Ortho Office Note

HISTORY OF PRESENT ILLNESS: [Reason(s) for consultation, including specific musculoskeletal concerns or symptoms such as joint pain, stiffness, swelling, injuries, fractures, deformities, etc.] [Detailed history of the presenting complaint(s), including onset, duration, severity, aggravating/alleviating factors, associated symptoms such as limitation of movement, previous injuries, or trauma.] [Any previous treatments such as physiotherapy, medications, or orthopaedic surgeries and the responses to these.] [Patient goals for the visit, if available and relevant.] PHYSICAL EXAM: "Well-appearing" [age] [man/woman] "in no apparent distress. Alert and oriented x 3. Normocephalic. Non-labored respirations on room air. Extremities are warm and well-perfused. Good peripheral pulses. Sensation intact in non-affected extremities." [Location of complaint with laterality.] [Skin findings such as intact skin, prior well-healed surgical scars, swelling, effusion, bruising, erythema, warmth, bony deformity, popeye deformity, hematoma, rash, abrasion, or signs of infection. Mention if compartments are soft or compressible. Gait description if observed — normal, antalgic, or ataxic. Mention presence or absence of foot drop.] [Specific physical examination findings or abnormalities observed.] [Exam findings specific to the affected area or system.] [Areas of pain to palpation or with movement, with severity described as mild, moderate, or exquisite.] [Strength testing results for relevant muscle groups — flexion/extension, empty can testing, resisted external rotation, belly press testing, plantarflexion/dorsiflexion, etc.] [Range of motion — active or passive — listed as flexion, extension, external rotation, internal rotation, plantarflexion, dorsiflexion, abduction, etc., noting any crepitus or stiffness.] [Special test results such as Lachman, McMurray’s, anterior/posterior drawer, valgus/varus stress testing, Hawkins, Neer’s, Spurling’s, FADIR, FABER, log roll, pivot shift, Thompson, Tinel’s, etc., with positive/negative notation and laterality.] [Neurovascular findings such as sensation, capillary refill < 2 seconds, good pulses.] "Patient otherwise NVI." IMAGING INTERPRETATION: [Mention number and type of X-ray views obtained, and note: "Independently reviewed by myself today demonstrating" followed by specific imaging findings described in plain language but with medical terminology.] ASSESSMENT: [Likely diagnosis with laterality.] - [Other diagnoses, if applicable.] PLAN: [Discussion of the diagnosis in detail, outlining all treatment options considered. Mention the plan of care decided upon. If surgery is recommended and agreed upon, note the conservative treatments the patient has tried and failed — such as cortisone injections, physical therapy, pain medications, or activity modification. If MRI is ordered, explain rationale including symptom duration, prior use of pain medication, completion of therapy, injections, or other conservative measures. Mention any counseling provided (e.g., smoking cessation, weight loss), relevant referrals, or ancillary support. Document follow-up plans and specific instructions provided.]