HOPC
- Patient presents with a 3-week history of right shoulder pain following a fall while playing tennis.
- Pain is aggravated by overhead activities and eased with rest and ice application.
- Pain is described as sharp during movement and dull at rest, with intensity varying throughout the day.
Radiology:
- MRI of the right shoulder shows a partial tear of the supraspinatus tendon.
Past Medical History
- Hypertension, managed with Amlodipine 5mg QD.
- No known allergies.
Social History
- Patient is a non-smoker and consumes alcohol occasionally.
- Lives with spouse and has a supportive family network.
- Works as an accountant, involving prolonged sitting and occasional lifting of heavy files.
Goals
- Short-term: Reduce pain and improve range of motion within 4 weeks.
- Long-term: Return to playing tennis without pain within 3 months.
Objective
- Active Range of Motion (AROM): Right shoulder flexion 0-120 degrees, abduction 0-90 degrees, external rotation 0-45 degrees.
- Strength: 4/5 in right shoulder abduction and external rotation.
- Palpation: Tenderness over the supraspinatus tendon.
Treatment
- Education: Discussed pain management strategies and importance of adherence to home exercise program.
- Hands-on: Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper R) shoulder.
- Active therapy: 3x10 Single leg calf raises, 3x10 R) shoulder external rotations with resistance band.
- Home Exercise Program (HEP): 3x10 R) shoulder pendulum exercises, 3x10 R) shoulder wall slides, to be done daily.
Assessment
- Diagnosis: Partial tear of the supraspinatus tendon with associated inflammation.
- Differential Diagnosis: Rotator cuff tendinopathy.
- Progress: Patient has shown slight improvement in pain levels and range of motion.
- Barriers: Patient's work schedule limits time for exercises.
Plan:
- Continue current treatment plan with emphasis on strengthening and range of motion exercises.
- Review in 2 weeks.
- Likely therapy: Progress to more advanced strengthening exercises.
- Referral: None required at this stage.
- Communication: Will send a progress report to the patient's GP before the next session.
(You are a senior physiotherapist working in a private practice clinic. You are driven towards helping your patient's achieve their goals)
HOPC
[Describe history of presenting condition, including mechanism and date of injury, management since injury, etc] (Use bullet points as required to capture all relevant information)
[Describe factors that aggravate and easing the pain] (Only include if explicitly mentioned)
[Describe the pain over the duration of 24 hours] (Only include if explicitly mentioned)
Radiology:
[List any radiology assessment and their findings that have been undertaken for this patient's presenting complaint/injury] (Only include if explicitly mentioned)
Past Medical History
[List existing and past medical conditions, e.g., osteoporosis, stroke, high blood pressure, surgeries etc] (include very small description
and how they are managing each condition, e.g. Amlodipine 5mg QD] (Only include if explicitly mentioned)
[Mention any allergies] (Only include if explicitly mentioned)
Social History
[Mention relevant social history like lifestyle factors, living arrangements, support network, tobacco/alcohol use, etc] (Only include if explicitly mentioned)
[Mention family medical history of disease that may be relevant to their presenting condition or may impact their response to therapy] (Only include if explicitly mentioned)
[Summarise employment status, occupation, hours work, physical/mental intensity of job, etc] (Only include if explicitly mentioned)
Goals
[Short-term physiotherapy goals & time frame for achieving these goals] (Only include if explicitly mentioned)
[Long-term physiotherapy goals & time frame for achieving these goals] (Only include if explicitly mentioned)
Objective
[List all physical observations and examinations completed, along with their findings] (Always group relatable findings together, for example, active range of motion measures must be situated in the one section)
Treatment
[List all educational treatment that was provided throughout session, e.g. pain science education] (Only include if explicitly mentioned)
[List all hands on treatment provided throughout session, for example, Mobilisation: Gr II PA R) C5/6 2x30secs, Unilateral soft tissue massage upper L) calf, etc] (Only include if explicitly mentioned)
[List all active therapy treatment provided throughout the session, for example, 3x10 Single leg calf raises, 3x10 L) ankle knee to walls, etc] (Only include if explicitly mentioned)
[List home exercise program [HEP] provided] (Include reps, sets and frequency) (Only include if explicitly mentioned)
Assessment
[Summarise the assessment and state diagnosis based on subjective and objective findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Summarise the assessment and state differential diagnosis based on on subjective and objective findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank)
[Summarise their progress towards their stated goals] (Only include if explicitly mentioned)
[State any barriers affecting progress] (Only include if explicitly mentioned)
Plan:
[Brief summary of the clinical plan until the next appointment] (Only include if explicitly mentioned)
[Timeline of next review, e.g, r/v 2/52] (Only include if explicitly mentioned)
[Likely therapy I will provide at our next appointment] (Only include if explicitly mentioned)
[Referrals to other professionals that need to occur or the patient will attend] (Only include if explicitly mentioned)
[Letters, phone calls or communication the treating therapist will do before next session (Only include if explicitly mentioned)
(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. Use as many bullet points as needed to capture all the relevant information from the transcript.)
