Orthopaedic Progress Note (custom)

Progress Note 1 November 2024 Subjective: - Follow-up visit for a right knee arthroscopy performed 6 weeks ago for a meniscal tear. - Patient reports gradual improvement in knee pain and swelling since the surgery. Pain is now intermittent, rated 2/10 on the visual analog scale (VAS), and primarily occurs with prolonged activity. Stiffness is present in the morning, resolving within 30 minutes. Patient denies any new injuries or trauma. Previous treatments included physiotherapy, which the patient found helpful. - Physiotherapy is progressing well. - Symptoms have improved since the last visit, with a decrease in pain and swelling. The patient is able to ambulate without assistive devices for short distances. Objective: - Physical examination reveals a well-healed arthroscopic incision sites. Mild effusion is present. Range of motion (ROM): flexion to 120 degrees, extension to 0 degrees. Strength testing: quadriceps 4/5, hamstrings 4/5. No joint instability noted. No deformity or tenderness. - The surgical wound appears well-healed with no signs of infection. - Neurovascular examination: Distal pulses palpable, capillary refill <2 seconds, no sensory deficits. - Investigations: X-rays of the right knee taken 4 weeks ago showed no acute bony abnormalities. Assessment & Plan: 1. Right Knee - Post-Arthroscopy - Assessment: The patient is recovering well from the arthroscopic meniscal repair. The diagnosis is post-operative recovery from arthroscopic meniscal repair, based on the patient's reported improvement in symptoms, physical examination findings, and the absence of any new complications. - Investigations planned: None at this time. - Non-surgical treatment options: Continue with physiotherapy, including exercises to improve strength and ROM. Patient to continue with home exercises. Recommend ice and elevation as needed. - Relevant referrals: Continue with physiotherapy. Additional Notes: - Patient educated on the importance of continued physiotherapy and adherence to the exercise program. Discussed potential complications, including infection, stiffness, and re-injury. Reviewed post-operative care instructions. - Patient expressed concerns about returning to sports. Discussed a gradual return to activity based on pain and function. - Informed consent process was completed including a discussion of the nature of the patient's condition, the nature of the treatment proposed, the treatment alternatives, and material risks. - Material risks of the procedure were discussed, including infection, bleeding, damage to nerves or vessels, fluid extravasation and compartment syndrome, tourniquet pain, persistent pain, synovial-cutaneous fistula, venous thromboembolism, and other medical or anesthetic complications.