Initial Detailed Consult

Presenting Complaint: [Presenting complaint] - [complaint history] Medical History: [Medical History] Medications: [Medications] Examination (only include this section if one or more of the subheadings below include data: SFMA, MUSCLE TESTING, Cervical Testing, Thoracic Testing, Shoulder Testing, Elbow, Wrist and Hand Testing, Functional and Structural, Range of Motion Testing) SFMA (only include this section if mentioned explicitly in transcript or contextual notes) [Cervical Flexion, Cervical Extension, Cervical Rotation] (only include if mentioned explicitly in transcript or contextual notes, record as FN, FP, DN or DP, and include any qualifying comments) [Multisegmental Flexion, Multisegmental Extension, Multisegmental Rotation] (only include if mentioned explicitly in transcript or contextual notes, record as FN, FP, DN or DP, and include any qualifying comments) [Upper Extremity #1] (only include if mentioned explicitly in transcript or contextual notes, record as FN, FP, DN or DP, and include any qualifying comments) [Upper Extremity #2] (only include if mentioned explicitly in transcript or contextual notes, record as FN, FP, DN or DP, and include any qualifying comments) [Single Leg Balance] (only include if mentioned explicitly in transcript or contextual notes, record as FN, FP, DN or DP, and include any qualifying comments including eyes open, eyes closed, time in seconds) [Overhead Squat] (only include if mentioned explicitly in transcript or contextual notes, record as FN, FP, DN or DP, and include any qualifying comments) [SFMA Breakouts] (only include if mentioned explicitly in transcript or contextual notes, record as FN, FP, DN or DP, and include any qualifying comments) MUSCLE TESTING (only include this section if mentioned explicitly in transcript or contextual notes, place each muscle on a new line, never use bullet points, list as L for left side, R for right side, list as a number out of 5, include any qualifying comments such as the presence of pain) [SERRATUS ANTERIOR] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [LATISSIMUS DORSI] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [UPPER TRAPEZIUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [MIDDLE TRAPEZIUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [LOWER TRAPEZIUS](only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [PECTORALIS MAJOR - TRANSVERSE] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [PECTORALIS MAJOR - OBLIQUE] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [MID DELTOID] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [ANTERIOR DELTOID] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [POSTERIOR DELTOID] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [BICEPS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [BRACHIALIS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [BRACHIORADIALIS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [TRICEPS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [WRIST FLEXORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [FLEXOR CARPI ULNARIS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [FLEXOR CARPI RADIALIS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [WRIST EXTENSORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [EXTENSOR CARPI ULNARIS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [EXTENSOR CARPI RADIALIS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [FINGER FLEXORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [FINGER EXTENSORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [FINGER ABDUCTORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [LUMBRICALS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [THUMB EXTENSION] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [THUMB FLEXION] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [THUMB ABDUCTION] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [THUMB ADDUCTION] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [THUMB LITTLE FINGER OPPOSITION] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [HAMSTRINGS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [GLUTEUS MAXIMUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [RSLR] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [PSOAS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [HIP ABDUCTORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [GLUTEUS MEDIUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [GUTEUS MINIMUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [TENSOR FASCIA LATAE] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [HIP ADDUCTORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [RECTUS FEMORIS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [QUADRICEPS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [POPLITEUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [GASTROCNEMIUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [SOLEUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [TIBIALIS ANTERIOR] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [PERONEAL GROUP] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [TOE FLEXORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [TOE EXTENSORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [EXTENSOR HALLUCIS LONGUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [FLEXOR HALLUCIS LONGUS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) [TOE ABDUCTORS] (only include if mentioned explicitly in transcript or contextual notes, list as L for left side, R for right side, and as a number out of 5 for each side, include any qualifying comments such as the presence of pain or the quality of onset of muscle activation) Cervical Testing (only include this section if any of the tests below are mentioned explicitly in transcript or contextual notes) [C COMPRESSION] (only include if mentioned explicitly in transcript or contextual notes, list as either + or -, include any qualifying comments such as the presence of pain or the quality of the movement) [C DISTRACTION] (only include if mentioned explicitly in transcript or contextual notes, list as either + or -, include any qualifying comments such as the presence of pain or the quality of the movement) [C KEMPS] (only include if mentioned explicitly in transcript or contextual notes, list as either + or -, include any qualifying comments such as the presence of pain or the quality of the movement) [FORAMINAL COMPRESSION - LAT FLEXION] (only include if mentioned explicitly in transcript or contextual notes, list as either + or -, include any qualifying comments such as the presence of pain or the quality of the movement) [FORAMINAL COMPRESSION - ROTATION] (only include if mentioned explicitly in transcript or contextual notes, list as either + or -, include