Ortho Concise Note

Patient: John Doe Date: October 5, 2023 Subjective: - Patient reports severe pain in the right knee, especially when walking or climbing stairs. - Symptoms have been present for the past 3 months and have progressively worsened. - Pain significantly impacts daily activities, including the ability to work and exercise. - Relevant past medical history includes a previous meniscus tear in the same knee. - Occupational history: Office worker with a sedentary lifestyle. Objective: - Physical examination reveals swelling and tenderness around the right knee. - Range of motion assessment shows limited flexion and extension. - Palpation findings indicate tenderness over the medial joint line. - Stability tests: Positive McMurray test indicating possible meniscus injury. Assessment: - Differential diagnoses include meniscus tear, osteoarthritis, and ligament injury. Plan: - Investigations planned: MRI of the right knee to confirm diagnosis. - Follow-up arrangements: Patient to return in 2 weeks for review of MRI results and further management plan.