Summary of injury and treatment
Patient sustained a right shoulder rotator cuff tear on 15 October 2024 during a fall at work. Underwent arthroscopic repair on 20 October 2024. Currently in a sling and participating in physiotherapy.
Current functional tolerances
Patient is currently unable to lift more than 5 pounds with the right arm. Limited range of motion in the right shoulder. Able to perform light activities of daily living with modifications.
Upcoming medical appointments
Follow-up appointment with Dr. Smith on 15 November 2024. Physiotherapy sessions twice a week.
Current medical certificate
Patient is currently signed off work until 1 December 2024. Restrictions include no lifting, pushing, or pulling with the right arm.
Pre-injury role title
Warehouse worker.
Normal working hours/days
Monday to Friday, 8:00 AM to 4:00 PM.
Work tasks
Loading and unloading trucks, moving packages, operating a forklift.
Physical requirements of tasks
Frequent lifting of up to 50 pounds, repetitive arm movements, prolonged standing.
Suitable work tasks for gradual return to work
Light administrative duties, such as data entry and phone calls. Modified tasks involving minimal use of the right arm.
Employer concerns and support of programme, barriers or opportunities
Employer is supportive of a gradual return to work. They are willing to provide modified duties and workplace accommodations. No barriers identified at this time.
Medications:
* Ibuprofen 400mg, as needed for pain
* Paracetamol 500mg, as needed for pain
Allergies:
* No known drug allergies.
Review of systems:
* Musculoskeletal: Right shoulder pain, stiffness, and limited range of motion.
Physical examination findings:
* Vitals: BP 120/80, HR 72, RR 16, Temp 37°C
* Right shoulder: Swelling and bruising present. Limited active and passive range of motion. Pain on palpation.
Assessment and differential diagnosis:
* Right shoulder rotator cuff tear, post-operative.
Plan of care:
* Continue physiotherapy twice a week.
* Home exercise program as prescribed by physiotherapist.
* Follow-up with Dr. Smith on 15 November 2024.
* Occupational therapy to assess functional capacity and facilitate a safe return to work.
* Review of work duties and potential modifications.
* Date: 1 November 2024
Summary of injury and treatment
[summary of injury and treatment] (Provide a concise summary of the patient's injury or injuries, including date of incident, nature of injury, body part(s) affected, and treatment to date. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Current functional tolerances
[current functional tolerances] (Describe the patient’s current ability to stand, sit, walk, lift, carry, bend, and perform other relevant physical tasks. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Upcoming medical appointments
[upcoming medical appointments] (List any upcoming appointments including provider, date, and purpose. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Current medical certificate
[current medical certificate status] (Provide the status or summary of any current medical certificate, including capacity, restrictions and expiry date. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Pre-injury role title
[pre-injury job title] (Insert the patient’s role title prior to the injury. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Normal working hours/days
[pre-injury work schedule] (List usual working hours and days prior to injury. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Work tasks
[pre-injury work tasks] (Summarise primary duties and responsibilities of the patient’s pre-injury role. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Physical requirements of tasks
[physical demands of job tasks] (Describe the physical components of the role such as lifting, standing, sitting, repetitive movements, etc. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Suitable work tasks for gradual return to work
[suitable duties for return-to-work programme] (Suggest modified or reduced duties that align with current functional tolerances and support a gradual return to work. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
Employer concerns and support of programme, barriers or opportunities
[employer input on return-to-work] (Summarise any employer concerns, willingness to support return-to-work programmes, barriers identified, and opportunities for workplace accommodations. Only include if explicitly mentioned in transcript, context or clinical note, else omit section entirely.)
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