Physiotherapist-Vorlage
Physio Initial MSK outpatient
Eine professionelle Physiotherapist-Vorlage für medizinisches Fachpersonal.
Über diese Vorlage
This 'Physio Initial MSK outpatient' template is designed for physiotherapists working in private practice clinics. It provides a structured format for documenting the initial assessment of patients with musculoskeletal (MSK) conditions. The template includes sections for history of presenting condition, radiology findings, past medical and social history, goals, objective findings, treatment provided, assessment, and plan. This template ensures comprehensive documentation, aiding in effective patient management and continuity of care. Ideal for capturing detailed patient information, it supports physiotherapists in delivering targeted and efficient treatment plans.
Vorlagenvorschau
HOPC
- Patient presents with a 3-week history of right shoulder pain following a fall while playing tennis.
- Pain is aggravated by overhead activities and eased with rest and ice application.
- Pain is described as sharp during movement and dull at rest, with intensity varying throughout the day.
Radiology:
- MRI of the right shoulder shows a partial tear of the supraspinatus tendon.
Past Medical History
- Hypertension, managed with Amlodipine 5mg QD.
- No known allergies.
Social History
- Patient is a non-smoker and consumes alcohol occasionally.
- Lives with spouse and has a supportive family network.
- Works as an accountant, involving prolonged sitting and occasional lifting of heavy files.
Goals
- Short-term: Reduce pain and improve range of motion within 4 weeks.
- Long-term: Return to playing tennis without pain within 3 months.
Objective
- Active Range of Motion (AROM): Right shoulder flexion 0-120 degrees, abduction 0-90 degrees, external rotation 0-45 degrees.
- Strength: 4/5 in right shoulder abduction and external rotation.
- Palpation: Tenderness over the supraspinatus tendon.
Treatment
- Education: Discussed pain management strategies and importance of adherence to home exercise program.
- Hands-on: Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper R) shoulder.
- Active therapy: 3x10 Single leg calf raises, 3x10 R) shoulder external rotations with resistance band.
- Home Exercise Program (HEP): 3x10 R) shoulder pendulum exercises, 3x10 R) shoulder wall slides, to be done daily.
Assessment
- Diagnosis: Partial tear of the supraspinatus tendon with associated inflammation.
- Differential Diagnosis: Rotator cuff tendinopathy.
- Progress: Patient has shown slight improvement in pain levels and range of motion.
- Barriers: Patient's work schedule limits time for exercises.
Plan:
- Continue current treatment plan with emphasis on strengthening and range of motion exercises.
- Review in 2 weeks.
- Likely therapy: Progress to more advanced strengthening exercises.
- Referral: None required at this stage.
- Communication: Will send a progress report to the patient's GP before the next session.
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