Subjective:
Patient presents today with ongoing pain in their left ankle, sustained during a netball game three weeks ago. The patient reports a twisting mechanism of injury. They have been following the home exercise program (HEP) and are reporting a gradual improvement in pain levels, currently rating it as a 3/10 at rest and 5/10 during activity. They report that they are able to walk without a limp, but still experience some stiffness in the mornings.
Patient valued outcomes (PVOs):
The patient's goals are to return to playing netball at their previous level of performance and to be able to run and jump without pain.
Objective Assessment:
Palpation: Tenderness to palpation over the anterior talofibular ligament (ATFL) and the lateral malleolus. No significant swelling noted.
ROM (Range of Motion): Ankle dorsiflexion: 10 degrees (reduced compared to the unaffected side). Ankle plantarflexion: 45 degrees. Inversion and eversion are within normal limits.
Strength: Pain-free strength in all directions. Slight weakness noted with resisted ankle inversion.
Proprioception: Reduced proprioception noted on the left ankle compared to the right.
Gait: Normal gait pattern observed.
Squat: Able to perform a single-leg squat on the right leg, but unable to do so on the left leg due to pain and instability.
IMPRESSION:
Left ankle sprain, likely grade 1-2. Reduced range of motion and proprioception. Patient is making good progress with current management.
PLAN:
Continue with current HEP. Progress exercises as tolerated. Review in one week.
TREATMENT:
Manual therapy to the ankle joint to improve range of motion. Proprioceptive exercises using a wobble board.
HEP (Home Exercise Programme):
Continue with ankle range of motion exercises (dorsiflexion, plantarflexion, inversion, eversion). Progress to single-leg balance exercises. Begin with 30 seconds holds, 3 times a day.
ADVICE:
Continue to ice the ankle after activity. Avoid activities that provoke pain. Gradually increase activity levels as tolerated.
NEXT DAY:
Continue with current management plan.
Subjective:
[Include how the patient is presenting today, the mechanism of injury, how their treatment is progressing, and timeline of injury] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Patient valued outcomes (PVOs):
[Include the patient’s goals for physiotherapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Objective Assessment:
Palpation: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ROM (Range of Motion): [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Strength: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Proprioception: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Feet: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Balance: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Gait: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Squat: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Jump: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Hop: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Up Toes: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Knees: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Shin: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Calf: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Neuro: [Describe neurological findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Leg Length: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Other: [Describe other relevant findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
IMPRESSION:
[Describe clinical impression] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
PLAN:
[Describe management plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
TREATMENT:
[Describe treatment provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
HEP (Home Exercise Programme):
[Describe prescribed home exercise programme] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ADVICE:
[Describe advice given to patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
NEXT DAY:
[Describe plan for next day] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
