FOLLOW-UP NOTE
APPOINTMENT DATE: 01 November 2024
SUBJECTIVE
Chief complaint and reason for follow-up: Patient returns for follow-up regarding persistent left knee pain, specifically anterior knee pain exacerbated by running and stair climbing. Reason for follow-up is to assess response to previous physiotherapy and consider further interventions.
Duration, timing, location, quality, and severity of symptoms: Symptoms have been ongoing for 6 months, intermittent at first but now more consistent, especially after activity. Pain is a dull ache, occasionally sharp, located around the patella. Severity is 6/10 with activity, 2/10 at rest.
Response to previous treatments or interventions since the last visit: Patient completed 8 weeks of physiotherapy focusing on quadriceps strengthening and gluteal activation. Initially reported mild improvement, but pain has plateaued over the last two weeks despite adherence to exercises. No new medications or injections since last visit.
Progression of symptoms since last visit — unchanged.
Aggravating or relieving factors: Aggravated by running, jumping, and prolonged sitting. Relieved by rest and ice. Self-management strategies include stretching and foam rolling, which provide temporary relief.
Previous episodes or recurring issues: Patient reports similar, less severe knee pain episode approximately two years ago after increasing running mileage, which resolved with rest.
Impact on current daily function, work, or physical activity: Unable to participate in weekly recreational football games. Difficulty with daily walks exceeding 30 minutes. Work as a software engineer is largely sedentary, but prolonged sitting can aggravate pain.
Associated symptoms: No swelling, locking, giving way, or systemic symptoms.
OBJECTIVE
Vital signs: BP 120/78 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C.
Physical examination findings:
Left Knee:
Inspection: No effusion, erythema, or gross deformity. Mild quadriceps atrophy noted compared to the right.
Palpation: Tenderness noted at the inferior pole of the patella and patellar facets.
Range of Motion: Full active and passive range of motion. Pain elicited with deep knee flexion.
Strength: 4/5 quadriceps strength on the left, 5/5 on the right. Hamstring and gluteal strength 5/5 bilaterally.
Special Tests: Patellar grind test positive on the left, indicating patellofemoral pain. Negative for meniscal tears (McMurray's) or ligamentous laxity (ACL/PCL Lachman, anterior/posterior drawer, MCL/LCL valgus/varus stress tests).
Gait: Antalgic gait noted during heel strike on the left, especially with faster walking.
Completed investigations and their results:
Plain X-ray Left Knee (dated 15 October 2024): No bony abnormalities, joint space narrowing, or signs of arthritis. Patella alta not evident.
ASSESSMENT
Most likely diagnosis based on clinical findings: Patellofemoral Pain Syndrome (PFPS) of the left knee.
Differential diagnoses considered: Patellar tendinopathy, chondromalacia patellae, meniscal tear (ruled out by examination).
PLAN
Planned investigations: None at this time. Will consider MRI if symptoms persist despite further conservative management.
Planned treatment or interventions:
1. Continue with current physiotherapy exercises, focusing on eccentric quadriceps loading and VMO strengthening.
2. Implement activity modification: Advise patient to reduce running intensity and duration, avoid aggravating activities like jumping and deep squats for 4-6 weeks.
3. Recommend use of a patellar tracking brace during aggravating activities.
4. Prescribe a short course of topical NSAID (diclofenac gel) for pain management.
5. Discuss the option of a corticosteroid injection if symptoms do not improve significantly in the next 4-6 weeks.
Additional actions: Provide patient education on proper warm-up/cool-down, footwear assessment, and gradual return to activity principles.
PROCEDURE NOTE
Injection type, side, and substance administered, and whether ultrasound guidance was used: Left knee infrapatellar fat pad corticosteroid injection (20mg Triamcinolone) under ultrasound guidance.
"The risks, benefits, and alternatives of the procedure were explained to the patient, and informed consent was obtained. The fees for the non-insured services were reviewed prior to the procedure."
Specific site, side, needle details, medication details, ultrasound usage, patient positioning, and technique used, including approach if relevant: Site: Left knee, infrapatellar fat pad. Needle: 25-gauge, 1.5-inch needle. Medication: 1ml (20mg) Triamcinolone acetonide mixed with 1ml (1%) Lidocaine. Ultrasound guidance used for precise needle placement and medication delivery. Patient positioned supine with knee slightly flexed. Technique: In-plane approach, needle advanced to the infrapatellar fat pad, confirmed by real-time ultrasound visualisation. "The skin overlying the injection site was cleaned with chlorhexidine and alcohol swabs, and a no-touch aseptic technique was used."
"After completion of the injection, the needle was withdrawn, and gentle pressure was applied to the injection site to minimize bleeding. A bandage was applied to cover the injection site. The procedure was well tolerated without any immediate complications. Post-injection care was reviewed. They were advised to monitor for any signs of infection, bleeding, or adverse reactions and to report any concerns promptly."
