Injury/Chief Complaint:
The patient presents with a left knee injury, specifically a suspected meniscal tear.
Referred by:
Referred by Dr. Jane Smith.
Dr. Jane Smith, GP.
Current Health Practitioners Involved in Care:
- Specialist – Nil involved in care
- General Practitioner – Dr. Thomas Kelly, 123 Main Street, Anytown
- Physiotherapist – Nil involved in care
- Exercise Physiologist – Nil involved in care
- Chiropractor – Nil involved in care
Occupational History:
- Software Engineer, work commenced 2010, ongoing
Sport and Recreational History:
- Soccer, amateur, 2 sessions per week, next competition details: None
Dietary History:
- Breakfast: Oatmeal with berries and nuts
- Morning tea: Apple and a handful of almonds
- Lunch: Salad with grilled chicken
- Afternoon tea: Yoghurt
- Dinner: Salmon with roasted vegetables
- Supper: None
- Snacks: Occasionally crisps
Supplements:
- Multivitamin, daily, self-initiated
- Vitamin D, daily, self-initiated
- No HASTA/Informed Sport/GlobalDRO certification or Therapeutic Use Exemption applied for.
History of Present Condition:
- The patient reports a sudden onset of left knee pain while playing soccer. The pain was immediate and sharp.
- Associated symptoms include swelling and a clicking sensation in the knee.
- Impact on ADLs: Difficulty with walking and squatting.
- Impact on sport/recreation: Unable to participate in soccer.
- Treatments/interventions already trialled: RICE protocol (rest, ice, compression, elevation) with minimal improvement.
Injury Mechanism and Timeline:
- Date of injury: 20 October 2024
- Mechanism of injury: Acute, twisting injury during soccer game.
- Timeline of symptom exacerbation: Symptoms have been consistent since the injury.
- Associated symptoms: Clicking, locking sensation during movement.
Previous Treatments (Rx):
- October 2024, RICE protocol, None, 7 days, minimal response, ongoing
Investigation History:
- MRI knee, left, 25 October 2024, Anytown Radiology
- Radiologist’s summary: Suspected meniscal tear.
Past Medical History:
- Nil
Medications:
- Ibuprofen 400mg, as needed for pain
- Nil herbal/OTC supplements
Allergies:
- Penicillin - hives
Social History:
- Smoker: No
- Alcohol use: Socially, 2-3 drinks per week
- Recreational drug use: No
- Living situation: Lives with partner
Family History:
- Father: Hypertension
Review of Systems:
- No other symptoms reported.
Physical Examination:
General:
- Well-appearing, vital signs stable.
HEENT:
- Normal.
Neck:
- Normal.
Cardiovascular:
- Normal.
Respiratory:
- Normal.
Abdomen:
- Normal.
Extremities:
- Left knee: Swelling, tenderness to palpation along the medial joint line, positive McMurray's test.
Neurological:
- Normal.
Skin:
- Normal.
Diagnosis:
- Suspected meniscal tear, left knee.
- Differential diagnoses: Meniscal tear, ligamentous injury, patellofemoral pain syndrome.
Treatment Plan:
1. Further investigations: None
2. Rehabilitation protocol: Referral to physiotherapist for strengthening and neuromuscular control exercises.
3. Medications prescribed: Ibuprofen 400mg, as needed for pain.
4. Referrals made: Physiotherapist, Dr. Anne Brown, appointment date: 08 November 2024.
5. Follow-up appointment details: 2 weeks, with Dr. Thomas Kelly.
6. Plan if current management fails to achieve desired outcome: Consider referral to orthopaedic surgeon.
Injury/Chief Complaint:
[insert injury/illness, stating the following features: the side of the body the injury is located in (right or left, if applicable, otherwise leave blank), and the general region/joint/body system that is involved] (Only include if explicitly mentioned in the transcript or context, else omit section entirely. Write in full sentence.)
Referred by:
[Insert source of referral from either GP, Physiotherapist, Exercise Physiologist, Chiropractor, Online] (Only include if explicitly mentioned in the transcript or context, else omit section entirely. Write in full sentence.)
[Insert name of referrer] (Only include if explicitly mentioned in the transcript or context, else omit section entirely. Write in full sentence.)
Current Health Practitioners Involved in Care:
- Specialist – [insert name and clinic location] (Only include if explicitly mentioned in transcript or context, otherwise state "Nil involved in care")
- General Practitioner – [insert name and clinic location] (Only include if explicitly mentioned in transcript or context, otherwise state "Nil involved in care")
- Physiotherapist – [insert name and clinic location] (Only include if explicitly mentioned in transcript or context, otherwise state "Nil involved in care")
- Exercise Physiologist – [insert name and clinic location] (Only include if explicitly mentioned in transcript or context, otherwise state "Nil involved in care")
- Chiropractor – [insert name and clinic location] (Only include if explicitly mentioned in transcript or context, otherwise state "Nil involved in care")
Occupational History:
- [insert job title, year work commenced, and year work ceased or note "ongoing"] (Only include if explicitly mentioned in the transcript or context. Use as many bullet points as needed.)
