Chief Complaint: Right knee pain and swelling after a fall.
Subjective:
- Patient reports a fall while skiing two weeks ago, resulting in immediate right knee pain and swelling. Pain is described as sharp, localized to the medial aspect of the knee, and exacerbated by weight-bearing and twisting motions. Patient reports previous injuries, but none to the right knee.
- Past medical history is significant for hypertension, well-controlled with medication. No prior orthopaedic surgeries.
- Current medications include lisinopril for hypertension and ibuprofen as needed for pain.
- Patient is a 45-year-old active individual, works as a software engineer, and enjoys skiing and hiking.
- No known drug allergies.
Objective:
- Pre-operative exam findings:
- Cardiac: Regular rate and rhythm
- Lungs: Clear to auscultation bilaterally
General Exam:
- Constitutional: Healthy appearing, no acute distress
- Psychiatric: Active and alert, normal mood and affect
- Gait and Station: Normal gait, patient is walking without assistive devices
- **Part of body examined:** Right knee
- Inspection: Skin intact. Mild swelling and ecchymosis noted medially.
- Palpation: Tenderness to palpation along the medial joint line and medial collateral ligament.
- Range of motion: Limited range of motion due to pain and swelling; flexion to 90 degrees.
- Strength: 5/5 strength with all testing.
- Stability: Mild medial joint line laxity noted with valgus stress testing.
- Special Test: Positive McMurray's test and valgus stress test at 30 degrees.
- Neurovascular examination findings: Distal pulses intact, no sensory deficits.
- Xrays: X-rays taken on 20 October 2024 at local imaging center, AP, lateral, and skyline views of the right knee. Findings: No acute fracture identified.
- Other studies: MRI of the right knee performed on 27 October 2024, revealing a complete tear of the medial meniscus and a partial tear of the medial collateral ligament.
Assessment & Plan:
1. Right Knee - Medial Meniscus Tear and MCL Sprain
- Assessment: Diagnosis of a complete tear of the medial meniscus and a partial tear of the medial collateral ligament based on clinical examination and MRI findings.
- Differential diagnosis: Consider other causes of knee pain, such as osteoarthritis, ligamentous injuries, and patellofemoral pain syndrome.
- Investigations planned: None
- Surgical treatment planned: Arthroscopic meniscectomy and MCL repair. The patient has been informed of the risks and benefits of the procedure.
- Non-surgical treatment options: Patient has been offered the option of non-operative management with bracing, physical therapy, and activity modification, but the patient has elected for surgical intervention.
- Pre-operative preparation: Patient to discontinue ibuprofen one week prior to surgery. Pre-operative education provided regarding the procedure, risks, and post-operative care.
- Post-operative care plan: Patient will be discharged home the same day. Patient will be seen in the office for a follow-up appointment in two weeks. Patient will be instructed to follow up with physical therapy for rehabilitation.
- Relevant referrals: Physical therapy referral provided.
Follow-up: 2 weeks
Xrays needed at next visit: PRN
Additional Notes:
- Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care.
- Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for.
- Any specific patient or family concerns addressed during the consultation.
ICD-10 Code: M23.23 - Derangement of meniscus, medial, current injury, right knee. Justification: This code accurately reflects the diagnosis of a medial meniscus tear in the right knee.
Chief Complaint: [Reason(s) for consultation, including specific musculoskeletal concerns or symptoms such as joint pain, stiffness, swelling, injuries, fractures, deformities, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Subjective:
- [Detailed history of the presenting complaint(s), including onset, duration, severity, aggravating/alleviating factors, associated symptoms such as limitation of movement, previous injuries, trauma, any previous treatments and responses, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Past medical and surgical history, highlighting any previous orthopaedic surgeries, musculoskeletal disorders, hospitalizations, outcomes, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Current medications, including any pain management medications, anti-inflammatories, supplements, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Social history, focusing on occupation, sports, physical activities, and lifestyle factors that may influence musculoskeletal health (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Allergies, including allergies to medications, metals, or other materials relevant to orthopaedic procedures, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
Objective: (all findings below in bullet format) (for all bullets in this section use the language in parenthesis below instead of not mentioned if not mentioned; if telemedicine visit don't include "Pre-operative exam findings" or "General Exam" findings, just state "Physical Exam: Telemedicine visit so exam findings are limited.")
