RE: Ms. Jane Smith, DOB: 12/03/1980
Provisional diagnosis:
Right shoulder impingement syndrome, secondary to repetitive overhead movements at work. Contributing factors include poor posture and muscle imbalances. The diagnosis is based on the patient's reported symptoms, physical examination findings (positive Neer's and Hawkins-Kennedy tests), and the exclusion of other potential causes.
PLAN
The therapeutic plan involves a multimodal approach, including manual therapy, therapeutic exercises, and patient education to reduce pain, restore range of motion, and improve shoulder function.
Recommended number of sessions:
6-8 sessions over a period of 4-6 weeks.
Treatment will consist of:
* Patient education regarding activity modification and posture correction.
* Soft tissue release techniques to the pectoralis major, minor, and upper trapezius muscles.
* Joint mobilisations to the glenohumeral and scapulothoracic joints.
* Deep tissue dry needling to the rotator cuff muscles.
A home exercise program has been provided.
The home exercise program includes stretching exercises for the shoulder and upper back muscles, strengthening exercises for the rotator cuff and scapular stabilisers, and postural correction exercises.
Possible additional exercise classes:
Consideration of clinical reformer Pilates classes to improve core stability and shoulder girdle control.
Further investigations required ?
No further investigations are required at this time.
If you have any further questions or concerns please do not hesitate to contact me on 01234 567890
Sincerely,
Dr. Emily Carter
Physiotherapist.
RE: [client's title, first name, last name, and date of birth] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Provisional diagnosis:
[detailed description of the provisional diagnosis, including contributing factors and the reasoning behind the diagnosis] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
PLAN
[overall therapeutic plan or approach] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Recommended number of sessions:
[recommended number of sessions and the duration over which they will occur] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Treatment will consist of:
[details of advice and education provided] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[details of soft tissue release techniques used or planned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[details of joint mobilisations techniques used or planned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[details of deep tissue dry needling techniques used or planned] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
A home exercise program has been provided.
[specific details or components of the home exercise program provided to the client] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Possible additional exercise classes:
[information regarding the recommendation or consideration of hydrotherapy classes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[information regarding the recommendation or consideration of clinical reformer Pilates classes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
[information regarding the recommendation or consideration of gym based rehabilitation classes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Further investigations required ?
[indication if further investigations are required, and if so, what type of investigations are needed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
If you have any further questions or concerns please do not hesitate to contact me on [Insert contact number]
Sincerely,
[name and professional title of the primary provider] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Physiotherapist.
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or omit the placeholder completely.) (Use as many lines, paragraphs or bullet points, depending on the format, as needed to capture all the relevant information from the transcript.)