Indication:
[describe the reason for the ultrasound, including symptoms such as pain, restricted movement, history of trauma, suspected rotator cuff tear, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Side:
[specify whether the ultrasound was performed on the left or right shoulder] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Findings
1. Biceps Tendon
Location:
[describe the location of the biceps tendon, such as in groove, subluxated, dislocated] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Appearance:
[describe the appearance of the biceps tendon, such as normal echotexture, tendinosis, partial or full-thickness tear] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
2. Subscapularis Tendon
Appearance:
[describe the appearance of the subscapularis tendon, such as normal, tendinosis, partial or full-thickness tear] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
3. Supraspinatus Tendon
Appearance:
[describe the appearance of the supraspinatus tendon, such as normal, tendinosis, partial or full-thickness tear] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
4. Infraspinatus and Teres Minor Tendons
Appearance:
[describe the appearance of the infraspinatus and teres minor tendons, such as normal, tendinosis, partial or full-thickness tear] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
5. Acromioclavicular (AC) Joint
Joint Space:
[describe the joint space of the AC joint, such as normal, widened, narrowed] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Joint Degeneration:
[describe the joint degeneration of the AC joint, such as normal, mild, moderate, severe] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Other Findings:
[describe any other findings in the AC joint, such as fluid collection, osteophytes] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
6. Subacromial-Subdeltoid (SASD) Bursa
Fluid Collection:
[describe the fluid collection in the SASD bursa, such as absent, mild, moderate, severe distension] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
7. Glenohumeral Joint
Joint Effusion:
[describe the joint effusion in the glenohumeral joint, such as absent, mild, moderate, severe] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Other Findings:
[describe any other findings in the glenohumeral joint, such as synovitis, labral abnormalities] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Additional Findings:
[describe any additional findings, such as calcifications, loose bodies, cysts, any other incidental findings] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Impression
Overall Summary:
[provide an overall summary of the findings, such as findings consistent with rotator cuff tendinosis, evidence of full-thickness tear of the supraspinatus, mild bursitis, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Suggested Follow-up or Recommendations:
[provide any suggested follow-up or recommendations, such as MRI, orthopedic referral, repeat ultrasound in 6-8 weeks, etc.] (Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
(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 included 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.)
