🩺 Record Detail

Patient Info

Name: Unknown
Age: Unknown
Date: 2026-09-30 14:12:41

Transcript

Patient: And then I played basketball, I guess, a couple, I went, I went relatively hard and made a couple of like, serious moves by the time I was done, like just the session, it was hurting, going up the stairs hurt a lot, and then, and it just, it just gets progressively worse, like, each day.
Doctor: So you're on Tylenol and you're on Celebrex.
Patient: Yes.
Doctor: So it looks like you have a knee sprain. Could be a medial collateral based on the location. Could be a meniscal. Yeah, so what we'll do is we'll ask the physiotherapist to see you.
Patient: Okay. All right. And then MRI or cast scan or ultrasound or anything like that.
Doctor: Well, maybe, maybe in the future, if it doesn't get better, a lot of these will get better without that. I'm going to increase your Celebrex to twice a day.
Patient: Okay.
Doctor: And that's going to be for 14 days.
Patient: Yeah.
Doctor: The times 14 days, then go back to 100 daily. I would say not to do any exercise specific with the turning or, you know, like the basketball is very jarring on it.
Patient: Yeah. I've been taking time off from lower body for sure. Um, I spoke with a physio, what was it last week? So he confirmed that, um, my right leg from my knee to my ankle is an inch shorter because of an injury I sustained when I was 10.
Doctor: Okay.
Patient: I was in SickKids Hospital for like a month and a half. It was pretty bad. But, um, so he confirmed that and he confirmed my shoulder popped out, so I was asking for more pain meds from before. Like I'm always okay, I just deal with it, but that's a start.
Doctor: So we'll get that going for you.
Patient: Okay. Is there anything you can do about my night meds, my sleep meds?
Doctor: What's your sleep meds?
Patient: It should have been, well, it should be Zafaclone, I guess what it is on the street, uh, Zafaclone. And I get, my doctor prescribed me two of the small tabs of, uh, Seroquel. But what you guys gave me here was 125. I turned down the 25 during the day because I didn't want it during the day. Uh, and I had a hundred at night and I went to Lindsay and they accused me of, uh, courting. And then I didn't sleep for like a month because that place is a nightmare. Uh, and I don't, I'm not one to afford meds, but I also don't like to take sleep meds at 6 PM. I'm sorry.
Doctor: Pardon me. Can I put you on melatonin for sleep?
Patient: Okay. If you can do that, that's great. Other than that, I need to see, uh, someone else who knows sleep meds. Cause I got, I've been saying, I, I've been like, I don't know, psych or someone. Cause I, I've been dealing with sleep deprivation since I was a child for trauma. I have PTSD from cops, PTSD from the military. Sleep is always an issue for me, right? I'm comfortable being uncomfortable so I can go for a few days of sleep no matter what.
Doctor: So I would treat you with melatonin for sleep.
Patient: Okay. Uh, you just told me that somebody accused you of courting.
Patient: Yes. And I took it for two days and I didn't sleep for the rest of the day. I'm just, I'm just being honest with you guys. Maybe I shouldn't be, because I tell you guys the truth and you guys, we know that.
Doctor: Thank you for that. All right, Gordon.
Patient: My pleasure. Good luck with everything, man.
Doctor: All right.

Clinical Notes

SOAP Clinical Note

Subjective

The patient reports experiencing knee pain after playing basketball, which worsens progressively each day. The patient mentions difficulty going up the stairs due to the pain. The patient has a history of a leg length discrepancy due to an injury sustained at age 10, confirmed by a physiotherapist. The patient also reports a history of shoulder dislocation and chronic sleep issues due to PTSD from past trauma, including military service. The patient is currently taking Tylenol and Celebrex for pain management and has been prescribed Zafaclone and Seroquel for sleep, but expresses dissatisfaction with the current sleep medication regimen.

Objective

The patient has been advised by a physiotherapist regarding a leg length discrepancy. The patient is currently on Tylenol and Celebrex for pain management. The patient reports dissatisfaction with the current sleep medication regimen and has been offered melatonin for sleep.

Assessment

  1. Knee sprain, possibly involving the medial collateral ligament or meniscus.
  2. Leg length discrepancy due to past injury.
  3. Chronic sleep disturbances related to PTSD.
  4. History of shoulder dislocation.

Plan

  1. Increase Celebrex dosage to twice daily for 14 days, then reduce to 100 mg daily.
  2. Refer the patient to a physiotherapist for further evaluation and management of the knee sprain.
  3. Advise the patient to avoid activities that involve turning or jarring movements, such as basketball.
  4. Prescribe melatonin for sleep management.
  5. Consider referral to a specialist for further evaluation of sleep disturbances related to PTSD.
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