Immediate pain relief reported following local anesthetic, if applicable: Patient reported significant (80%) immediate pain relief in the left knee after the local anaesthetic injection.
I have documented the assessment using an AI-assisted scribe to ensure accuracy and efficiency in note-taking.
Time Spent with Patient: 35 minutes
Start Time: 10:00
End Time: 10:35
FOLLOW-UP NOTE
APPOINTMENT DATE: [Enter today's date] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
SUBJECTIVE
[Chief complaint and reason for follow-up, including any new or ongoing symptoms or specific requests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Duration, timing, location, quality, and severity of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Response to previous treatments or interventions since the last visit, including medications, injections, physiotherapy, or other therapies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Progression of symptoms since last visit — improved, worsened, or unchanged] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Aggravating or relieving factors, including recent self-management strategies and their effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Previous episodes or recurring issues relevant to the current complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Impact on current daily function, work, or physical activity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated symptoms, including systemic or regional features] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
OBJECTIVE
[Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Physical examination findings, including joint-specific or system-specific findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Completed investigations and their results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; omit any pending or planned tests.)
ASSESSMENT
[Most likely diagnosis based on clinical findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Differential diagnoses considered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PLAN
[Planned investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Planned treatment or interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Additional actions such as referrals, counselling, or follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PROCEDURE NOTE
[Include procedure note section] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit the entire procedure note section.)
[Injection type, side, and substance administered, and whether ultrasound guidance was used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"The risks, benefits, and alternatives of the procedure were explained to the patient, and informed consent was obtained. The fees for the non-insured services were reviewed prior to the procedure." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Specific site, side, needle details, medication details, ultrasound usage, patient positioning, and technique used, including approach if relevant] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"The skin overlying the injection site was cleaned with chlorhexidine and alcohol swabs, and a no-touch aseptic technique was used." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"After completion of the injection, the needle was withdrawn, and gentle pressure was applied to the injection site to minimize bleeding. A bandage was applied to cover the injection site. The procedure was well tolerated without any immediate complications. Post-injection care was reviewed. They were advised to monitor for any signs of infection, bleeding, or adverse reactions and to report any concerns promptly." (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Immediate pain relief reported following local anesthetic, if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
"I have documented the assessment using an AI-assisted scribe to ensure accuracy and efficiency in note-taking." (Always include verbatim.)
Time Spent with Patient: [Total transcription recording time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Start Time: [hh:mm in 24-hour format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
End Time: [hh:mm in 24-hour format] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(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.)
FOLLOW-UP NOTE
APPOINTMENT DATE: [Enter today's date]
SUBJECTIVE
[Chief complaint and reason for follow-up, including any new or ongoing symptoms or specific requests] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Duration, timing, location, quality, and severity of symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Response to previous treatments or interventions since the last visit, including medications, injections, physiotherapy, or other therapies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Progression of symptoms since last visit — improved, worsened, or unchanged] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Aggravating or relieving factors, including recent self-management strategies and their effectiveness] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Previous episodes or recurring issues, if relevant to current complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Impact on current daily function, work, or physical activity] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Associated symptoms, including systemic or regional features] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
OBJECTIVE
[Vital signs] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Physical examination findings, including joint-specific or system-specific findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Completed investigations and their results] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Only include if results are explicitly documented; do not include pending or planned tests here.)
ASSESSMENT
[Most likely diagnosis based on clinical findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Differential diagnoses considered] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PLAN
[Planned investigations] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Planned treatment or interventions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Additional actions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
PROCEDURE NOTE
[Include procedure note section if mentioned] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Start with the injection and side, and what was injected (e.g., corticosteroid, hyaluronic acid, platelet-rich plasma), and indicate if ultrasound guidance was used] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Next include, "The risks, benefits, and alternatives of the procedure were explained to the patient, and informed consent was obtained. The fees for the non-insured services were reviewed prior to the procedure."] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Include the specific site, side, needle details, medication details, and whether or not ultrasound was used. Describe patient positioning and technique used, including approach if relevant. Include "The skin overlying the injection site was cleaned with chlorhexidine and alcohol swabs, and a no-touch aseptic technique was used."] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[End with, "After completion of the injection, the needle was withdrawn, and gentle pressure was applied to the injection site to minimize bleeding. A bandage was applied to cover the injection site. The procedure was well tolerated without any immediate complications. Post-injection care was reviewed. They were advised to monitor for any signs of infection, bleeding, or adverse reactions and to report any concerns promptly."] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
[Mention if the patient reported immediate relief of pain from the local anesthetic, if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
I have documented the assessment using an AI-assisted scribe to ensure accuracy and efficiency in note-taking.
Time Spent with Patient: [total transcription recording time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Start Time: [Start time as per recording start time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in 24-hour format.)
End Time: [End time as per recording start time] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in 24-hour format.)
