Subjective:
SHx:
* Works as a software engineer, desk-based job.
* Enjoys hiking and cycling on weekends.
HOPC:
* Fell while hiking 2 weeks ago, landing on outstretched hand.
* Immediate pain and swelling in wrist.
* Saw GP who suspected sprain.
* Pain has gradually improved but still limits activities.
Severity:
* Worst symptom severity: 7/10 during activity.
* Average symptom severity: 3/10 at rest.
Irritability:
* Symptoms persist for up to 30 minutes after aggravating activity.
Nature:
* Pain is described as a dull ache with occasional sharp twinges.
* Pain is located in the dorsal aspect of the left wrist.
Neuro/Red Flags:
* No reported neurological symptoms.
Improving:
* Condition is slowly improving.
PRx:
* Rest, ice, and over-the-counter pain medication.
Aggs:
* Wrist extension, gripping, and weight-bearing activities.
Activity Limitations:
* Unable to do push-ups.
* Difficulty typing for extended periods.
Eases:
* Rest, ice, and elevation.
24/24:
* Pain is worst in the morning and after activity.
* Pain is minimal at night.
Meds:
* Ibuprofen as needed.
PMHx:
* No relevant past injuries.
Exercise:
* Has access to a gym and some basic equipment at home.
* Has prior experience with strength training.
Expectations:
* Patient expects to regain full wrist function.
Goals:
* Return to hiking and cycling without pain.
* Be able to type comfortably for work.
Objective:
Observation:
* Mild swelling over the dorsal aspect of the left wrist.
* No bruising or redness.
* No obvious asymmetry.
Palpation:
* Tenderness to palpation over the scaphoid and distal radius.
* No significant tightness noted.
* Pain reproduced with palpation of the scaphoid.
Functional Tests:
* Gait: Normal.
* Hopping: Pain-free.
* Squatting: Pain-free.
AROM:
* Wrist flexion: 0-60 degrees, pain at end range (P1).
* Wrist extension: 0-45 degrees, pain at end range (P1).
* Radial deviation: 0-20 degrees, pain at end range (P1).
* Ulnar deviation: 0-30 degrees, pain at end range (P1).
PROM:
* Wrist flexion: 0-70 degrees.
* Wrist extension: 0-50 degrees.
* Radial deviation: 0-25 degrees.
* Ulnar deviation: 0-35 degrees.
Strength/Capacity:
* Grip strength: 20 kg (left), 30 kg (right), LSI = 67%, pain score 4/10.
Neuro:
* SLR: Negative.
* Slump: Negative.
* ULTT: Negative.
Special Tests:
* Scaphoid shift test: Positive, pain and clunk.
Action:
Treatment:
* Wrist mobilisations to improve joint mobility.
* Soft tissue massage to forearm muscles.
* Taping to provide support and reduce pain. // Reassessment: Pain reduced to 2/10.
Education:
* Importance of activity modification.
* Instructions on home exercises.
* Explanation of injury and healing process.
Exercise Program:
* Wrist flexion/extension with light resistance: 3 sets of 10 reps.
* Grip strengthening with a stress ball: 3 sets of 10 reps.
Plan:
Planned progression of activity or load:
* Gradual increase in activity levels as tolerated.
Next physiotherapy session and focus:
* Review progress and adjust treatment plan.
* Progress exercises.
Short-term goals:
* Reduce pain to 0-2/10 at rest.
* Improve wrist range of motion.
Long-term goals:
* Return to full function.
* Return to hiking and cycling.
Patient-Friendly Summary:
Today, we discussed your wrist injury and performed a thorough assessment. We found some tenderness and limited movement, but overall, things are improving. We did some hands-on treatment to help with your pain and movement. For the next session, we'll check how you're doing and adjust your exercises. Keep up with your home exercises, and we'll gradually increase your activity levels. We'll work towards getting you back to your hobbies and work without pain.
Subjective:
SHx:
[work, hobbies, interests] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
HOPC:
[history of current complaint including mechanism of injury, date of injury, clinical course since, and progression leading up to appointment] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Severity:
[worst symptom severity] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[average symptom severity] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Irritability:
[duration symptoms persist after aggravating activity] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Nature:
[description of pain quality e.g. achy, throbbing, sharp, tight] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
[location of symptoms, as precise as possible] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Neuro/Red Flags:
[neurological or systemic red flag symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Improving:
[current trend of condition e.g. improving, worsening, stable] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
PRx:
[treatments or strategies already trialled, including other providers or self-management] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Aggs:
[activities/incidents that provoke symptoms, described specifically] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Activity Limitations:
[activities patient feels unable to do due to condition] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Eases:
[factors or strategies that reduce severity or duration of symptoms] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
24/24:
[symptom behaviour over 24 hours including morning/night patterns] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Meds:
[current medications relevant or not relevant to current complaint] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
PMHx:
[relevant past injuries or conditions] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Exercise:
[gym access, equipment available, prior experience] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Expectations:
[patient expectations of physiotherapy] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Goals:
[patient goals for recovery and function] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Objective:
Observation:
[visual findings such as swelling, bruising, redness, asymmetry] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Palpation:
[tenderness, tightness, reproduction of pain] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Functional Tests:
[performance of functional movements including gait, hopping, squatting, with qualitative or quantitative measures] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
AROM:
[active range of motion including joint, side, movement, range, and symptoms with P1/P2 notation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
PROM:
[passive range of motion findings for relevant joints] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Strength/Capacity:
[strength or capacity test results including movement, side, values, LSI, pain scores, and technique comments if provided] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Neuro:
[nerve tension test results such as SLR, slump, ULTT] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Special Tests:
[specific joint or condition tests with side and result, including pain if stated] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Action:
Treatment:
[manual therapy, massage, dry needling, taping including treated region and post-treatment reassessment using // notation] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Education:
[clinically important education topics affecting diagnosis, prognosis, symptom management, return to sport, or exercise progression] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write 2–3 bullet points only.)
Exercise Program:
[prescribed or progressed exercises with sets x reps and purpose if not obvious] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Plan:
Planned progression of activity or load:
[planned progression] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Next physiotherapy session and focus:
[focus for next session] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Short-term goals:
[short-term goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Long-term goals:
[long-term goals] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write as bullet points.)
Patient-Friendly Summary:
[summary for patient including injury timelines, what was done today and why, next session focus, long-term progressions, and what they should do in the meantime. Write in professional but relaxed style mirroring transcript language] (Only include if explicitly mentioned in transcript or context, else omit section entirely. Write in short paragraphs.)
(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 include 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.)
