Consultation Summary

Orthopaedic Surgeon - Consultation Summary Diagnosis Patient presents with a left rotator cuff tear, specifically involving the supraspinatus tendon, sustained during a fall onto an outstretched arm. Clinical assessment and MRI findings confirm a full-thickness tear with mild retraction. Treatment Plan / Advice * Recommend surgical repair of the rotator cuff tear. * Prescribe a short course of oral analgesics for pain management. * Advise ice application and rest for the initial post-injury period. * Discuss the importance of a structured post-operative physiotherapy rehabilitation programme. Action for GP Please continue the patient's current medication regimen. Referral for pre-operative assessments, including blood tests and ECG, will be organised by our clinic. Kindly advise the patient to maintain current activity restrictions until surgical intervention. Follow-up The patient is scheduled for a pre-operative consultation with the orthopaedic registrar in two weeks to discuss surgical details and answer any further questions. Surgical date to be confirmed following pre-operative clearance. Assessment The patient, a 55-year-old male, reported sudden onset of left shoulder pain and weakness after a fall yesterday. He describes constant dull ache, exacerbated by movement, particularly abduction and external rotation. On examination, there was tenderness over the greater tuberosity, restricted active range of motion, and positive Neer and Hawkins impingement signs. Supraspinatus strength was graded 2/5, with significant pain on resisted abduction. Neurovascular examination of the upper limb was unremarkable.