Patient's identity verified
Informed consent to proceed with the telehealth consultation obtained from the patient/carer
Limitations of telehealth explained to patient/carer
Subjective:
Patient presents today with a chief complaint of right knee pain, which started approximately 6 weeks ago after twisting the knee while playing football. The pain is described as a sharp, intermittent pain, exacerbated by activity and weight-bearing. The patient reports no specific injury but recalls a 'pop' sensation at the time of onset. The pain is located primarily in the medial aspect of the knee. The patient denies any locking, giving way, or instability. The patient reports that the pain is worse in the morning and improves with rest. The patient has tried over-the-counter pain medication (ibuprofen) with minimal relief.
Past medical history and past surgical history:
* No significant past medical history.
* No prior surgeries.
Medications:
* Ibuprofen 400mg as needed for pain.
Social history:
Patient is a 32-year-old male, works as an accountant, and is active in sports. He is a non-smoker and drinks alcohol occasionally.
Allergies:
* No known drug allergies.
Objective:
* Vitals: Blood pressure 130/80 mmHg, Heart rate 78 bpm, SpO2 98% on room air.
* Inspection: No obvious deformity, swelling, or ecchymosis. Mild effusion noted.
* Palpation: Tenderness to palpation along the medial joint line.
* Range of Motion: Full active and passive range of motion, but pain with terminal flexion.
* Special Tests: Positive McMurray's test, negative Lachman's test, negative varus/valgus stress tests.
Investigations with results:
* X-rays of the right knee were ordered and reviewed. No acute bony abnormalities were identified. Mild degenerative changes were noted.
Assessment and Plan:
1. Right Medial Meniscus Tear
* Assessment: Based on the history, physical examination findings, and imaging results, the most likely diagnosis is a tear of the medial meniscus.
* Differential diagnoses:
* Medial collateral ligament sprain.
* Osteoarthritis.
* Patellofemoral pain syndrome.
* Investigations planned:
* MRI of the right knee to confirm the diagnosis and assess the extent of the tear.
* Treatments planned:
* RICE (Rest, Ice, Compression, Elevation).
* Activity modification.
* Physical therapy to improve range of motion and strength.
* Consideration of arthroscopic surgery if symptoms persist or worsen.
* Relevant referrals:
* Referral to a physical therapist for rehabilitation.
2. Mild Osteoarthritis
* Assessment: Mild degenerative changes noted on X-ray.
* Differential diagnoses:
* Meniscal tear.
* Ligamentous injury.
* Investigations planned:
* Repeat X-rays in 6 months.
* Treatments planned:
* Activity modification.
* Weight management.
* Consideration of NSAIDs for pain relief.
* Relevant referrals:
* Referral to a physical therapist for rehabilitation.
3. No other issues identified.
Patient's identity verified
Informed consent to proceed with the telehealth consultation obtained from the patient/carer
Limitations of telehealth explained to patient/carer
Subjective:
[Current issues, reasons for visit, history of presenting complaints etc] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraphs of full sentences.)
[Past medical history and past surgical history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[Medications] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
[Social history] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in paragraph or bullet point format.)
[Allergies] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as list.)
Objective:
[Physical or mental state examination findings, including vitals and system-specific examination] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Use as many bullet points as needed to capture the examination findings.)
[Investigations with results] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
Assessment and Plan:
[1. Issue, problem or request 1 (issue, request or condition name only)]
- [Assessment, likely diagnosis for Issue 1 (condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Differential diagnoses for Issue 1] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Investigations planned for Issue 1] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Treatments planned for Issue 1] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Relevant referrals for Issue 1] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
[2. Issue, problem or request 2 (issue, request or condition name only)]
- [Assessment, likely diagnosis for Issue 2 (condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Differential diagnoses for Issue 2] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Investigations planned for Issue 2] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Treatments planned for Issue 2] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Relevant referrals for Issue 2] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
[3. Issue, problem or request 3, 4, 5 etc (issue, request or condition name only)]
- [Assessment, likely diagnosis for Issue 3, 4, 5 etc (condition name only)] (Only include if explicitly mentioned in transcript or context, else omit section entirely.)
- [Differential diagnoses for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Investigations planned for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Treatments planned for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
- [Relevant referrals for Issue 3, 4, 5 etc] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet point list.)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)