Physiotherapist's Note (custom)

Physiotherapist's Note (custom) Patient Information: - Name: Sarah Jenkins, Date of Birth: 15/03/1988, Address: 123 Oak Avenue, London, SW1A 0AA, Contact Information: 07700 900300, sarah.jenkins@email.com, Employment status: Full-time Office Administrator, Physical demands of job: Prolonged sitting, keyboard use, occasional lifting of light files, Work-related activities: Data entry, team meetings. - General exercise and activity levels: Walks 30 minutes, 3-4 times per week; attends one yoga class weekly. Medical History: - List of medical conditions: Mild osteoarthritis in right knee (diagnosed 5 years ago). - Previous surgeries/treatments: None relevant to current complaint. - Allergies: Penicillin (rash). - Medications: Paracetamol (as needed for knee pain), Multivitamin. - Relevant social history: Lives with partner, non-smoker, occasional alcohol. - Family medical history: Mother has osteoporosis. Current Condition/Complaint: - Primary injury, problem, or complaint: Right shoulder pain, particularly during overhead movements. - Date of onset or surgery: Approximately 6 weeks ago. - Description of how the injury occurred or complaint began: Gradual onset, exacerbated after a weekend of gardening, specifically pruning high branches. - Details of any prior therapy, interventions, and/or surgery: Attempted self-management with RICE protocol and over-the-counter pain relief with limited success. - Progression of complaint and nature of symptoms, if applicable: Pain initially intermittent, now more constant, sharp with movement, dull ache at rest. Worse at night, disturbing sleep. Patient Goals: - Short-term physiotherapy goals & time frame for achieving these goals: Reduce pain to 3/10 (from current 7/10) within 2 weeks, improve sleep quality, and restore ability to reach overhead without sharp pain. - Long-term physiotherapy goals & time frame for achieving these goals: Full, pain-free range of motion in right shoulder within 8 weeks, able to return to gardening activities, including pruning, without exacerbation. - Progress towards stated goals (if applicable): Patient reports slight reduction in resting pain (from 7/10 to 6/10) since initial consultation, but overhead movement remains problematic. Subjective: - Detailed narrative of the patient's self-report of their current status, symptoms, reason for visit etc: Ms. Jenkins reports persistent right shoulder pain, rating it as 6/10 at rest and 8/10 with movement, especially abduction and external rotation. She describes the pain as sharp during active movement and a dull ache when sedentary. She struggles with daily activities such as getting dressed, washing her hair, and reaching for items in high cupboards. Sleep is regularly disturbed, waking her 2-3 times per night due to pain. She is concerned about her ability to continue her gardening hobby and work-related tasks requiring reaching. - Patients activity level, disability, social history: Patient finds it difficult to lift her arm above shoulder height, limiting her ability to perform tasks at work. She avoids lifting heavy objects at home and has temporarily stopped yoga due to pain. Socially, she is frustrated by her inability to participate in activities she enjoys. - Goals and prior response to treatment intervention (if applicable): Patient is motivated to recover full shoulder function. She tried over-the-counter anti-inflammatories, which provided minimal temporary relief. - Information from family or caregivers (if applicable): Partner reports Ms. Jenkins has been noticeably irritable due to pain and lack of sleep. Objective: - Physical examination details: Inspection revealed no significant swelling or bruising. Palpation noted tenderness over the supraspinatus insertion. Active range of motion (AROM) in the right shoulder: Flexion to 120 degrees (painful at end range), Abduction to 110 degrees (painful throughout), External Rotation to 45 degrees (painful). Internal Rotation to 60 degrees (pain-free). Passive range of motion (PROM) was slightly greater but still restricted and painful at end ranges. - Observations, tests, and measurements by the therapist: Hawkins-Kennedy test positive (pain at 70 degrees flexion and internal rotation), Neer's impingement test positive. Empty Can test elicited pain and weakness in supraspinatus. External rotator strength graded 3/5, internal rotator strength 4/5. Cervical spine ROM full and pain-free. - Specific measurements and assessment findings: Right shoulder circumference 32 cm (left 32 cm). Pain scale (NRS) 6/10 at rest, 8/10 with overhead movement. - Factors affecting progress and any need for modification in the plan (if applicable): Patient's current pain level and sleep disturbance are significant barriers to progress. Her work-related activities involving prolonged sitting and keyboard use may contribute to postural issues affecting shoulder mechanics. Treatment: - Detailed treatment interventions including, intensity, duration, location on body, left or right side: Manual therapy (soft tissue release) to right upper trapezius, levator scapulae, and pectoralis minor, 10 minutes, moderate intensity. Joint mobilisations (grade II-III) to right glenohumeral joint, 5 minutes. Therapeutic exercises including pendulum exercises, scapular retraction exercises (rows with light resistance band), and external rotation isometric holds for right shoulder, 3 sets of 10 repetitions, low intensity. Cryotherapy to right shoulder for 15 minutes post-exercise. - Equipment required and its usage (if applicable): Resistance band (light) for home exercise program. A/E: - Education strategies for the patient: Educated patient on proper posture for computer work and gardening. Advised on pain management strategies including regular icing and avoidance of aggravating activities. Provided handout with home exercise program and instructions on gradual return to activity. Plan: - Detailed follow up plans for treatment and next steps: Follow-up appointment scheduled for 1 November 2024, in one week, to review progress, reassess pain and ROM, and progress home exercise program. Continue current treatment plan. - Anticipated goals and expected outcomes (if applicable): Anticipate a reduction in pain and improved sleep within the next week, with a goal of starting light strengthening exercises for the rotator cuff. - Referrals to other professionals (only if needed): None at this time, will monitor progress for potential orthopaedic referral if conservative management is ineffective. Assessment: - Therapist's professional opinion based on subjective and objective findings: Ms. Jenkins presents with symptoms consistent with right shoulder impingement syndrome, likely involving the supraspinatus tendon. Contributing factors include prolonged overhead activities (gardening) and potentially poor ergonomics at work. The pain is impacting her daily activities, work, and sleep. - Prioritized problems list: 1. Right shoulder pain (6-8/10). 2. Restricted right shoulder AROM (especially flexion, abduction, external rotation). 3. Sleep disturbance due to pain. 4. Difficulty with ADLs and work tasks. 5. Weakness in right external rotators and supraspinatus.