Telehealth note

Patient's identity verified Informed consent to proceed with the telehealth consultation obtained from the patient/carer Limitations of telehealth explained to patient/carer Subjective: Patient presents today with a chief complaint of right knee pain, which started approximately 6 weeks ago after twisting the knee while playing football. The pain is described as a sharp, intermittent pain, exacerbated by activity and weight-bearing. The patient reports no specific injury but recalls a 'pop' sensation at the time of onset. The pain is located primarily in the medial aspect of the knee. The patient denies any locking, giving way, or instability. The patient reports that the pain is worse in the morning and improves with rest. The patient has tried over-the-counter pain medication (ibuprofen) with minimal relief. Past medical history and past surgical history: * No significant past medical history. * No prior surgeries. Medications: * Ibuprofen 400mg as needed for pain. Social history: Patient is a 32-year-old male, works as an accountant, and is active in sports. He is a non-smoker and drinks alcohol occasionally. Allergies: * No known drug allergies. Objective: * Vitals: Blood pressure 130/80 mmHg, Heart rate 78 bpm, SpO2 98% on room air. * Inspection: No obvious deformity, swelling, or ecchymosis. Mild effusion noted. * Palpation: Tenderness to palpation along the medial joint line. * Range of Motion: Full active and passive range of motion, but pain with terminal flexion. * Special Tests: Positive McMurray's test, negative Lachman's test, negative varus/valgus stress tests. Investigations with results: * X-rays of the right knee were ordered and reviewed. No acute bony abnormalities were identified. Mild degenerative changes were noted. Assessment and Plan: 1. Right Medial Meniscus Tear * Assessment: Based on the history, physical examination findings, and imaging results, the most likely diagnosis is a tear of the medial meniscus. * Differential diagnoses: * Medial collateral ligament sprain. * Osteoarthritis. * Patellofemoral pain syndrome. * Investigations planned: * MRI of the right knee to confirm the diagnosis and assess the extent of the tear. * Treatments planned: * RICE (Rest, Ice, Compression, Elevation). * Activity modification. * Physical therapy to improve range of motion and strength. * Consideration of arthroscopic surgery if symptoms persist or worsen. * Relevant referrals: * Referral to a physical therapist for rehabilitation. 2. Mild Osteoarthritis * Assessment: Mild degenerative changes noted on X-ray. * Differential diagnoses: * Meniscal tear. * Ligamentous injury. * Investigations planned: * Repeat X-rays in 6 months. * Treatments planned: * Activity modification. * Weight management. * Consideration of NSAIDs for pain relief. * Relevant referrals: * Referral to a physical therapist for rehabilitation. 3. No other issues identified.