Orthopedic Evaluation Template

Orthopedic Consultation
History of present illness:  
The patient, a 45-year-old male, reports ongoing right knee pain and swelling after a fall during a soccer game three weeks ago. The pain is sharp and intensifies with movement, especially when ascending stairs. The patient has a history of knee injuries but no prior surgeries. Over-the-counter pain medications have provided minimal relief. The purpose of this visit is to evaluate the necessity of surgical intervention to restore full function and relieve pain.
Medical/Surgical History:  
- Previous knee sprain (2018)  
- Hypertension (managed with medication)  
Medications:  
- Ibuprofen 400mg as needed for pain  
- Lisinopril 10mg daily  
- Medication profile is available on the NS Drug Information System  
Social/Occupational History and Functional Inquiry:  
- Occupation: Office worker  
- Recreational soccer player  
- Non-smoker, occasional alcohol use  
- No known allergies  
Physical Examination:  
- Vitals: Blood pressure 130/85 mmHg, Heart rate 78 bpm  
- Right knee: Swelling, tenderness on palpation, limited range of motion, decreased strength  
- Neurovascular examination: Intact  
Investigations:  
- X-ray: No fractures, mild joint effusion  
- MRI: Suspected meniscal tear  
Assessment & Plan:  
1. Right Knee Meniscal Tear  
- Differential diagnosis: Consideration of ligamentous injury  
- Investigations planned: Arthroscopy for definitive diagnosis  
- Surgical treatment planned: Arthroscopic meniscectomy, outpatient procedure  
- Non-surgical treatment options: Physiotherapy post-surgery  
- Pre-operative preparation: Cease NSAIDs 5 days prior to surgery  
- Post-operative care plan: Physiotherapy twice weekly, follow-up in 2 weeks  
- Relevant referrals: Physiotherapy  
Additional Notes:  
- Patient education on the meniscal tear, surgical procedure, and rehabilitation importance  
- Informed consent was obtained after a discussion of the nature of the treatment proposed, the nature of the condition, the treatment alternatives, the expected postoperative course, and material risks which include but are not limited to pain, swelling, wound complications, periprosthetic joint infection, venous thromboembolism, stiffness, instability, wear and loosening, fracture, neurovascular injury, leg length discrepancy, malalignment, medical/anesthetic complications, and even death. The patient gave informed consent for the discussed procedure.