Subjective Assessment:
Patient presents today with a 2-week history of neck pain following a car accident. The mechanism of injury was a whiplash-type movement. The patient reports that the pain is gradually improving with treatment. The pain is described as a dull ache in the neck, radiating to the left shoulder.
Aggravated by: Prolonged sitting, looking at a computer screen, and driving.
Eased by: Rest, heat, and gentle stretching.
Mandatory questions:
Night/Constant/Bilateral Pain/Weight Loss: No night pain, constant pain, bilateral pain, or weight loss reported.
Dizziness/Vertigo/Drop attacks/Nausea: No dizziness, vertigo, drop attacks, or nausea reported.
Dysphasia/Dysarthria/Swallow/Oro-facial: No dysphasia, dysarthria, swallowing difficulties, or oro-facial symptoms reported.
Vision/Diplopia/Nystagmus: No vision changes, diplopia, or nystagmus reported.
Increased sweating/Night sweats: No increased sweating or night sweats reported.
Power loss/Numbness/Pins & needles: Occasional numbness and pins and needles in the left arm.
Headaches/Migraine: Occasional headaches.
Prolonged steroids/Osteoporosis: No prolonged steroid use or osteoporosis reported.
Anti-coagulants: Not taking anti-coagulants.
Sleep Disturbance: Difficulty sleeping due to pain.
Cough/Sneeze: No cough or sneeze.
Metal Implants: No metal implants.
Relevant Medical History:
Patient has a history of mild asthma, well-controlled with an inhaler.
VAS:
VAS score of 4/10.
Scan/X-rays:
X-rays of the cervical spine were taken and showed no fractures or dislocations.
PMH:
See Relevant Medical History.
Patient valued outcomes (PVOs):
Patient wants to return to work and be able to drive without pain.
Objective Assessment:
VBA: Negative.
Spurlings: Positive on the left.
Posture: Forward head posture.
Neck Movements: Reduced range of motion in all directions, especially rotation to the left.
Neck Palpation: Tenderness to palpation in the left trapezius and levator scapulae muscles.
Thoracic Movements: Within normal limits.
Thoracic Palpation: No tenderness.
Shoulders: No pain on shoulder movements.
Neural: Upper limb tension test positive on the left.
Sensory: Decreased sensation to light touch in the left C6 dermatome.
Motor: Strength is 5/5 in all myotomes.
Other: No other findings.
Impression:
Cervical sprain/strain with associated myofascial pain.
Plan:
Continue with physiotherapy treatment, including manual therapy, exercises, and education. Review in one week.
Treatment:
Manual therapy to the cervical spine and upper thoracic spine. Soft tissue massage to the left trapezius and levator scapulae. Provided education on posture and ergonomics.
HEP (Home Exercise Programme):
Cervical range of motion exercises, postural correction exercises, and scapular stabilisation exercises.
Advice:
Advised to avoid prolonged sitting and to take regular breaks. Provided advice on posture and ergonomics. Encouraged to continue with home exercises.
Next Day:
Continue with current treatment plan.
Subjective Assessment:
[Include how the patient is presenting today, the mechanism of injury, how their treatment is progressing, and timeline of injury] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Aggravated by: [Describe aggravating factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Eased by: [Describe easing factors] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Mandatory questions:
Night/Constant/Bilateral Pain/Weight Loss: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Dizziness/Vertigo/Drop attacks/Nausea: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Dysphasia/Dysarthria/Swallow/Oro-facial: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Vision/Diplopia/Nystagmus: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Increased sweating/Night sweats: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Power loss/Numbness/Pins & needles: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Headaches/Migraine: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Prolonged steroids/Osteoporosis: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Anti-coagulants: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Sleep Disturbance: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Cough/Sneeze: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Metal Implants: [Record findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Relevant Medical History:
[Describe relevant medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
VAS:
[Record VAS score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Scan/X-rays:
[Describe scans/X-rays and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
PMH:
[Describe past medical history] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Patient valued outcomes (PVOs):
[Describe patient’s goals for physiotherapy] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Objective Assessment:
VBA: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Spurlings: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Posture: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Neck Movements: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Neck Palpation: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Thoracic Movements: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Thoracic Palpation: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Shoulders: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Neural: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Sensory: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Motor: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Other: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Impression:
[Describe clinical impression] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
[Describe management plan] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Treatment:
[Describe treatment provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
HEP (Home Exercise Programme):
[Describe prescribed home exercise programme] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Advice:
[Describe advice given to patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Next Day:
[Describe plan for next day] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit section entirely. Never come up with your own patient details, assessment, plan, interventions, evaluation, or next steps—use only the transcript, contextual notes, or clinical note as reference for all information. If any information related to a placeholder has not been explicitly mentioned, do not state that in the output; simply leave the relevant placeholder or section out entirely. Use as many lines, paragraphs, or bullet points as needed to capture all relevant information from the transcript.)
