Live Transcript
DoctorAapko yeh dard kab se ho raha hai?
PatientSir, do hafte se... especially subah uthne mein bahut takleef hoti hai.
DoctorDono ghutnon mein? Ya sirf right mein?
PatientDono mein, par right zyada hai. Seedha baith nahi pata properly.
DoctorRight knee mein swelling hai. ROM limited. X-ray suggest karta hoon.
PatientPehle bhi ek baar hua tha, Diclofenac diya tha unhone.
Generated SOAP Note
Subjective
Patient reports bilateral knee pain for 2 weeks, worse on waking. Morning stiffness prominent. No fever or systemic symptoms. History of prior episode 8 months ago, managed with Diclofenac with resolution.
Objective
Right knee: mild peri-articular swelling, tenderness on medial joint line, ROM limited at 90 degrees flexion. Left knee: no visible swelling, mild crepitus on flexion.
Assessment
Likely early osteoarthritis, bilateral knees (ICD-10: M17.0). Rule out early inflammatory arthritis given bilateral presentation.
Plan
X-ray bilateral knees AP/lateral views. Tab Diclofenac 50mg BD x 7 days with food. Physiotherapy referral for quadriceps strengthening. Follow-up in 2 weeks or earlier if worsening.