Subjective:
Patient presents today with a complaint of right knee pain following a fall during a football match two weeks ago. The patient reports the pain is worse with running and jumping. The patient has been icing the knee and taking over-the-counter pain medication with minimal relief. The patient reports that the pain is a 6/10 on the pain scale.
Patient valued outcomes (PVOs):
Patient wants to return to playing football without pain.
Social Hx:
Patient is a 14-year-old male who is active in sports.
Posture:
Increased lumbar lordosis noted. Mild genu valgum bilaterally.
Gait:
Antalgic gait noted on the right side. Decreased knee flexion during stance phase on the right.
Run:
Patient unable to run due to pain.
Feet:
Normal arches noted.
Inv/Ev (Inversion/Eversion):
No significant findings.
Squat:
Patient unable to perform a full squat due to pain.
Unilateral Squat:
Unable to perform on the right side due to pain.
Jump:
Unable to jump on the right leg.
Hop:
Unable to hop on the right leg.
Up on Toes:
Full range of motion bilaterally.
Static Balance:
Good balance bilaterally.
Dynamic Balance:
Reduced balance on the right leg.
Flexibility:
Hamstring tightness bilaterally.
Strength:
Quadriceps strength reduced on the right side. Hamstring strength reduced on the right side.
Knees:
Tenderness to palpation over the medial joint line of the right knee. Mild effusion noted.
IMPRESSION:
Suspected meniscal injury of the right knee.
PLAN:
Further assessment with MRI. Commence physiotherapy treatment to address pain and improve range of motion.
TREATMENT:
Patient education on activity modification. Ice and elevation. Gentle range of motion exercises.
HEP (Home Exercise Programme):
Quadriceps sets, hamstring stretches, and gentle range of motion exercises.
ADVICE:
Advised to avoid activities that aggravate symptoms. Follow up with MRI and return for further physiotherapy.
NEXT DAY:
Review MRI results and progress with physiotherapy treatment.
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.)
Social Hx:
[Describe relevant social history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
BHx:
[Describe relevant birth history if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Milestones:
[Describe developmental milestones if applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Posture:
[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.)
Run:
[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.)
Inv/Ev (Inversion/Eversion):
[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.)
Unilateral 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 on Toes:
[Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Static Balance:
[Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Dynamic Balance:
[Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Flexibility:
[Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Beighton Score:
[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.)
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.)
Scoliosis (any curves in spine):
[Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Other:
[Describe other 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.)
