Subjective:
VAS: 6/10
Aggravated by: Reaching overhead and sleeping on the right side.
Eased by: Rest and ice.
Social Hx: Patient is a builder and works full time.
Mandatory Questions:
Night/Constant/Bilateral Pain/Weight Loss: No night pain, no constant pain, unilateral pain, no weight loss.
Dizziness/Vertigo/Drop attacks/Nausea: Denies.
Dysphasia/Dysarthria/Swallow/Oro-facial: Denies.
Vision/Diplopia/Nystagmus: Denies.
Increased sweating/Night sweats: Denies.
Power loss/Numbness/Pins & needles: Reports some numbness in the hand.
Headaches/Migraine: Denies.
Prolonged steroids/Osteoporosis: Denies.
Anti-coagulants: Denies.
Sleep disturbance: Reports difficulty sleeping due to pain.
Cough/Sneeze: Denies.
Metal Implants: Denies.
Scans/X-rays:
X-rays taken 2 weeks ago showed mild AC joint arthrosis.
Past Medical History/Previous Injury:
No previous shoulder injuries. Patient had a fractured wrist 5 years ago.
Patient Valued Outcome:
Patient wants to return to work without pain.
Objective Assessment:
Posture: Forward head posture, rounded shoulders.
Movements: Painful active and passive range of motion in abduction and external rotation.
Impingement Tests: Positive Neer's and Hawkins-Kennedy tests.
Capsular Tests: Limited external rotation.
Scapular Control: Scapular dyskinesis noted.
AC Joint Tests: Positive AC joint compression test.
1st Rib: Negative.
SC Joint: Negative.
Palpation: Tenderness over the supraspinatus tendon and AC joint.
Neck: No referred pain from the neck.
ULTTs: Negative.
Thoracic: No thoracic involvement.
Elbow: No elbow involvement.
Other: No other findings.
IMPRESSION:
Right shoulder impingement syndrome with AC joint arthrosis.
PLAN:
Advise on activity modification, ice, and pain relief. Commence with shoulder rehabilitation exercises.
TREATMENT:
Soft tissue massage to the shoulder muscles. Shoulder mobilisations. Education on posture.
Home Exercise Programme:
Pendulum exercises, scapular retractions, and external rotation exercises.
Advice given:
Advised on activity modification, ice application, and posture correction.
Plan for Next Day:
Review patient's progress and adjust the treatment plan as needed. Provide further education on home exercises.
Subjective:
VAS: [Describe patient’s VAS score] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Aggravated by: [Describe factors that aggravate symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Eased by: [Describe factors that ease symptoms] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Social Hx: [Describe relevant social history] (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.)
Scans/X-rays:
[Describe relevant scans/X-rays and findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Past Medical History/Previous Injury:
[Describe relevant past medical history and injuries] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Patient Valued Outcome:
[Describe patient’s valued outcome] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Objective Assessment:
Posture: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Movements: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Impingement Tests: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Capsular Tests: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Scapular Control: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
AC Joint Tests: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
1st Rib: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
SC Joint: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Palpation: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Neck: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
ULTTs: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Thoracic: [Describe findings] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Elbow: [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 treatments provided] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Home Exercise Programme:
[Describe prescribed home exercise programme] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Advice given:
[Describe advice provided to the patient] (Only include if explicitly mentioned in transcript, contextual notes or clinical note; otherwise omit completely.)
Plan for Next Day:
[Describe planned actions 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.)
