CONSULTATION NOTE:
PATIENT NAME: Mr. John Smith
AGE: 55 years
MAIN COMPLAINT:
The patient presents with a painful bunion on his left foot. The pain is located at the base of the big toe and is exacerbated by walking and wearing shoes. He reports that the pain has been gradually worsening over the past year.
HISTORY OF MAIN COMPLAINT:
The patient first noticed a small bump on the inside of his left foot approximately one year ago. Over time, the bump has increased in size, and the pain has become more frequent and intense. He denies any specific injury or trauma to the foot. The pain is typically worse at the end of the day and after prolonged standing or walking. He has tried over-the-counter pain relievers, which provide minimal relief.
TREATMENT TO DATE:
The patient has tried over-the-counter pain relievers, including ibuprofen and paracetamol, with limited success. He has also tried wearing wider shoes, which has provided some temporary relief.
INVESTIGATIONS TO DATE:
X-rays:
X-rays of the left foot were taken at an outside facility six months ago, showing a prominent bunion deformity.
ACTIVITY LEVEL:
Occupation: Accountant
Sports: Occasional walking
Hobbies: Gardening
EXPECTATIONS:
1. Relief from pain.
2. Improved ability to walk comfortably.
3. Correction of the bunion deformity.
PAST MEDICAL HISTORY:
The patient has a history of hypertension, well-controlled with medication. He denies any other significant medical conditions.
Smoker: No
DVT risk factors or history: No
PAST SURGICAL HISTORY:
The patient had an appendectomy at age 10.
CURRENT MEDICATION:
Lisinopril 10mg daily for hypertension.
ALLERGIES:
No known drug allergies.
CLINICAL EXAMINATION:
Gait: Antalgic gait, favouring the left foot.
Walking aid: None
BMI: 28
Ht: 1.78 m.
Wt: 89 kg.
INSPECTION:
There is a prominent bunion deformity on the left foot with medial deviation of the first metatarsal and lateral deviation of the great toe. There is also associated erythema and swelling over the bunion.
PALPATION:
Tenderness: Tenderness to palpation over the medial eminence of the first metatarsal head.
Masses: No palpable masses other than the bunion itself.
Crepitus: No crepitus appreciated.
Temperature: No increased temperature.
Pulses: Dorsalis pedis and posterior tibial pulses are palpable and strong.
Neurological: Intact sensation and motor function in the foot and ankle.
RANGE OF MOTION:
Reduced range of motion at the first metatarsophalangeal joint due to pain and deformity. Dorsiflexion is limited to 10 degrees, and plantarflexion is limited to 20 degrees.
STRESS TESTS:
First ray instability: No instability appreciated.
Bunion deformity reducible: The bunion deformity is partially reducible with manual manipulation.
Push up test: Negative.
JOINT ABOVE AND BELOW:
The ankle and knee joints are stable and have a full range of motion.
RADIOLOGICAL INVESTIGATIONS:
X-ray:
Date: 1 November 2024. X-rays confirm the presence of a bunion deformity with an increased intermetatarsal angle and hallux valgus angle.
X-ray metrics:
IMA: Left 15°, right 2°
HVA: Left 40°, right 5°
DMAA: Left 10°, right 2°
Interphalangeus angle: Left 5°, right 2°
MRI:
Date: Not performed.
Ultrasound:
Date: Not performed.
CT Scan:
Date: Not performed.
LABORATORY INVESTIGATIONS:
Not performed.
ASSESSMENT:
Left foot bunion deformity (hallux valgus) with associated pain and functional limitations.
PLAN:
1. Discuss conservative management options, including shoe modifications, padding, and orthotics.
2. Consider referral to a podiatrist for custom orthotics.
3. Discuss surgical options, including bunionectomy, if conservative measures fail.
4. Schedule a follow-up appointment in 6 weeks to reassess the patient's condition and response to treatment.
5. Provide patient education on bunion care and management.
6. Prescribe pain medication as needed.
7. Order X-rays of the left foot for pre-operative planning if surgery is considered.
CONSULTATION NOTE:
PATIENT NAME: Mr/Mrs. [Patient's name] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**AGE:** [Patient's age] years (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**MAIN COMPLAINT:**
[Describe the main complaint of the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**HISTORY OF MAIN COMPLAINT:**
[Describe the history of the main complaint, including onset, duration, and progression] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**TREATMENT TO DATE:**
[Describe any treatments the patient has received to date for the main complaint] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**INVESTIGATIONS TO DATE:**
X-rays:
[Describe any X-ray investigations conducted prior to today’s date, including findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
**ACTIVITY LEVEL:**
Occupation: [Describe the patient's occupation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Sports: [Describe the patient's involvement in sports] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Hobbies: [Describe the patient's hobbies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
**EXPECTATIONS:**
1. [Describe the patient's first expectation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
2. [Describe the patient's second expectation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
3. [Describe the patient's third expectation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
**PAST MEDICAL HISTORY:**
[Describe the patient's past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Write in paragraphs of full sentences.)
Smoker: [Indicate if the patient is a smoker] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
DVT risk factors or history: [Indicate if the patient has risk factors or history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
**PAST SURGICAL HISTORY:**
[Describe the patient's past surgical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**CURRENT MEDICATION:**
[Describe the patient's current medications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**ALLERGIES:**
[Describe the patient's allergies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**CLINICAL EXAMINATION:**
Gait: [Describe the patient's gait] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Walking aid: [Describe any walking aid used] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
BMI: [Describe the patient's BMI] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Ht: [Patient's height] m. (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Wt: [Patient's weight] kg. (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**INSPECTION:**
[Describe findings from the inspection] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**PALPATION:**
Tenderness: [Describe tenderness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Masses: [Describe masses] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Crepitus: [Describe crepitus] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Temperature: [Describe temperature changes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Pulses: [Describe pulse findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
Neurological: [Describe neurological findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
**RANGE OF MOTION:**
[Describe range of motion findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**STRESS TESTS:**
First ray instability: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Bunion deformity reducible: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Push up test: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**JOINT ABOVE AND BELOW:**
[Describe condition of the joint above and below] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**RADIOLOGICAL INVESTIGATIONS:**
X-ray:
**Date:** [Describe date and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
X-ray metrics:
IMA: Left [add value]°, right [add value]° (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
HVA: Left [add value]°, right [add value]° (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
DMAA: Left [add value]°, right [add value]° (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Interphalangeus angle: Left [add value]°, right [add value]° (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
MRI:
**Date:** [Describe MRI findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Ultrasound:
**Date:** [Describe ultrasound findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
CT Scan:
**Date:** [Describe CT findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
**LABORATORY INVESTIGATIONS:**
[Describe laboratory investigations and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**ASSESSMENT:**
[Describe assessment of the patient's condition] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
**PLAN:**
1. [Describe first item in plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
2. [Describe second item in plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
3. [Describe third item in plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
4. [Describe fourth item in plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
5. [Describe fifth item in plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
6. [Describe sixth item in plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
7. [Describe seventh item in plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely. Write in brief bullet points.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; else 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, depending on the format, as needed to capture all relevant information from the transcript.)
