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SAMPLE REPORTProperty of AugMend Health · illustrative output, not a real patient encounter

John P.

Initial Assessment · Sessions 2A & 3A
Wednesday, August 27, 2025 · Awaiting sign-off

Rapid review

  • 68-year-old employed male with bilateral knee osteoarthritis (R > L) and right-knee instability on stair descent1; pain 2–3/10 baseline rising to 7–8/10 at worst2, sharp and stabbing3, intermittent and progressively worsening over years4.
  • Active fall-risk concern on stair descent with load-carrying — patient explicitly endorses the knee “may give out”5; pattern is progressive, not acute. Lifestyle modification refused on principle6.
  • Sleep insufficiency (~6 h/night) attributed to frequent work travel, not pain7; no psychiatric risk indicators: PHQ-8 0% (5), AUDIT-C low-moderate (4/12, 33%), DAST-10 1/10, no suicidal/homicidal ideation8.
  • Strong protective profile: dense social network (wife, sister, multiple long-term friends), life-satisfaction 9–10/10, intact treatment understanding, ibuprofen 600 mg providing partial relief9.
  • Patient expresses a clinically actionable value-action tension: he understands the risk, prefers maintaining lifestyle over modification, and asks for help managing pain without giving up valued activities10.
Source evidence
Assistant
What's been most concerning to you about your knee over these past months?
Patient
“I'm concerned that one of my, my knee, particularly my right knee may give out... it's been steadily getting worse — I'm worried I'll be heading downstairs carrying something and it just gives.”
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Risk assessment

T1 Low — Functional Safety · Monitor
Primary indicator
Fall risk on stair descent with progressive right-knee instability under load-carrying5
Contributing
Sleep insufficiency (~6 h/night) reducing physiologic reserve7; lifestyle-modification resistance6
Psychiatric
No suicidal or homicidal ideation; no pain catastrophizing (PCS 0%); no severe anxiety (GAD-7 10%)8
Protective
Dense social network · life-satisfaction 9–10/10 · active coping & positive reframing9 · medication adherence and treatment understanding intact
Patient denies suicidal ideation, denies pain catastrophizing, and screens negative for substance misuse. T1 reflects a functional-physical risk — the right knee may give out under load — coupled with a value-action tension around lifestyle modification that warrants follow-up rather than escalation.

Summary of patient needs

  1. Orthopedic evaluation for progressive right-knee OA with fall-risk semiology (patient-acknowledged).
  2. Pain-management plan compatible with frequent work travel — escalation beyond ibuprofen 600 mg when partial relief insufficient.
  3. Shared decision-making around lifestyle modification: address the value-action tension without coercive framing.
  4. Sleep evaluation in the context of work travel; consider whether 6 h/night reflects schedule or unrecognized pathology.
  5. Continuity with patient's strong informal supports — engage spouse if/when treatment plans change.
Pain (worst)
8 / 10
VAS · narrative
Sleep
~6 h
work-travel attributed
PHQ-8
0%
no depression signal
Life-satisfaction
9–10
/10 self-report
Domain detail follows
  1. Key Information & Presenting Concern
  2. Medical History
  3. Current Medications & Allergies
  4. Mental Health & Substance Use Screening
  5. Functional Status
  6. Social Determinants & Psychosocial Context
  7. Family History
  8. Risk & Safety Screening
  9. Prior Treatment & Response
  10. Patient Goals & Readiness
  11. Review of Systems

Domain 01 Key Information & Presenting Concern 2 sessions · Aug 25, Aug 27, 2025

Patient is a 68-year-old married, employed male evaluated across two CAS sessions for bilateral knee osteoarthritis with progressive right-knee involvement and patient-reported instability under load-carrying on stair descent.

“It's been steadily getting worse — I'm concerned my right knee may give out.” Patient · Session 2A · Chief complaint5

Onset, course, and trigger to seek care

Onset
Years (described as ongoing process)11
Trajectory
Progressively worsening; intermittent with high day-to-day variability4
Trigger to present
Right-knee instability under load on stair descent with frequent business travel5
Patient framing
Attributes exacerbation to prior hip replacement on contralateral side12

Pain profile

Location
Bilateral knees; right > left13
Quality
Sharp, stabbing3
Intensity
Session 1: 2–3/10 baseline · 7–8/10 worst. Session 2: 3–4/10 baseline · one day reached 7/102
Pattern
Intermittent; high intra-day and day-to-day variability4
Aggravators
Walking · going downstairs · sit-to-stand transitions · carrying heavy loads · weather changes · prolonged inactivity14
Alleviators
Sleep · ibuprofen 600 mg · physical therapy · acetaminophen · slow initial walking after standing · ongoing activity15

Domain 02 Medical History

Active & current diagnoses

Primary
Osteoarthritis, bilateral knees · right knee more symptomatic Active
Comorbid
Obesity (patient attributes contribution to knee aggravation)16
Surgical
History of hip replacement (date / side not captured this encounter) Verify
Missing information. Onset date of OA diagnosis · indication and date for prior hip replacement · history of intra-articular knee procedures — none documented this encounter; recommend verification at first in-person follow-up.

Domain 04 Mental Health & Substance Use Screening

PHQ-8
0% (5)
Minimal · no signal
GAD-7
10% (PCL-5 4%)
Below threshold
PCS
0%
No catastrophizing
AUDIT-C
4 / 12 (33%)
Low-moderate range
DAST-10
1 / 10 (10%)
Minimal concern
Suicidality
None
Patient denies

Mood, anxiety, sleep

Patient denies depressed mood, anhedonia, hopelessness, and pain catastrophizing across both sessions. Anxiety screening below clinical threshold. Psychosocial functioning reported as notably intact: PHQ-8 0%, PCS 0%, PCL-5 4%, life-satisfaction 9–10/10, dense social support8.

Clinical note. Substance-use screening is age-appropriate and does not currently signal escalation; alcohol-pain link is patient-recognized and should be folded into shared decision-making rather than re-litigated as a behavior change campaign.

Domain 05 Functional Status

Day-to-day functioning is largely preserved with two domains showing measurable knee-pain interference (recreation and exercise). Patient continues full-time employment with frequent business travel, manages personal medication and self-care independently.

Work / income
Employed full-time; frequent travel for work; No impact from pain21
Daily activities
Minimal pain interference; ADLs preserved Minimal
Sleep
~6 h/night, attributed to work travel rather than pain22
Recreation
Moderate pain interference reported24 Moderate
Exercise
Self-modifications during prolonged sitting before loading25 Self-edits
Self-care
Independent — manages medications appropriately27

Domain 08 Risk & Safety Screening

Tier 1 · Functional safety

Low — Monitor
Trigger 1 · Fall risk
Right-knee instability during stair descent worsened by load-carrying — clinically significant fall hazard in 68-year-old5
Trigger 2 · Trajectory
Progressively worsening; patient acknowledges need for professional evaluation4
Trigger 3 · Sleep insufficiency
~6 h/night attributed to work travel — chronic partial sleep deprivation7
Absent indicators
Suicidal ideation · self-harm · psychosis · pain catastrophizing (PCS 0%) · severe anxiety · substance misuse
Risk classifications are programmatic, not clinical diagnosis. Reviewing provider may reclassify on examination.