SAW Initial template

Summary of injury and treatment Patient sustained a right shoulder rotator cuff tear on 15 October 2024 during a fall at work. Underwent arthroscopic repair on 20 October 2024. Currently in a sling and participating in physiotherapy. Current functional tolerances Patient is currently unable to lift more than 5 pounds with the right arm. Limited range of motion in the right shoulder. Able to perform light activities of daily living with modifications. Upcoming medical appointments Follow-up appointment with Dr. Smith on 15 November 2024. Physiotherapy sessions twice a week. Current medical certificate Patient is currently signed off work until 1 December 2024. Restrictions include no lifting, pushing, or pulling with the right arm. Pre-injury role title Warehouse worker. Normal working hours/days Monday to Friday, 8:00 AM to 4:00 PM. Work tasks Loading and unloading trucks, moving packages, operating a forklift. Physical requirements of tasks Frequent lifting of up to 50 pounds, repetitive arm movements, prolonged standing. Suitable work tasks for gradual return to work Light administrative duties, such as data entry and phone calls. Modified tasks involving minimal use of the right arm. Employer concerns and support of programme, barriers or opportunities Employer is supportive of a gradual return to work. They are willing to provide modified duties and workplace accommodations. No barriers identified at this time. Medications: * Ibuprofen 400mg, as needed for pain * Paracetamol 500mg, as needed for pain Allergies: * No known drug allergies. Review of systems: * Musculoskeletal: Right shoulder pain, stiffness, and limited range of motion. Physical examination findings: * Vitals: BP 120/80, HR 72, RR 16, Temp 37°C * Right shoulder: Swelling and bruising present. Limited active and passive range of motion. Pain on palpation. Assessment and differential diagnosis: * Right shoulder rotator cuff tear, post-operative. Plan of care: * Continue physiotherapy twice a week. * Home exercise program as prescribed by physiotherapist. * Follow-up with Dr. Smith on 15 November 2024. * Occupational therapy to assess functional capacity and facilitate a safe return to work. * Review of work duties and potential modifications. * Date: 1 November 2024