Compte rendu de consultation d’orthopédie

Motif de consultation: [Specific musculoskeletal complaints or symptoms that brought the patient to the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Plainte actuelle: [Detailed history of current complaint(s), including onset, duration, severity, aggravating or relieving factors, associated symptoms, previous injuries, trauma, prior treatments and their effectiveness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Antécédents: [Medical and surgical history, highlighting any previous orthopedic surgery, musculoskeletal disorders, hospitalizations and outcomes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Traitements en cours: [Current treatments, including medications, supplements and other therapeutic interventions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Activités sociales et mode de vie: [Social context, including occupation, sports activities, physical activities and lifestyle factors that may influence musculoskeletal health] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Allergies: [Allergies, including drug allergies, metal allergies or sensitivities to other materials relevant for orthopedic procedures] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Exploration clinique Constantes vitales: [Vital signs] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Examen clinique: [Clinical examination findings, with emphasis on musculoskeletal assessment including inspection, palpation, range of motion, strength evaluation, joint stability, presence of deformity, swelling or tenderness] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Examen neurologique: [Neurovascular examination findings, assessing nerve function and vascular status of the affected area when applicable] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Résultats d'examens: [Results of additional tests, including imaging and laboratory studies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Plan 1. [Orthopedic problem or pathology] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Assessment, including probable diagnosis and its rationale based on subjective and objective data] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Differential diagnoses, considering other musculoskeletal or systemic pathologies that may present with similar symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Planned additional tests, specifying any additional imaging, laboratory studies or evaluations necessary for definitive diagnosis or surgical planning] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Planned surgical treatment, detailing the type of intervention, expected outcomes and potential risks] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Non-surgical treatment options, including physiotherapy, medication treatments and lifestyle modifications] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Preoperative preparation, including necessary lifestyle modifications, premedication and instructions] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Postoperative management plan, covering expected hospital stay duration, rehabilitation, pain management and follow-up consultations] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Relevant referrals or specialist consultations if necessary] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) 2. [Additional orthopedic problems or pathologies] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) [Follow the same structure as above for each additional problem or pathology identified] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Notes supplémentaires: [Additional notes] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Éducation du patient: [Patient education regarding the diagnosed pathology, procedures, potential complications and importance of rehabilitation and adherence to follow-up] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Plan de soins: [Pre- and postoperative care instructions, including activity restrictions, wound care and signs of complications to monitor] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.) Préoccupations: [Any specific concerns of the patient or family addressed during the consultation] (Only include if explicitly mentioned in transcript, contextual notes or clinical note, otherwise omit completely.)