KNEE FOLLOW-UP EXAMINATION
NAME: Sarah Elizabeth Jenkins
DATE: 1 November 2024
FILE: SEJ-K-007
TITLE: Mrs.
SIDE: Right
The patient is 6 months post-operative from an ACL reconstruction on the right knee.
---
History:
= Medical diseases: Mrs. Jenkins has a history of well-controlled essential hypertension, managed with daily medication. She also has a history of seasonal allergies, which are managed with over-the-counter antihistamines as needed.
= Medication used: Amlodipine 5mg daily for hypertension. Loratadine as needed for allergies. She also takes a daily multivitamin and a glucosamine supplement for joint health, which she started approximately 3 months ago.
= Allergies: Penicillin (rash), environmental allergens (seasonal).
= Complications: Mrs. Jenkins experienced mild post-operative swelling for the first 4 weeks, which resolved with RICE therapy and physiotherapy. There were no surgical site infections or deep vein thromboses.
Previous Treatment Right Knee:
Mrs. Jenkins underwent an arthroscopic anterior cruciate ligament (ACL) reconstruction with a hamstring autograft on 1 May 2024. Prior to surgery, she completed 8 weeks of pre-operative physiotherapy to improve quadriceps strength and range of motion. Post-operatively, she has been diligent with her physiotherapy regimen, focusing on strengthening, proprioception, and gait training. Her previous treatments included RICE (rest, ice, compression, elevation) immediately post-injury and NSAIDs for pain management.
Right Knee:
Mrs. Jenkins reports persistent occasional stiffness, particularly in the mornings and after prolonged sitting, rated 2/10 on a pain scale. She also notes some mild clicking with deep knee flexion but denies locking or instability. She has been able to return to light jogging and cycling, but still experiences some apprehension with pivoting movements. No new swelling or redness. She feels her quadriceps strength is improving but still not at pre-injury levels.
Orthopaedic complaints not related to the knees:
Patient denies any other orthopaedic complaints at this time.
---
Examination:
Right knee examination – Tibio-femoral joint:
* Alignment: Neutral mechanical axis. No obvious valgus or varus deformity.
* Gait: Mild antalgic gait noted, favoring the right leg slightly. Ambulated without assistive devices.
* Scarring: Well-healed surgical incisions, non-tender, non-erythematous.
* Swelling: No significant effusion palpated.
* Atrophy: Mild quadriceps atrophy noted compared to the left, approximately 1cm circumference difference.
* Tenderness: Mild tenderness along the medial joint line with deep palpation.
* Range of motion: Full extension (0 degrees). Flexion to 135 degrees. Pain occurs at end-range flexion.
* Meniscus findings: Negative for medial and lateral meniscal tears on McMurray's test.
* Collateral ligament findings: Medial collateral ligament (MCL) stable, no laxity. Lateral collateral ligament (LCL) stable, no laxity.
Right knee examination – Patella:
* Alignment: Patella centrally aligned.
* Tracking: Smooth tracking throughout range of motion.
* Apprehension sign: Negative.
* Tenderness: No patellar tenderness.
* Crepitus: Mild crepitus with patellar mobilisation.
Other orthopaedic examination findings:
No other orthopaedic examination findings were performed at this visit.
---
Special investigations:
Right knee X-rays:
Recent X-rays (dated 25 October 2024) show good hardware placement for ACL reconstruction with no signs of osteolysis. Joint spaces are preserved, and no acute bony pathology is identified.
Right knee MRI:
Not indicated at this time.
Right knee other special investigations:
Not indicated at this time.
---
Diagnosis:
Right knee:
* Status post ACL reconstruction (6 months). Mild quadriceps weakness and persistent stiffness. Apprehension with pivoting activities.
Other general diagnosis:
* Essential hypertension (well-controlled).
* Seasonal allergies.
---
Treatment plan:
Right knee:
Further investigations: No further investigations planned at this time.
Conservative: Continue current physiotherapy regimen with increased focus on quadriceps strengthening, plyometrics, and agility drills. Introduce sport-specific training. Emphasize proprioceptive exercises. Continue glucosamine supplement. Prescribe a topical NSAID gel for localized stiffness as needed.
General measures:
Advised patient to continue regular exercise, maintain a healthy weight, and follow up with her GP for blood pressure management. Patient advised to gradually increase activity levels and avoid high-impact pivoting sports until cleared by the surgeon or physiotherapist.
Follow-up plan including timing and what is planned for the follow-up: Return for review in 3 months to assess progress and readiness for full return to sport.
Medication prescribed:
Diclofenac 1% gel, apply to right knee up to three times daily as needed for pain/stiffness.
KNEE FOLLOW-UP EXAMINATION
NAME: [Insert patient’s full name] (Only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit completely. Write in a single line.)
DATE: [Insert date of consultation] (Only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit completely. Write in a single line.)
FILE: [Insert patient file number or ID] (Only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit completely. Write in a single line.)
