Subjective Assessment:
Patient presents today with ongoing right knee pain following a twisting injury sustained during a football match three weeks ago. The patient reports a gradual improvement in pain levels since the initial injury, but still experiences pain with activity and prolonged standing. The patient reports they are progressing well with their home exercises.
VAS: 4/10
Aggravating factors: Prolonged standing, squatting, and running.
Easing factors: Rest, ice, and elevation.
Scans: No scans have been performed.
General Mandatory questions:
Night/Constant/Bilateral Pain/Weight Loss: No night pain, no constant pain, no bilateral pain, and no weight loss.
Increased sweating/Night sweats: No increased sweating or night sweats.
Power loss/Numbness/Pins & needles: No power loss, numbness, or pins and needles.
Prolonged steroids/Osteoporosis: No prolonged steroid use or osteoporosis.
Anti-coagulants: Not on anti-coagulants.
Sleep Disturbance: Sleep is not disturbed.
Metal Implants: No metal implants.
Relevant Medical History:
No relevant medical history.
Past Medical History:
No past medical history.
Patient valued outcomes (PVOs):
Patient aims to return to playing football and be able to run without pain.
Objective:
Posture: Normal.
Alignment: Normal.
Functional: Squatting is limited by pain. Able to walk without a limp.
Gait: Normal gait pattern.
ROM: Full active and passive range of motion, with pain at end range flexion.
Special Knee Tests: McMurray's test negative. Lachman's test negative. Varus and valgus stress tests negative.
Patella Tests: Patella tracking normal.
Tracking: Normal.
Patellar tendon: No tenderness.
Tibial tuberosity: No tenderness.
Bursa/Fat pads: No tenderness.
Popliteal area: No tenderness.
Feet/Ankles: No issues.
Hips: No issues.
Other: No other relevant findings.
Impression:
Suspected mild meniscal injury with associated joint effusion.
Plan:
Continue with current home exercise program. Advise on activity modification. Review in one week.
Treatment:
Manual therapy to address quadriceps and hamstring tightness. Education on activity modification.
HEP (Home Exercise Programme):
Continue with quadriceps strengthening exercises, hamstring stretches, and calf stretches.
Advice:
Advised on the importance of activity modification and the use of ice after activity. Provided education on pain management strategies.
Next day:
No specific plan for the next day.
Subjective Assessment:
[Include how the patient is presenting today, the mechanism of injury, how their treatment is progressing, and timeline of injury] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
VAS: [Record patient’s VAS score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Aggravating factors: [Describe factors that aggravate symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Easing factors: [Describe factors that ease symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Scans: [Describe scans and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
General Mandatory questions:
Night/Constant/Bilateral Pain/Weight Loss: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Increased sweating/Night sweats: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Power loss/Numbness/Pins & needles: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Prolonged steroids/Osteoporosis: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Anti-coagulants: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Sleep Disturbance: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Metal Implants: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Relevant Medical History:
[Describe relevant medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History:
[Describe past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Patient valued outcomes (PVOs):
[Include patient’s goals for physiotherapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
Posture: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Alignment: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Functional: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Gait: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ROM: [Describe range of motion findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Special Knee Tests: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Patella Tests: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Tracking: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Patellar tendon: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Tibial tuberosity: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Bursa/Fat pads: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Popliteal area: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Feet/Ankles: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Hips: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Other: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Impression:
[Describe clinical impression] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Describe management plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Treatment:
[Describe treatment provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
HEP (Home Exercise Programme):
[Describe prescribed home exercise programme] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Advice:
[Describe advice given to patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Next day:
[Describe plan for next day] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise 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 as needed to capture all relevant information from the transcript.)
