Current Condition/Complaint:
- Right shoulder pain and limited range of motion.
- Onset 15 October 2024.
- Patient reports pain started after lifting a heavy box at work.
- No prior therapy or surgery.
- Pain has gradually worsened over the past two weeks.
Social History:
- Works as a warehouse operative, physically demanding job.
- Exercises 3 times per week.
Medical History:
- No known medical conditions.
- No previous surgeries.
- No known allergies.
- Medications: None.
- Non-smoker, drinks alcohol occasionally.
- Family history of osteoarthritis.
Patient Goals:
- Short-term: Reduce pain and improve shoulder range of motion within 4 weeks.
- Long-term: Return to full work duties without pain within 3 months.
Subjective:
- Patient reports a sharp pain in the right shoulder, radiating down the arm. Pain is worse with overhead activities and at night. Reports a pain score of 7/10.
- Patient is able to perform activities of daily living with some difficulty.
- No prior treatment.
- No information from family or caregivers.
Objective:
- Observation: Patient guarding right shoulder.
- Range of motion: Limited shoulder flexion, abduction, and internal rotation. Painful arc noted.
- Strength testing: Weakness in shoulder abduction and external rotation.
Assessment:
- Right shoulder impingement syndrome.
- Prioritized problems: Pain, limited range of motion, weakness.
- No progress towards stated goals at this time.
- Plan will be modified if no improvement is seen in 2 weeks.
Treatment:
- Manual Therapy: Soft tissue mobilisation to the shoulder muscles.
- Exercise Therapy: Range of motion exercises, strengthening exercises (rotator cuff).
- In clinic: Ultrasound therapy.
- Home exercise programme: Patient instructed on home exercises.
- Education strategies for the patient: Advice on activity modification.
Plan:
- Treatment plan: 2 sessions per week for 4 weeks, including manual therapy, exercise therapy, and ultrasound. Re-assessment in 2 weeks.
- Anticipated goals: Reduction in pain, improved range of motion, and improved strength.
- No referrals needed.
Current Condition/Complaint:
- [Primary injury, problem, or complaint] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Date of onset or surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Description of how the injury occurred or complaint began] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Details of any prior therapy, interventions, and/or surgery] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Progression of complaint and nature of symptoms, if applicable] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Social History:
- [Employment status, physical demands of job, work-related activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [General exercise and activity levels] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Medical History:
- [List of medical conditions] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Previous surgeries/treatments] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Allergies] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Medications] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Relevant social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Family medical history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Patient Goals:
- [Short-term physiotherapy goals & time frame for achieving these goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Long-term physiotherapy goals & time frame for achieving these goals] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Subjective:
- [Detailed narrative of the patient's self-report of their current status, symptoms, reason for visit etc] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Patient's activity level, disability, social history] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Goals and prior response to treatment intervention (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Information from family or caregivers (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Objective:
- [Physical examination details] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Observations, tests, and measurements by the therapist] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Specific measurements and assessment findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Assessment:
- [Therapist's professional opinion based on subjective and objective findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Prioritized problems list] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Progress towards stated goals (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Factors affecting progress and any need for modification in the plan (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Treatment:
- [Manual Therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Exercise Therapy] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [In clinic] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Home exercise programme] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Education strategies for the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
Plan:
- [Detailed treatment plan including interventions, frequency, and duration] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Anticipated goals and expected outcomes (if applicable)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
- [Referrals to other professionals (only if needed)] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note; otherwise omit completely.)
(For each section, only include if explicitly mentioned in transcript or context, else 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.)
