Initial Worker's Compensation Consultation:
Date of Injury/Incapacitation: 1 November 2024
Employer: ACME Corp
Occupation: Construction Worker
Other Attendees: None
History of Injury:
- Patient reports a fall from scaffolding while working on a construction site. He landed on his left shoulder.
- Left shoulder
- None
- X-ray of the left shoulder was performed and showed a fracture.
Current Symptoms:
- Patient reports severe pain in his left shoulder, rated 8/10. He also reports some bruising and swelling. He denies any numbness or tingling in his arm or hand.
Past Medical History:
- Patient has a history of hypertension, well-controlled with medication.
- None
Medications:
- Lisinopril 20mg daily
- Paracetamol 1g as needed for pain
Allergies:
- NKDA
Examination:
- Inspection reveals bruising and swelling over the left shoulder. Palpation elicits tenderness over the left clavicle. Range of motion is limited due to pain. Neurovascular examination of the left arm is intact.
Diagnosis:
- Left clavicle fracture
- Possible rotator cuff injury
Work Capacity:
- Patient is currently unfit for work.
- Patient is restricted from any activities involving lifting, pushing, or pulling with his left arm.
- Return to work is estimated in 6-8 weeks.
Management Plan:
- Patient advised to rest, ice, and elevate the injured arm. Sling provided. Follow-up with an orthopaedic surgeon recommended.
- X-ray of the left shoulder (already done).
- Paracetamol 1g as needed for pain.
- Referral to Dr. Smith, Orthopaedic Surgeon.
- Follow-up appointment in 2 weeks.
Initial Worker's Compensation Consultation:
Date of Injury/Incapacitation: [State the date that of injury specified during the consult]
Employer: [State the name of the patient's Employer] (only include if found in the transcript, context or clinical note; else omit completely)
Occupation: [State the patient's Occupation] (only include if found in the transcript, context or clinical note; else omit completely)
Other Attendees: [Identify any other people attending the consult with patient and if possible their role] (only include if found in the transcript, context or clinical note; else omit completely)
History of Injury:
- [Create a detailed summary of any events described by the patient] (only include if found in the transcript, context or clinical note; else omit completely)
- [Identify the body Part(s) Affected as a result of the injury] (only include if found in the transcript, context or clinical note; else omit completely)
- [summarize any treatment received so far for the injury] (only include if found in the transcript, context or clinical note; else omit completely)
- [summarize any investigation results] (only include if found in the transcript, context or clinical note; else omit completely)
Current Symptoms:
- [List the symptoms experienced by the patient including relevant negatives] (only include if found in the transcript, context or clinical note; else omit completely)
Past Medical History:
- [Describe any past Medical History provided or discussed during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
- [List any Previous Surgeries in bullet form] (only include if found in the transcript, context or clinical note; else omit completely)
Medications:
- [List any Medications and Herbal Supplements in bullet form] (only include if found in the transcript, context or clinical note; else omit completely)
Allergies:
- [List any Allergies in bullet form] (only include if found in the transcript, context or clinical note; else omit completely)
Examination:
- [Create a detailed list of the Physical Examination Findings discussed during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
Diagnosis:
- [Describe the Primary Diagnosis stated during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
- [List any Differential Diagnoses mentioned by the doctor during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
Work Capacity:
- [Summarize the current work capacity] (only include if found in the transcript, context or clinical note; else omit completely)
- [Summarize any restrictions and limitations provided by the doctor during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
- [Summarize an estimated time for Return to Work is provided, describe that here] (only include if found in the transcript, context or clinical note; else omit completely)
Management Plan:
- [Describe the Treatment Plan given] ((only include if found in the transcript, context or clinical note; else omit completely)
- [List any Investigations that were ordered during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
- [List any Medications Prescribed during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
- [List any Referral that were provided during the consult] (only include if found in the transcript, context or clinical note; else omit completely)
- [Follow-up Plan] (only include if found in the transcript, context or clinical note; else omit completely)
(Never come up with your own patient details, assessment, diagnosis, interventions, evaluation or plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included 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 section blank)
