Subjective:
Mechanism of Injury: Patient reports a twisting injury to their left ankle while playing football. The injury occurred when they landed awkwardly after jumping for a header.
Injury Timeline: The injury occurred 3 days ago. Initially, there was immediate pain and swelling. The patient rested for the first 24 hours, but the pain has persisted. They attempted to walk on it the following day, which aggravated the pain.
Symptoms: Patient reports sharp pain on the lateral side of the left ankle, with associated swelling and bruising. They also report pain with weight-bearing and difficulty with walking and running. There is also a feeling of instability.
Severity, Irritability, Nature (SIN): Severity: 7/10 at worst, Irritability: High, Nature: Mechanical
Visual Analogue Scale (VAS): 7/10
Activities-specific Balance Confidence Scale (ABC): Not assessed at this visit.
Aggravating Factors: Walking, running, and any weight-bearing activities. The pain increases with prolonged standing.
Easing Factors: Rest, ice, and elevation provide some relief.
Past Musculoskeletal History: No previous ankle injuries.
General Health History: No relevant medical history. Taking no medications.
Sports, Hobbies, ADLs, Family, Vocation: Patient is a keen footballer and plays regularly. They work as a software engineer and have a desk job.
Thoughts, Concerns, Questions, Fears: Patient is concerned about the severity of the injury and the impact on their ability to play football.
Stated Diagnosis: Patient suspects a sprain.
Objective:
Observation: Swelling and bruising are noted on the lateral aspect of the left ankle. Patient is guarding the ankle and walks with a limp.
Functional Testing: Single leg stance on the left leg is significantly impaired, unable to maintain balance for more than a few seconds. Hopping is painful and limited.
Active Range of Motion (AROM): Dorsiflexion limited to 0 degrees due to pain and plantarflexion limited to 20 degrees due to pain. Inversion and eversion are also limited and painful.
Passive Range of Motion (PROM): Dorsiflexion limited to 5 degrees due to pain and plantarflexion limited to 25 degrees due to pain. Inversion and eversion are also limited and painful.
Strength Testing: Resisted plantarflexion and eversion are painful and weak (4/5). Resisted dorsiflexion and inversion are painful and weak (3/5).
Special or Diagnostic Tests: Not performed at this visit.
Neurological Testing - Strength: Not assessed at this visit.
Neurological Testing - Sensation: Not assessed at this visit.
Neurological Testing - Neurodynamic: Not assessed at this visit.
Neurological Testing - Reflexes: Not assessed at this visit.
Treatment:
"Informed verbal consent gained & warnings given (IVCG & WG) applied to any form of treatment."
Soft Tissue Release (STR): Applied to the surrounding musculature, including the peroneals and calf muscles.
Joint Mobilisations (OMT): Grade 1-2 mobilisations to the talocrural joint.
Dry Needling / Acupuncture (DN): Not performed at this visit.
Home Exercise Program (HEP): Patient instructed on RICE protocol (Rest, Ice, Compression, Elevation) and gentle ankle range of motion exercises.
Gym Program (GP): Not applicable at this stage.
Exercise Prescription Details: Gentle ankle range of motion exercises: 10 repetitions, 3 times per day.
Education Provided: Patient educated on the nature of the injury, prognosis, and importance of rest and activity modification. Advised on the use of ice and compression.
Referrals Made: Advised to follow up with GP if symptoms do not improve.
Analysis:
Summary of Diagnosis, Prognosis, and Key Findings: Suspected Grade 2 lateral ankle sprain. Prognosis is good with appropriate management. Key findings include pain, swelling, limited range of motion, and functional limitations.
Plan:
Next Booking: Review in 1 week.
Treatments Discussed: Continue RICE protocol, continue with gentle range of motion exercises, and progress to weight-bearing as tolerated.
Planned Exercise Progressions: Progress to weight-bearing exercises and proprioceptive exercises as pain subsides.
Jobs Promised to be Organised: Provide patient with a handout on ankle sprain management.
Subjective:
[Mechanism of Injury] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include details such as force, direction, surface, or environmental context.)
[Injury Timeline] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Describe story, progression, time course, and key aggravations or re-injuries over time.)
[Symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include relevant descriptors, locations, and quality of symptoms.)
[Severity, Irritability, Nature (SIN)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Visual Analogue Scale (VAS)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include score if given.)
[Activities-specific Balance Confidence Scale (ABC)] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include score if used.)
[Aggravating Factors] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Consider prompting for duration, frequency, and functional relevance.)
[Easing Factors] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include examples such as rest, positions, medication, support, movement.)
[Past Musculoskeletal History] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include previous episodes, injuries, surgeries – site-specific if available.)
[General Health History] (Only include if explicitly mentioned in transcript or context, else omit section entirely. May include medications, RED-S, menopause status, or body weight/BMI.)
[Sports, Hobbies, ADLs, Family, Vocation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Describe functional roles and participation context – home/work/sport.)
[Thoughts, Concerns, Questions, Fears] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include patient beliefs, psychosocial flags, and expectations.)
[Stated Diagnosis] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use only if patient states or has been given a specific diagnosis.)
Objective:
[Observation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include findings such as swelling, bruising, gait, posture, asymmetry.)
[Functional Testing] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include test type, outcome, performance quality. Specify side, task, and tolerance if applicable.)
[Active Range of Motion (AROM)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Passive Range of Motion (PROM)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Strength Testing] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Specify if MMT, HHD, or other; side, grade, pain/weakness findings.)
[Special or Diagnostic Tests] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include test name, result, symptom reproduction, sensitivity/specificity if applicable.)
[Neurological Testing - Strength] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Neurological Testing - Sensation] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Neurological Testing - Neurodynamic] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Neurological Testing - Reflexes] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
Treatment:
"Informed verbal consent gained & warnings given (IVCG & WG) applied to any form of treatment."
[Soft Tissue Release (STR)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Joint Mobilisations (OMT)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Dry Needling / Acupuncture (DN)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Home Exercise Program (HEP)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Gym Program (GP)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Exercise Prescription Details] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include exercise name(s), sets x reps, intensity or RPE/load, frequency per week, and any relevant safety or post-exercise soreness warnings.)
[Education Provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include diagnosis, prognosis, management strategy, reassessment plan or self-monitoring advice.)
[Referrals Made] (Only include if explicitly mentioned in transcript or context, else omit section entirely. May include imaging (X-ray / US / MRI), corticosteroid injection, GP / Sports Medicine / Second Opinion.)
Analysis:
[Summary of Diagnosis, Prognosis, and Key Findings] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Integrate relevant subjective and objective findings to support clinical reasoning.)
Plan:
[Next Booking] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
[Treatments Discussed] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Include e.g., continue STR next session, trial OMT, review in 1 week, reassess strength.)
[Planned Exercise Progressions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. e.g., plan to increase RPE, add resistance band, transition to gym-based loading.)
[Jobs Promised to be Organised] (Only include if explicitly mentioned in transcript or context, else omit section entirely. e.g., send exercises, follow up with GP, provide letter for work/sport clearance.)
(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.)
