Clinic Correspondence for New Patient Template

Name: John Doe
Thank you for referring John to me. Please find feedback from our session below.
Diagnosis:
John has been diagnosed with a ruptured anterior cruciate ligament (ACL) in his right knee. This injury aligns with the mechanism of injury described during his soccer match.
Plan:
We will start with a conservative management strategy, including physical therapy to enhance the surrounding muscles. If there is no progress, we will consider surgical options.
History:
John presented with a history of right knee pain following a soccer match two weeks ago. He reports instability and swelling in the knee. John is a 25-year-old professional soccer player and was accompanied by his coach during the visit. He is currently unable to participate in his sport due to the injury.
Functional limitations:
John is unable to run or pivot on his right leg, which significantly impacts his ability to play soccer.
Treatment to date:
John has been taking over-the-counter pain medication and has attended two sessions of physiotherapy focusing on range of motion exercises.
Past medical history:
John has no significant past medical or surgical history. His family history is unremarkable. He is a non-smoker and has no known allergies.
Medications:
Ibuprofen 400mg as needed.
Examination:
John's vital signs are stable. On examination, there is swelling and tenderness over the right knee. The Lachman test is positive, indicating ACL instability.
Imaging:
MRI of the right knee shows a complete tear of the ACL with associated bone bruising.
Management:
We plan to continue with physical therapy and reassess in four weeks. If there is no improvement, we will discuss surgical options. John has been referred to a sports psychologist to help cope with the psychological impact of his injury.
Many thanks again for the referral.