New Patient - Letter [Orthopaedic Surgeon]

Diagnosis: - Right shoulder rotator cuff tear Plan: - Advised on conservative management including physiotherapy and activity modification - Discussed the option of corticosteroid injection - Scheduled a follow-up appointment in 6 weeks Thank you for referring John Smith who I reviewed today. John is a 55 year old accountant male who presents with right shoulder pain. He reports the onset of pain approximately 3 months ago, following a fall. The pain is described as a sharp ache, exacerbated by overhead activities and at night. He denies any specific injury. The pain is rated as 7/10 on the visual analogue scale. He has tried over-the-counter analgesics with minimal relief. He reports significant functional limitations, including difficulty reaching overhead and sleeping. He has not tried physiotherapy. John is a non-smoker and drinks alcohol socially. He lives at home with his wife and is independent with all activities of daily living. He has no significant past medical or surgical history. He takes no regular medications and has no known allergies. Physical examination revealed tenderness to palpation over the supraspinatus tendon. Active range of motion was limited in abduction and external rotation. Strength testing revealed weakness in external rotation. The Neer's and Hawkins tests were positive. An MRI scan of the right shoulder was performed in October/2024 at the local imaging centre, which confirmed a full-thickness tear of the supraspinatus tendon. I discussed the diagnosis of a rotator cuff tear with John, explaining the findings of the MRI scan. We discussed both conservative and surgical treatment options. I provided information on physiotherapy and activity modification. I also discussed the option of a corticosteroid injection. We discussed the risks and benefits of each option. John was provided with patient resources on rotator cuff tears. He expressed concerns about the impact of his shoulder pain on his work, which I addressed. Thank you for your ongoing care of John Smith. Please feel free to get in touch if you have any questions or require further information regarding the management plan. Yours Sincerely,