Multi-Issue GP Consultation

Created by

Andrew Kelly

Specialty

General Practitioner

Last edited

10/20/2026

Uses

0 times

Issue 1: Right knee pain

Reports gradual onset of right medial knee pain over the past 3 weeks following an increase in daily walking. Pain is dull and aching, worse when descending stairs and after prolonged sitting. Denies any acute trauma, locking, giving way or systemic features such as fever. Has tried paracetamol 1000 mg PO QID PRN with minimal relief.

Examination

Walks with a mild antalgic gait favouring the right leg. Right knee shows trace effusion with no erythema or increased warmth. Mild tenderness palpated along the medial joint line. ROM is 0 to 120 degrees, limited at end-range flexion by discomfort. McMurray test, Lachman test, and varus and valgus stress tests are negative.

Impression

Right knee osteoarthritis flare. DDx medial meniscal degeneration.

Plan

Order weight-bearing X-ray of the right knee to assess joint space narrowing. Commence meloxicam 15 mg PO daily with food for 2 weeks to manage inflammation.

Advised to cease immediately if gastrointestinal discomfort occurs. Refer to physiotherapy for quadriceps strengthening and load management. Advised to apply ice packs after exercise and reduce walking distance temporarily. Review in 2 weeks with imaging results or earlier if swelling worsens or locking develops.

Issue 2: Hypertension review and repeat scripts

Attends for routine blood pressure check and renewal of regular antihypertensive medication. Home BP readings have averaged 135/85 mmHg over the past month. Compliant with perindopril 5 mg PO daily and reports no side effects such as dry cough or dizziness. Denies chest pain, SOB, palpitations or ankle oedema.

Examination

BP 134/82 mmHg sitting, HR 72 bpm regular. HS dual with no murmurs, and chest is clear to auscultation bilaterally. No peripheral oedema noted.

Impression

Essential hypertension, well controlled.

Plan

Provide repeat prescription for perindopril 5 mg PO daily with 5 repeats. Order routine annual bloods including FBE, UEC, LFT, fasting lipids and HbA1c. Encourage ongoing adherence to a low-sodium diet and regular low-impact aerobic exercise. Review in 6 months for next routine BP check.

Issue 3: Insomnia and work-related stress

Reports difficulty falling asleep for the past 4 weeks due to increased workload and upcoming deadlines. Takes up to 2 hours to fall asleep, averaging 5 hours of sleep per night. Feels fatigued during the day with reduced concentration, but denies pervasive low mood or anhedonia. Drinks 3 cups of coffee daily, with the last cup at 16:00. Denies suicidal ideation or self-harm thoughts.

Examination

Appears tired but well groomed and cooperative. Speech is normal in rate, volume and tone. Mood is described as stressed, and affect is reactive and congruent. Thought form is logical and goal-directed with no delusions or perceptual disturbances. Insight and judgement are intact.

Impression

Acute insomnia secondary to work-related stress.

Plan

Provide education on sleep hygiene principles to improve sleep latency.

Advised to cease caffeine intake after 12:00 and avoid screens for 1 hour before bed. Recommend trial of over-the-counter melatonin 2 mg PO nocte 1 hour before bed for 3 weeks. Declined formal psychological referral at this stage, preferring to trial lifestyle measures first. Review in 4 weeks to assess sleep quality and mood, or earlier if mood deteriorates.

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