onset after 5 minutes, intensity 7/10, sharp pain in patellar tendon.
Activity Limitations:
* Squatting
* Running
* Prolonged sitting
Program:
* Patient has been consistent with home exercises, performing them 5 times per week.
* Patient reports some difficulty with the eccentric loading exercises, but overall, the program is manageable.
Goals:
* Return to running without pain.
* Be able to squat to full depth.
* Return to playing football.
Additional Subheadings:
* Sleep: Patient reports good sleep quality, no issues.
* Stress: Patient reports moderate stress levels due to work.
Objective:
* Observation: Mild swelling noted around the right knee.
* Palpation: Tenderness over the patellar tendon.
* Functional Tests: Squatting: limited to 45 degrees, pain at 6/10. Hopping: unable to hop on right leg.
* Active Range of Motion: Knee flexion: 110 degrees, pain 5/10. Knee extension: full, no pain.
* Passive Range of Motion: Knee flexion: 130 degrees, no pain. Knee extension: full, no pain.
* Strength Testing: Quadriceps: 4/5, pain 4/10.
* Special Tests: Patellar tendon palpation positive for pain.
Action:
* Manual therapy: Patellar tendon mobilisations, region: right knee. // Reassessment: improved pain levels to 3/10.
* Education: Discussed the importance of proper warm-up and cool-down routines.
* Exercise Program: Eccentric squats: 3 sets of 10 reps, focus on controlled descent.
Plan:
Planned progression of activity or load:
* Gradual increase in running distance and intensity.
Next physiotherapy session and focus:
* Review progress, reassess symptoms, and progress exercises.
Short-term goals:
* Reduce pain to 2/10 at rest.
Long-term goals:
* Return to sport within 6 weeks.
Patient-Friendly Summary:
Today, we reviewed your progress and discussed your knee pain. You've been doing well with your exercises, and your pain levels have decreased. We worked on some hands-on techniques to help with your patellar tendon. Next time, we'll focus on progressing your exercises and gradually increasing your activity levels. The goal is to get you back to running and playing football without pain. We will be aiming to get you back to sport within 6 weeks.
Date: 1 November 2024
Subjective:
[summary of how the patient reports they are progressing overall, including relevant external appointments or events affecting symptoms, framed in terms of their perception of injury or rehab progress] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[current experience of overall pain] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[symptoms including location, nature, severity, and irritability] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Aggs:
[activities or incidents that provoke symptoms, including timeframe, intensity, and symptom nature/location] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points, with each aspect on a new line and timeframe specified.)
Activity Limitations:
[activities the patient feels limited in due to their condition] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Program:
[patient comments on their program, including adherence, difficulty, painful exercises, and dosage] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Goals:
[goals stated by the patient, related to what they would like to do but currently cannot due to their condition] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Additional Subheadings:
[specific topics discussed such as sleep, stress, comorbidities. Use same bullet point structure as above.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Objective:
[observation findings such as swelling, bruising, redness, asymmetry] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points using medical abbreviations where appropriate.)
[palpation findings such as tenderness, tightness, or reproduction of pain] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[functional test results, including performance of movements such as gait, hopping, squatting, with qualitative or specific performance measures] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[active range of motion results including joint, side, movement, range, and symptom location/intensity. Mark pain onset as P1 and subsequent limit as P2.] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[passive range of motion findings for relevant joints] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[strength or capacity testing including movement, side, values, LSI, and pain scores if relevant] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[neurological findings such as nerve tension tests (SLR, slump, ULTT)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[special test results including test name, side, result, and pain score/quality if reported] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Action:
[treatments provided such as manual therapy, massage, dry needling, taping. Include region treated and any post-treatment reassessment using format // reassessment findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[education provided to the patient on clinically important topics affecting diagnosis, prognosis, symptom management, return to sport, or exercise progression] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points, limit to 2–3 key items.)
[exercise program prescribed or progressed, listed as sets x reps with purpose if not obvious] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Plan:
Planned progression of activity or load:
[planned progression of activity or load] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Next physiotherapy session and focus:
[next physiotherapy session and focus] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Short-term goals:
[short-term goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Long-term goals:
[long-term goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Patient-Friendly Summary:
[simple, professional summary of the patient’s injury, timelines, what was done in the session and why, what will be done next and why, and future progressions, written in plain language for patient communication] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in short paragraphs with relaxed tone mirroring clinician’s style in transcript.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)