TITLE: [Insert patient’s title] (Only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit completely. Write in a single line.)
SIDE: [Insert the side examined today for follow-up: Right or Left or Both] (Only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit completely.)
[If the other knee is starting to cause symptoms, specify which knee] (Only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit completely.)
[State the follow-up timeframe: post-operative time since surgery, or duration the other knee has been painful] (Only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit completely.)
---
History:
= Medical diseases: [Insert past and current medical diseases] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
= Medication used: [Insert current and past medications, including over-the-counter medications and supplements] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
= Allergies: [Insert known allergies and reactions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
= Complications: [Insert complications experienced during treatment to date or as a consequence of the operation performed] (Only include if explicitly mentioned in the consultation, transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Previous Treatment Right Knee:
[Summarize all treatments and interventions for the right knee (conservative and surgical) and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Right Knee:
[Insert new complaints or treatment response regarding the right knee, including onset, duration, character, aggravating/relieving factors, and associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Previous Treatment Left Knee:
[Summarize all treatments and interventions for the left knee (conservative and surgical) and outcomes] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Left Knee:
[Insert new complaints or treatment response regarding the left knee, including onset, duration, character, aggravating/relieving factors, and associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Orthopaedic complaints not related to the knees:
[Insert description of other orthopaedic complaints not related to the knees] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
---
Examination:
Right knee examination – Tibio-femoral joint:
[Insert findings from examination of the right tibio-femoral joint (alignment, gait, scarring, drainage/sinuses, swelling, bruising, effusion, atrophy, warmth, Baker’s cyst, synovitis, tenderness, crepitus/clicking)] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert range of motion and whether pain occurs in flexion or extension at end range] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert meniscus findings (medial/lateral), tests used, and any meniscal cysts] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert collateral ligament findings, grading if stated, and tests used] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert postero-medial and/or postero-lateral corner findings if diagnosed] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
Right knee examination – Patella:
[Insert findings from examination of the right patello-femoral joint (alignment, tracking, Q-angle if stated, apprehension sign, tenderness, crepitus, patellar mobilisation pain, lateral retinaculum tightness)] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
Left knee examination – Tibio-femoral joint:
[Insert findings from examination of the left tibio-femoral joint (alignment, gait, scarring, drainage/sinuses, swelling, bruising, effusion, atrophy, warmth, Baker’s cyst, synovitis, tenderness, crepitus/clicking)] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert range of motion and whether pain occurs in flexion or extension at end range] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert meniscus findings (medial/lateral), tests used, and any meniscal cysts] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert collateral ligament findings, grading if stated, and tests used] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
[Insert postero-medial and/or postero-lateral corner findings if diagnosed] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
Left knee examination – Patella:
[Insert findings from examination of the left patello-femoral joint (alignment, tracking, Q-angle if stated, apprehension sign, tenderness, crepitus, patellar mobilisation pain, lateral retinaculum tightness)] (Only include if explicitly mentioned in the clinical examination; otherwise omit completely. Write in a concise manner with a bulleted format.)
Other orthopaedic examination findings:
[Insert findings from examination of other orthopaedic areas if performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
---
Special investigations:
Right knee X-rays:
[Insert right knee X-ray findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Right knee MRI:
[Insert right knee MRI findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Right knee other special investigations:
[Insert other right knee investigations (e.g., CT, ultrasound, lab tests) and findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Left knee X-rays:
[Insert left knee X-ray findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Left knee MRI:
[Insert left knee MRI findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Left knee other special investigations:
[Insert other left knee investigations (e.g., CT, ultrasound, lab tests) and findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
---
Diagnosis:
Right knee:
[Insert diagnosis for the right knee] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Left knee:
[Insert diagnosis for the left knee] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Other orthopaedic diagnosis:
[Insert any other orthopaedic diagnoses not related to the knees] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Other general diagnosis:
[Insert any other general medical diagnoses] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
---
Treatment plan:
Right knee:
Further investigations: [Insert further investigations planned for the right knee] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Conservative: [Insert conservative treatment plan for the right knee] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Theatre: [Insert surgical plan for the right knee, including procedure and rationale] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Left knee:
Further investigations: [Insert further investigations planned for the left knee] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Conservative: [Insert conservative treatment plan for the left knee] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Theatre: [Insert surgical plan for the left knee, including procedure and rationale] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
General measures:
[Insert general advice applicable to the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
[Insert follow-up plan including timing and what is planned for the follow-up] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Medication prescribed:
[Insert medications prescribed during the consultation, including dosage and instructions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
Other orthopaedic conditions:
[Insert treatment plans for other orthopaedic conditions identified] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely. Write in paragraphs of full sentences.)
(For each section, only include if explicitly mentioned in the attachment, transcript, contextual notes or clinical note; otherwise omit the section entirely. Never come up with your own patient details, examination findings, diagnoses, investigations, or management plans—use only the attachment, 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 it is missing; simply omit the placeholder or section entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information.)