any qualifying comments such as the presence of pain or the quality of the movement) [FORAMINAL COMPRESSION - KEMPS OVERPRESSURE] (only include if mentioned explicitly in transcript or contextual notes, list left and right as either + or -, include any qualifying comments such as the presence of pain or the quality of the movement) [UPPER LIMB TENSION TESTS RADIAL NERVE MEDIAN NERVE 1 MEDIAN NERVE 2 ULNAR NERVE] (only include if mentioned explicitly in transcript or contextual notes, list as either + or -, include any qualifying comments such as the presence, character and location of pain and symptoms, and a comparison of left to right) Thoracic Testing (only include this section if any of the tests below are mentioned explicitly in transcript or contextual notes) [1st RIB RESTRICTION] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain or the quality of the movement) [ADAM'S FORWARD BEND] (only include if mentioned explicitly in transcript or contextual notes, list as either + or -, include any qualifying comments such as the side of rib humping) [ADSON'S TEST] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain or symptoms) [RESPIRATION] (only include if mentioned explicitly in transcript or contextual notes, include any qualifying comments such as chest breathing, diaphragmatic breathing, asymmetries in movement, and the presence of pain) [THORACIC ROTATION/EXTENSION, HAND ON OPPOSITE SHOULDER] (only include if mentioned explicitly in transcript or contextual notes, list left and right as FN, FP, DN or DP, include any qualifying comments such as the presence and location of any pain or the quality of the movement) [THORACIC ROTATION/EXTENSION, HAND BEHIND LOWER BACK] (only include if mentioned explicitly in transcript or contextual notes, list left and right as FN, FP, DN or DP, include any qualifying comments such as the presence and location of any pain or the quality of the movement) [THORACIC ROTATION/EXTENSION, HAND BY EAR, ELBOW OUT] (only include if mentioned explicitly in transcript or contextual notes, list left and right as FN, FP, DN or DP, include any qualifying comments such as the presence and location of any pain or the quality of the movement) Shoulder Testing (only include this section if any of the tests below are mentioned explicitly in transcript or contextual notes) [EMPTY CAN] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, note whether a + finding is associated with thumb up or thumb down, include any qualifying comments such as the presence of pain or weakness) [BEAR HUG] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain or weakness) [HORNBLOWERS/INFRASPINATUS] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain or weakness) [SPEEDS] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain or weakness) [O'BRIENS] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, note whether a + finding is associated with palm up or thumb down, include any qualifying comments such as the presence of pain or weakness) [YERGASONS] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain or weakness) [BICEPS LOAD TEST] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain or weakness) [NEERS] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain) [ACROMIOCLAVICULAR JOINT] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain and the direction of movement associated with joint restriction such as abduction, flexion, internal or external rotation, extension) [STERNOCLAVICULAR JOINT] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain and the direction of movement associated with joint restriction such as abduction, flexion, internal or external rotation, extension) [SULCUS SIGN] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain) [GLENOHUMERAL AP GLIDE] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the direction of excess movement or the presence of pain) [PAINFUL ARC] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the portion of the arc causing pain) [ARM DROP TEST] (only include if mentioned explicitly in transcript or contextual notes, list left and/or right as either + or -, include any qualifying comments such as the presence of pain) Elbow, Wrist and Hand Testing (only include this section if any of the tests below are mentioned explicitly in transcript or contextual notes) [CARPAL COMPRESSION] [SCAPHOID COMPRESSION] [TFCC COMPRESSION] [MEDIAL ELBOW PALPATION] [LATERAL ELBOW PALPATION] [PHALENS TEST] [REVERSE PHALENS TEST] [GRIP] Functional and Structural (only include this section if any of the tests below are mentioned explicitly in transcript or contextual notes) [HANDEDNESS] (only include dominant hand, foot and/or eye if mentioned explicitly in transcript or contextual notes) [GAIT - WALKING] [GAIT - RUNNING] [FOOTWEAR] [SQUAT - BODYWEIGHT] [SQUAT - OVERHEAD] [SQUAT - BARBELL] [SQUAT - SANDBAG] [NECK FLEXION MOVEMENT PATTERN] [DEEP NECK FLEXOR ENDURANCE] [TRUNK FLEXION MOVEMENT PATTERN] [SHOULDER ABDUCTION] [PUSH UP] [WEIGHTED SHOULDER FLEXION] [SEATED TOE TOUCH] [HIP EXTENSION MOVEMENT PATTERN] (only include if mentioned explicitly in transcript or contextual notes, list either left, right or bilateral centre of rotation in lumbar spine, opposite shoulder lift, and/or limited hip extension, as well as any additional information if mentioned in transcript or contextual notes) [HIP FLEXION MOVEMENT PATTERN] [HIP ABDUCTION MOVEMENT PATTERN] [LEG LENGTH DISCREPANCY] (only include if mentioned explicitly in transcript or contextual notes, list either left or right short femur and/or tibia) Range of Motion Testing (only include this section if any of the tests below are mentioned explicitly in transcript or contextual notes) [SEATED NECK RANGE OF MOTION] [SUPINE NECK RANGE OF MOTION] [SUPINE UPPER CERVICAL RANGE OF MOTION] [SEATED TRUNK ROTATION] [SHOULDER ABDUCTION] [SHOULDER FLEXION] [SHOULDER EXTENSION] [SHOULDER ROTATION SEATED] [SHOULDER ROTATION PRONE] [ELBOW FLEXION] [ELBOW EXTENSION] [ELBOW SUPINATION] [ELBOW PRONATION] [WRIST FLEXION] [WRIST EXTENSION] [WRIST ULNAR DEVIATION] [WRIST RADIAL DEVIATION] [FINGER FLEXION] [FINGER EXTENSION] [FINGER ABDUCTION] [THUMB ABDUCTION] [THUMB EXTENSION] [THUMB OPPOSITION] [HIP ROTATION SEATED] [HIP ROTATION PRONE] [HIP ROTATION SUPINE] [HIP FLEXION] [HIP EXTENSION] [HIP ABDUCTION] [HIP ADDUCTION] [KNEE FLEXION] [KNEE EXTENSION] [KNEE INTERNAL ROTATION] [KNEE EXTERNAL ROTATION] [ANKLE DORSIFLEXION] [KNEE TO WALL] [ANKLE PLANTARFLEXION] [ANKLE EVERSION] [ANKLE INVERSION] Working Diagnosis: [Working Diagnosis] Treatment: [Treatment] Home Care: [home care patient to undertake/complete/follow] Treatment Plan: [treatment plan] (Never come up with your own patient details, assessment, plan, interventions, evaluation, and 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.)