GP Note NorthWest Ireland

Subjective: - Follow up for previously discussed condition. - ICE: Patient's ideas are that the pain is getting worse, concerns are that it is something serious, expectations are to get pain relief. - Current issues: Patient presents with increased pain in their left knee, which started after a fall while walking on the beach in Bundoran. The pain is described as a sharp, throbbing pain, worse with weight-bearing. - Past medical history: Nil. - FH: Mother with a history of osteoarthritis. - SH: Lives alone, works as a teacher in Sligo, non-smoker, drinks alcohol socially, no illicit drug use. - Medications: Ibuprofen 400mg as needed for pain. - Allergies: NKDA. Objective: - Physical examination: Left knee examination revealed swelling, tenderness to palpation over the medial joint line, and a reduced range of motion. No effusion noted. - Vital signs: BP 130/80 mmHg, HR 78 bpm, RR 16, Temp 36.8°C. - Chaperone: Patient declined a chaperone. Assessment: 1. Left knee pain. - Assessment: Likely meniscal tear. Plan: 1. Investigations planned: X-ray of the left knee. - Treatment planned: Continue Ibuprofen for pain relief, advise rest and ice. - Relevant referrals: Referral to physiotherapy. - Patient has given consent for AI transcription using Heidi AI for the consultation. Heidi AI is GDPR compliant.