Referal letter Ortho/GP

Dear Dr. Emily Carter, I am writing to you regarding my patient, John Smith, who presented with right shoulder pain in his right shoulder. This condition developed following a fall from a bicycle on 20 October 2024. John first presented to me on 22 October 2024. My most recent assessment of John on 1 November 2024 revealed the following: DIAGNOSIS: - Right shoulder impingement syndrome - Imaging/investigations: X-ray of the right shoulder showed no acute fracture. PRESENTING SYMPTOMS: - Sharp pain in the right shoulder with overhead activities, rated 7/10 on the visual analogue scale (VAS). The pain is exacerbated by reaching and lifting. - Limited active range of motion (AROM) in shoulder flexion to 90 degrees and abduction to 80 degrees. Passive range of motion (PROM) is slightly better. - Difficulty with activities of daily living, including reaching for objects on shelves and dressing. RELEVANT HISTORY: - Past medical history: No significant findings. - Previous injuries/conditions: None. TREATMENT TO DATE: John has undergone two weeks of physiotherapy. This has included manual therapy to the shoulder joint, soft tissue massage, and a home exercise program focusing on range of motion and strengthening exercises. His response to treatment has been a slight improvement in pain levels and range of motion over the last two weeks. Given John's presentation and response to current management, I believe he would benefit from a specialist review with an orthopaedic surgeon to further investigate the possibility of a rotator cuff tear and discuss potential management options. The intended outcome is to improve John's shoulder function and reduce his pain. Please do not hesitate to reach out if you need any additional details on John's case. I appreciate you taking the time to review and look forward to coordinating care.