Ortho Concise Note
Created by
Richard Wood
Specialty
Orthopaedic Surgeon
Last edited
10/20/2026
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About this template
A structured template for orthopaedic consultation documentation. It covers the patient's symptoms and relevant history, examination findings, differential diagnoses, planned investigations, and follow-up arrangements.
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Patient
Thomas Wright (DOB: 14/08/1989, NHS: 492 817 3054)
Date
24/05/2024
Subjective
- R knee medial joint line pain, swelling, and mechanical locking.
- Daily symptoms; 6/52 duration following a twisting injury playing football.
- Unable to squat, kneel, or descend stairs comfortably; walks with a limp.
- Fit and well; nil previous R knee injuries; takes ibuprofen 400 mg PO TID PRN.
- Self-employed plumber (heavy manual labour, frequent kneeling).
Objective
- Antalgic gait; mild R knee effusion; no erythema or quadriceps wasting; NV intact distally.
- ROM 0–110° flexion (limited by pain); full extension.
- Focal tenderness over the R medial joint line.
- Lachman, anterior/posterior drawer, and varus/valgus stress tests negative; McMurray's test positive for medial pain and a palpable click.
Assessment
- R medial meniscal tear (bucket-handle vs radial tear)
- Early medial compartment chondropathy
Plan
- Urgent MRI R knee and weight-bearing AP/lateral/skyline radiographs.
- Orthopaedic clinic review in 4/52 with imaging results to discuss arthroscopic intervention; referred to physiotherapy in the interim.
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