Sport and Recreational History:
- [insert sport, level (amateur/semi-pro/pro), number of training sessions per week, and next competition details] (Only include if explicitly mentioned in the transcript or context. Use as many bullet points as needed.)
Dietary History:
- [describe typical breakfast]
- [describe typical morning tea]
- [describe typical lunch]
- [describe typical afternoon tea]
- [describe typical dinner]
- [describe typical supper]
- [describe any snacks] (Only include if explicitly mentioned in the transcript or context. Use bullet points.)
Supplements:
- [list any supplements taken e.g. creatine, protein powder (include brand), multivitamins, vitamin D/B12/Iron, duration, and whether prescribed or self-initiated]
- [list whether patient has verified HASTA/Informed Sport/GlobalDRO certification or applied for Therapeutic Use Exemption] (Only include if explicitly mentioned in the transcript or context. Use bullet points.)
History of Present Condition:
- [describe onset, duration, and characteristics of current symptoms or injury]
- [mention associated symptoms]
- [describe impact on ADLs, work, sport/recreation]
- [mention psychological impact if relevant]
- [list treatments/interventions already trialled and their outcomes] (Only include if explicitly mentioned in transcript or context. Write as bullet points.)
Injury Mechanism and Timeline:
- [date of injury (exact or estimated)]
- [mechanism of injury – repetitive/acute, activity involved]
- [timeline of symptom exacerbation or flare-up for chronic cases]
- [associated symptoms such as weakness, numbness, instability, etc., and when they occur – e.g. during activity vs rest] (Only include if explicitly mentioned in transcript or context. Use bullet points.)
Previous Treatments (Rx):
- [month and year], [name of treatment], [type e.g. Physiotherapy, PRP injection], [number of sessions], [response to treatment], [duration of response]
(Use as many bullet points as needed for each treatment. Only include if explicitly mentioned.)
Investigation History:
- [imaging modality and body region], [date], [radiology centre]
- [radiologist’s summary or conclusion] (Only include if explicitly mentioned in transcript or context. Use bullet points.)
Past Medical History:
- [list relevant conditions, hospitalisations, surgeries] (Only include if explicitly mentioned in transcript or context.)
Medications:
- [current medications with dose and frequency]
- [herbal/OTC supplements] (Only include if explicitly mentioned in transcript or context.)
Allergies:
- [list allergies and reactions] (Only include if explicitly mentioned in transcript or context.)
Social History:
- [smoking, alcohol use, recreational drug use, living situation] (Only include if explicitly mentioned in transcript or context.)
Family History:
- [relevant familial health conditions] (Only include if explicitly mentioned in transcript or context.)
Review of Systems:
- [list any positive or negative symptoms reported during systemic review] (Only include if explicitly mentioned in transcript or context.)
Physical Examination:
General:
[general appearance and vital signs] (Only include if explicitly mentioned in transcript or context.)
HEENT:
[findings from head, eyes, ears, nose, throat] (Only include if explicitly mentioned in transcript or context.)
Neck:
[neck exam findings] (Only include if explicitly mentioned in transcript or context.)
Cardiovascular:
[cardiovascular findings] (Only include if explicitly mentioned in transcript or context.)
Respiratory:
[respiratory findings] (Only include if explicitly mentioned in transcript or context.)
Abdomen:
[abdominal findings] (Only include if explicitly mentioned in transcript or context.)
Extremities:
[examination findings for extremities] (Only include if explicitly mentioned in transcript or context.)
Neurological:
[neurological findings] (Only include if explicitly mentioned in transcript or context.)
Skin:
[skin findings] (Only include if explicitly mentioned in transcript or context.)
Diagnosis:
- [summary of clinical findings and provisional diagnosis]
- [differential diagnoses in order of likelihood] (Only include if explicitly mentioned in transcript or context. Use bullet points.)
Treatment Plan:
1. [further investigations: modality, body region, date]
2. [rehabilitation protocol: list exercises/modalities such as strengthening, neuromuscular control, foam rolling]
3. [medications prescribed: name, dose, frequency]
4. [referrals made: practitioner, appointment date]
5. [follow-up appointment details: timing, practitioner]
6. [plan if current management fails to achieve desired outcome]
(Only include if explicitly mentioned in transcript or context. Use numbered list.)
(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.)