- "Pre-operative exam findings:" (include this bullet only if surgery is planned during the visit, include heart and lung exam, if no mention of heart and lung exam state in bullet format " - Cardiac: Regular rate and rhythm", and on the next bullet " - Lungs: Clear to auscultation bilaterally") (if visit is stated to be a telemedicine visit state that this was a telemedicine visit and exam findings are limited, don't include any of the pre-operative exam findings or general exam findings)
"General Exam:"
- "Constitutional:" (general appearance of patient, if no information provided state "Healthy appearing, no acute distress")
- "Psychiatric:" (any psychiatric findings, if no psychiatric information provided state "Active and alert, normal mood and affect")
- "Gait and Station" (any mention of how the patient is walking or standing, if no information provided state "Normal gait, patient is walking without assistive devices")
- "Part of body examined:" (state parts of body mentioned in exam) (this bullet in bold)
- "Inspection:" (general appearance of the body part examined focusing on swelling, erythema, bruising, signs of infection, signs of trauma; if no information provided state "Skin intact. No signs of swelling, drainage, erythema, ecchymosis or other signs of trauma or infection")
- "Palpation:" (state any areas of tenderness to palpation; if no information provided, state "No tenderness to palpation.")
- "Range of motion:" (state any description of range of motion; if no information provided, state "Full ROM.")
- "Strength:" (state any description of strength of body part examined; if no information provided, state "5/5 strength with all testing.")
- "Stability:" (state any description of instability of body part examined; if no information provided, state "No instability or ligamentous laxity noted.")
- "Special Test:" (list positive or negative findings for any special tests such as Durkan's, Tinel's, Speed's, Apprehension test, etc.; if no information provided, state "None.")
- [Neurovascular examination findings, assessing nerve function and blood supply in the affected area, if relevant (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- "Xrays:" [State date taken, where taken from, which views, and the xray findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- "Other studies:" [If available state date of study and where taken from, include MRI, lab, EMG, or any other non x-ray results discussed (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
"Assessment & Plan:"
[1. Orthopaedic Issue or Condition]
- [Assessment, including the likely diagnosis and rationale based on subjective and objective findings (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Differential diagnosis, considering other potential musculoskeletal or systemic conditions that may present with similar symptoms (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Investigations planned, specifying any additional imaging, laboratory tests, or assessments needed for a definitive diagnosis or surgical planning (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Surgical treatment planned, detailing the type of surgery, expected outcomes, and potential risks (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Non-surgical treatment options, including physiotherapy, medications, lifestyle modifications, etc. (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Pre-operative preparation, including any necessary lifestyle modifications, pre-medication, and instructions (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Post-operative care plan, covering expected hospital stay, rehabilitation, physiotherapy, pain management, and follow-up appointments (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Relevant referrals, e.g., to rheumatology, physiotherapy, pain management, etc., if needed (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[2. Additional Orthopaedic Issues or Conditions]
- [Follow the same structure as above for each additional issue or condition identified (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
"Follow-up:" [when next follow-up was discussed, should be either a time frame in weeks or "PRN" (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
"Xrays needed at next visit:" [what xrays should be taken at next visit, if none discussed state "PRN" (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
[Additional Notes: (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Patient education on the diagnosed condition, surgical procedures, potential complications, and the importance of rehabilitation and adherence to post-operative care (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Instructions for pre-operative and post-operative care, including activity restrictions, wound care, signs of complications to watch for (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
- [Any specific patient or family concerns addressed during the consultation (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
ICD-10 Code: [Relevant ICD-10 code and description, with justification (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)]
(For each section, only include if explicitly mentioned in transcript or context, else 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.)
