Sports Medicine Initial Consultation

Injury/Chief Complaint: The patient presents with a left knee injury, specifically a suspected meniscal tear. Referred by: Referred by Dr. Jane Smith. Dr. Jane Smith, GP. Current Health Practitioners Involved in Care: - Specialist – Nil involved in care - General Practitioner – Dr. Thomas Kelly, 123 Main Street, Anytown - Physiotherapist – Nil involved in care - Exercise Physiologist – Nil involved in care - Chiropractor – Nil involved in care Occupational History: - Software Engineer, work commenced 2010, ongoing Sport and Recreational History: - Soccer, amateur, 2 sessions per week, next competition details: None Dietary History: - Breakfast: Oatmeal with berries and nuts - Morning tea: Apple and a handful of almonds - Lunch: Salad with grilled chicken - Afternoon tea: Yoghurt - Dinner: Salmon with roasted vegetables - Supper: None - Snacks: Occasionally crisps Supplements: - Multivitamin, daily, self-initiated - Vitamin D, daily, self-initiated - No HASTA/Informed Sport/GlobalDRO certification or Therapeutic Use Exemption applied for. History of Present Condition: - The patient reports a sudden onset of left knee pain while playing soccer. The pain was immediate and sharp. - Associated symptoms include swelling and a clicking sensation in the knee. - Impact on ADLs: Difficulty with walking and squatting. - Impact on sport/recreation: Unable to participate in soccer. - Treatments/interventions already trialled: RICE protocol (rest, ice, compression, elevation) with minimal improvement. Injury Mechanism and Timeline: - Date of injury: 20 October 2024 - Mechanism of injury: Acute, twisting injury during soccer game. - Timeline of symptom exacerbation: Symptoms have been consistent since the injury. - Associated symptoms: Clicking, locking sensation during movement. Previous Treatments (Rx): - October 2024, RICE protocol, None, 7 days, minimal response, ongoing Investigation History: - MRI knee, left, 25 October 2024, Anytown Radiology - Radiologist’s summary: Suspected meniscal tear. Past Medical History: - Nil Medications: - Ibuprofen 400mg, as needed for pain - Nil herbal/OTC supplements Allergies: - Penicillin - hives Social History: - Smoker: No - Alcohol use: Socially, 2-3 drinks per week - Recreational drug use: No - Living situation: Lives with partner Family History: - Father: Hypertension Review of Systems: - No other symptoms reported. Physical Examination: General: - Well-appearing, vital signs stable. HEENT: - Normal. Neck: - Normal. Cardiovascular: - Normal. Respiratory: - Normal. Abdomen: - Normal. Extremities: - Left knee: Swelling, tenderness to palpation along the medial joint line, positive McMurray's test. Neurological: - Normal. Skin: - Normal. Diagnosis: - Suspected meniscal tear, left knee. - Differential diagnoses: Meniscal tear, ligamentous injury, patellofemoral pain syndrome. Treatment Plan: 1. Further investigations: None 2. Rehabilitation protocol: Referral to physiotherapist for strengthening and neuromuscular control exercises. 3. Medications prescribed: Ibuprofen 400mg, as needed for pain. 4. Referrals made: Physiotherapist, Dr. Anne Brown, appointment date: 08 November 2024. 5. Follow-up appointment details: 2 weeks, with Dr. Thomas Kelly. 6. Plan if current management fails to achieve desired outcome: Consider referral to orthopaedic surgeon.