Progress Note

(You are a senior physiotherapist working in a private practice clinic. You are driven towards helping your patient's achieve their goals) History of Present Condition Mr. John Smith, a 45-year-old male, presents today with complaints of right shoulder pain and limited range of motion. The pain began approximately six weeks ago following a fall while playing football. He reports a sharp, localised pain in the shoulder that worsens with overhead activities and at night. The pain has gradually worsened over the past few weeks, and he now experiences difficulty reaching for objects on high shelves and sleeping comfortably. Mr. Smith reports his activity level has decreased significantly due to the pain, and he has had to modify his work duties as a result. He has not sought any prior treatment for this injury. His goal is to return to playing football and be able to lift his children without pain. Objective: Postural observations in static positions: * Forward head posture noted. * Rounded shoulders observed. Range of motion testing: * Right shoulder flexion: 90 degrees (normal 180 degrees). * Right shoulder abduction: 80 degrees (normal 180 degrees). * Right shoulder external rotation: 20 degrees (normal 60 degrees). Strength Testing: * Right shoulder abduction: 3/5 (moderate weakness). * Right shoulder external rotation: 3/5 (moderate weakness). Observations, tests, and measurements by the therapist: * Positive Hawkins-Kennedy test. * Positive Neer's test. * Palpation reveals tenderness over the supraspinatus tendon. Specific measurements and assessment findings: * VAS pain scale: 7/10 at rest. Assessment: Based on the subjective and objective findings, Mr. Smith is diagnosed with right shoulder impingement syndrome. His limited range of motion and weakness are consistent with this diagnosis. The patient has demonstrated a good response to the initial treatment session. The plan will be modified to include more aggressive stretching and strengthening exercises. The patient was educated on proper posture and activity modification to avoid aggravating the symptoms. The patient will continue to benefit from skilled physical therapy to address aforementioned impairments and limitations to return to their activities of choice. Charges & Exercises Performed: * Manual therapy to the right shoulder (30 minutes). * Therapeutic exercises including range of motion and strengthening exercises (30 minutes). * Frequency: 2 times per week for 4 weeks. * Duration: 60 minutes per session. Pt educated/counseled on: * Proper posture. * Activity modification. * Home exercise program.