First Contact Practitioner Consultation

First Contact Practitioner Consultation History: Right shoulder, deltoid region. Onset approximately 3 weeks ago, gradual onset, constant ache. Severity: 6/10 on a Numeric Pain Rating Scale, worsening with movement. Symptoms include a dull, aching pain, occasional sharp twinges with reaching overhead, and stiffness, particularly in the mornings. Patient reports difficulty sleeping on the affected side. Background: Medical history: No significant past medical history relevant to musculoskeletal conditions. Denies diabetes, rheumatoid arthritis, or previous shoulder injuries. Current medications: Paracetamol 500mg as needed for pain, taken intermittently. Social history: Patient is a 45-year-old right-hand dominant office worker (data entry). Reports significant functional impact, struggling with overhead tasks at work and unable to participate in recreational tennis. Lives alone. Previous investigations: None. Previous treatments: None attempted prior to this consultation, aside from over-the-counter pain relief. Examination: Chaperone use: Not applicable, patient declined and felt comfortable. General examination findings: Patient appears comfortable at rest. No obvious deformity or discolouration. Good general mobility on observation, except for the affected shoulder. Specific musculoskeletal examination findings: Inspection: Mild asymmetry with right shoulder slightly protracted. No swelling or erythema. Palpation: Tenderness over the anterior deltoid and supraspinatus insertion. No warmth. Active Range of Motion (AROM): Flexion: 120 degrees (painful past 90) Abduction: 110 degrees (painful past 80) External Rotation: 45 degrees (painful) Internal Rotation: 60 degrees (mild discomfort) Passive Range of Motion (PROM): Slightly limited end-range flexion and abduction, with pain reported. Resisted Isometric Movements: Weakness and pain with shoulder flexion, abduction, and external rotation. Strong and painless internal rotation. Special Tests: Neer's Impingement Test positive. Hawkins-Kennedy Test positive. Empty Can Test mildly painful but strong. Apprehension Test negative. Neurological: Sensation intact to light touch in C5-T1 dermatomes. Reflexes (biceps, triceps) 2+ bilaterally. No signs of neurological deficit. Red Flags: Absence of red flag symptoms. Patient denies fever, night sweats, unexplained weight loss, new onset weakness, or bowel/bladder changes. Yellow Flags: Patient expresses concern about returning to tennis and impact on work, indicating moderate fear-avoidance beliefs. Reports increased stress due to pain limiting daily activities. Assessment: Clinical impression and working diagnosis: Right shoulder impingement syndrome, likely involving the supraspinatus tendon. Contributing factors include occupational demands and potential deconditioning. Diagnostic codes: M75.4 - Impingement syndrome of shoulder. Management: Treatment plan and interventions provided: 1. Education on shoulder mechanics and posture. 2. Manual therapy: Soft tissue release to deltoid and upper trapezius. Posterior glide mobilisation to glenohumeral joint. 3. Therapeutic exercises: Scapular stabilisation exercises (e.g., wall slides, rows), gentle rotator cuff strengthening (e.g., external rotation with resistance band), pendulum exercises for pain relief. Analgesia prescribed or recommended: Continue Paracetamol as needed. Advised on NSAID options if pain persists, to discuss with GP. Exercise prescription or physiotherapy recommendations: Provided printed exercise sheet with clear instructions for daily performance. Emphasised consistency and avoiding pain during exercises. Investigations arranged including blood tests or imaging: None arranged at this stage. Will consider MRI if no improvement with conservative management in 4-6 weeks. Injections or procedures performed: None. Referrals made to other services: None. Fitness for work assessment: Advised to modify overhead activities at work. Provided advice on ergonomic adjustments for computer use. Patient Education: Advice on diagnosis and expectations: Explained shoulder impingement in lay terms, emphasising that it is a common, treatable condition. Discussed realistic recovery timeline (typically 6-12 weeks for significant improvement with adherence to exercises). Self-care and lifestyle advice provided: Advised on proper posture, avoiding sustained overhead positions, and applying ice for pain relief. Encouraged continuation of general physical activity within pain limits. Patient information leaflets given: Leaflet on 'Understanding Shoulder Impingement' and 'Home Exercise Programme for Shoulder Pain'. Safety Netting: Advice to return if problem worsens or no improvement within 2-3 weeks, or if new symptoms (e.g., numbness, significant weakness) develop. Follow-up: Follow-up arrangements and timeframe: Review in 1-2 weeks to assess progress and advance exercise programme. Booked for 1 November 2024.