Workflow: Summarising a Complex Orthopaedic Case History

Complex orthopaedic cases — revision joint replacement, persistent post-operative pain, failed previous surgery, multi-level spinal pathology — accumulate years of clinic letters, operative notes, imaging reports, and physiotherapy records. Reading through all of it before a complex review takes time you rarely have. This workflow uses an AI tool to produce a structured clinical summary from anonymised key facts.

1. Read the case notes yourself first

   Before you give the tool anything to work with, read the key documents yourself. You need to understand the clinical narrative: what happened, in what order, what was tried, what worked, and what the current clinical question is. The tool can only organise the information you provide — it cannot determine what is clinically important without your direction.

2. Write an anonymised chronological summary of the key facts

   On a blank document, write the key facts in chronological order: the original presentation, the diagnoses made, the treatments undertaken, the surgical history, the investigations, the current symptoms, and the clinical question. Remove all identifying information. Use age range rather than exact age. This becomes your source material.

3. Open the tool and specify the output format

   Open your AI tool and type: "I am an orthopaedic surgeon preparing a structured case summary. I will give you anonymised clinical bullet points in chronological order. Organise them into a structured summary with these headings: Initial Presentation, Diagnosis, Surgical History, Investigations, Current Status, Clinical Question. Do not add any clinical information I have not provided. Do not include clinical recommendations."

4. Provide your anonymised bullet points

   Paste your chronological notes. The tool will produce a structured summary. Read it carefully against your original source material.

5. Check the chronology is accurate

   Complex cases with multiple prior surgeries or long histories are exactly the cases where chronological errors matter most. A case summary that implies a revision was performed before the primary operation, or that a complication occurred at a different surgical stage, will mislead the clinician reading it. Check every event in the correct sequence.

6. Sharpen the clinical question

   The "Clinical Question" section of the summary is often the most useful for an MDT discussion or second opinion. If the tool's version of your clinical question is too vague — "what is the best management?" — ask it to help you phrase it more specifically: "Rewrite the clinical question as a specific, focused question based on the case summary. Offer two or three formulations and I will choose the most accurate one." Pick the version that most precisely captures what you need.

7. Ask for a one-paragraph oral summary

   If you are presenting this case verbally — at an MDT, a complex case review, or a second opinion consultation — ask the tool: "Write a two- to three-sentence oral summary of this case that I could read aloud at the start of a presentation. Include only the most essential facts." Read it aloud. Adjust any sentence that is harder to say than it looks on the page.

8. Use the summary as a preparation tool, not a clinical record

   The AI-generated summary is for your preparation. Do not paste it into the patient record, submit it as a formal referral document, or use it as a substitute for the original clinical notes. It is a structured overview to help you think clearly before a complex clinical conversation.

What this means for you

A well-structured case summary allows a second-opinion consultant, an MDT, or a complex case review panel to engage with the clinical question immediately — rather than spending twenty minutes reconstructing the history from a pile of letters. The tool compresses the structural work. Your clinical expertise guides what goes into it and what the summary means.

When not to use this workflow

For straightforward post-operative reviews where the clinical picture is simple, this level of preparation is not needed. This workflow is for genuinely complex cases — multiple prior surgeries, diagnostic uncertainty, persistent symptoms despite treatment, or cases being referred for second opinion — where the volume and complexity of the clinical history is itself the challenge.

Remember: AI is a helpful assistant, not a clinician. You make the call.