First Orthopaedic Shoulder Consult and Ultrasound

[Patient age, gender, referring clinician name and role, and presenting complaint with location] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) History of Presenting Complaint - [Patient complaint, mechanism of injury, and duration of symptoms] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) - [Description of pain, impact on activities of daily living, and any night pain] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences.) - Previous Treatments: [Summary of previous treatments including medications, injections, physiotherapy, and other modalities, and their effect] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Past Medical History - [Relevant orthopaedic or systemic conditions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Allergies: [List of allergies and associated reactions] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Medications: [List of current medications] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Social History: [Summary of smoking status, alcohol use, and activity levels] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Examination - Inspection: [Summary of inspection findings such as atrophy, swelling, or scars] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Tenderness: [Summary of palpation findings for tenderness across relevant anatomical sites] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Active Range of Motion: [Details of active and passive range of motion comparing the affected side to the contralateral side, including specific movements using summarised format such as "FE 120/180"] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Special Tests Rotator Cuff: - Biceps: [Results of Yergason's test and Speed's test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Subscapularis: [Results of Push Off test and Belly Press test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Supraspinatus: [Results of Jobe's test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Infraspinatus: [Results of External Rotation Pain or Lag test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Teres Minor: [Results of Hornblower's sign] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Impingement Tests: [Results of impingement tests performed] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Special Tests Laxity/Instability: - Sulcus Sign: [Result of Sulcus sign] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Anterior Drawer Test: [Result of Anterior Drawer test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Posterior Drawer Test: [Result of Posterior Drawer test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Apprehension Test: [Result of Apprehension test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Relocation Test: [Result of Relocation test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - O'Brian's Test: [Result of O'Brian's test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Grind Test: [Result of Grind test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Posterior Labrum Traction and Slide Test: [Result of Posterior Labrum Traction and Slide test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Kim's Lesion Test: [Result of Kim's Lesion test] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Neurovascular Status: [Details of neurovascular examination findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Special Investigations X-Rays - [Summary of X-ray findings including specific pathologies noted] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Ultrasound - Biceps Tendon: [Findings related to the biceps tendon] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - ACJ: [Findings related to the acromioclavicular joint] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Subscapularis: [Findings related to the subscapularis] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Supraspinatus: [Findings related to the supraspinatus including tear measurements] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Infraspinatus: [Findings related to the infraspinatus] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Teres Minor: [Findings related to teres minor] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Subdeltoid Subacromial Bursa: [Findings related to the subdeltoid subacromial bursa] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Findings related to dynamic tests performed during ultrasound] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Posterior Labrum: [Findings related to the posterior labrum] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Posterior Glenoid Notch: [Findings related to the posterior glenoid notch] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Posterior Inferior Capsule Thickness: [Measurement of posterior inferior capsule thickness in mm] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Additional Comments: [Any additional comments on the ultrasound findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) MRI - [Summary of MRI findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) CT - [Summary of CT findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) NCS - [Summary of nerve conduction study findings] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Assessment - [Working diagnosis with summary of related pathologies] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Do not invent or infer a diagnosis. Write as bullet points.) - [Impact of the condition on quality of life] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Plan - [Summary of discussion of non-surgical and surgical options] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Recommended surgical procedure and confirmation that the procedure, implants, rehabilitation, benefits, and complications were discussed, and consent status] (Only include if surgery is explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Potential Risks of Surgery Discussed Included But Is Not Limited To [List of specific surgical risks discussed such as infection, deep vein thrombosis, stiffness, pain, nerve or vessel injury, and major systemic risks] (Only include if surgical risks are explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Details of any patient education materials provided] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Referrals made for further surgical planning including specialist nurse referral or preoperative imaging] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - Surgery Planned For [Date of planned surgery] (Only include if a surgery date is explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Summary of non-surgical plan including any injections, physiotherapy, and follow-up arrangements] (Only include if a non-surgical plan is explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - "Injected 2ml Celestone and 10ml Marcaine under ultrasound guidance and sterile technique into the" [anatomical site of injection such as subdeltoid bursa, biceps sheath, acromioclavicular joint, or knee] (Only include if an injection is explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Details of the patient's decision-making process including any options being considered or next steps being scheduled] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Other Investigations Tests Not Performed or Discussed: [Summary of investigations that were considered but not performed or not discussed, with rationale] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) Additional Comments - [Summary of any current or recent personal stressors mentioned including bereavement, family illness, relocation, or employment changes] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Details of any billing discount discussed including the type of discount or the amount or percentage] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.)