Date of Injury: 20 October 2024
Location of the injury: Right shoulder
Chief Complaint: Pain and limited range of motion in the right shoulder.
Onset: Sudden onset after lifting a heavy box.
Aggravating Factors: Lifting, reaching overhead, and sleeping on the right side.
Easing Factors: Rest, ice, and over-the-counter pain medication.
Red Flag Questions: No reported fever, numbness, or weakness.
Imagining: X-rays taken, no fractures identified.
General Health: Generally healthy, no significant medical history.
Work: Works as a warehouse operative, requires frequent lifting.
Activities: Enjoys swimming and gardening.
Medication: Ibuprofen as needed for pain.
Have they injured this previously: No previous injuries to the right shoulder.
Any previous injuries: Minor ankle sprain 5 years ago.
Goal of physiotherapy: To regain full range of motion and return to work duties without pain.
Date of Injury: [date of injury] (only include date of injury if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Location of the injury: [location of the injury] (only include location of the injury if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Chief Complaint: [chief complaint] (only include chief complaint if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Onset: [onset] (only include onset if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Aggervating Factors: [aggravating factors] (only include aggravating factors if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Easing Factors: [easing factors] (only include easing factors if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Red Flag Questions: [red flag questions] (only include red flag questions if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Imagining: [imaging] (only include imaging if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
General Health: [general health] (only include general health if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Work: [work] (only include work if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Activities: [activities] (only include activities if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Medication: [medication] (only include medication if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Have they injured this previously: [previous injury to this area] (only include previous injury to this area if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Any previous injuries: [any previous injuries] (only include any previous injuries if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
Goal of physiotherapy: [goal of physiotherapy] (only include goal of physiotherapy if it has been explicitly mentioned in the transcript, contextual notes or clinical note, otherwise omit completely.)
(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 include 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 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.)
