Physiotherapy Initial Assessment

Patient information: - Employment status: Employed as a software engineer. - Age: 32 - Sex: Male - General exercise and activity levels: Sedentary lifestyle, desk job, infrequent exercise. - Pronouns: He/Him Consent: - Verbal consent to assessment and treatment: Patient provided verbal consent. Acupuncture checklist: - VCG and answers to: Patient denies any of the contraindications. PC: - Presenting condition, specifying which side of the body, which limb or joint etc: Right shoulder pain. HPC: - History of presenting condition, stating exactly where the history began with this and how they got there: Patient reports onset of pain 2 weeks ago after lifting a heavy box. Pain gradually worsened over the past week. - Subjective information related to the presenting condition: Patient describes a sharp, aching pain in the right shoulder, exacerbated by overhead movements and sleeping on the right side. Reports occasional clicking. NRS: - Pain scores: Pain at rest: 3/10. Pain with activity: 7/10. Special Questions: - Questions about clicking, popping or grinding, sensation, giving way, power, dizziness, double vision, etc.: Reports occasional clicking in the shoulder. No reports of giving way, dizziness or double vision. 24 Hour Pattern: - Pain pattern over the day, AM / PM behaviours: Pain is worse in the morning and after prolonged sitting. Pain increases with overhead activities. Aggs: - List of aggravating factors: Overhead activities, reaching, sleeping on right side, prolonged sitting. Eases: - List of easing factors: Rest, ice, over-the-counter pain medication. PMH: - Past medical history, including threads: No significant past medical history. DH: - Drug history, a list of any medications being taken: Ibuprofen as needed. SH: - Any additional social history not already captured in the patient information above: Non-smoker, drinks alcohol socially. Goals / Expectations: - Patient goals and their expectations from the physiotherapist going forward through sessions: Patient wants to reduce pain and regain full range of motion to return to normal activities. Objective: - Observations, including postural observations: Forward head posture, rounded shoulders. - List of all objective assessments divided into joints and the range of motion assessed: - Right shoulder: - Flexion: 160 degrees - Abduction: 140 degrees - External Rotation: 40 degrees - Internal Rotation: 60 degrees - Power (MRC) assessed at that joint: - Shoulder abduction: 4/5 - Shoulder flexion: 4/5 - Special tests: Positive for Neer's test, Hawkins-Kennedy test. RX: - Thorough breakdown of all treatment provided in session: Soft tissue massage to the right shoulder and upper trapezius. Shoulder range of motion exercises. Patient education on posture and activity modification. - Advice, education or advisories for future attention given to patient: Advised to continue with home exercises. Ice application for pain relief. Schedule follow-up appointment in one week. Analysis: - Diagnosis quoted in the manner of a problem list, with medical terminology: Right shoulder impingement syndrome. - Any differential diagnosis/contributing factors mentioned within the session: Possible rotator cuff tendinopathy. Plan: - Plan including next appointment and any tasks agreed in session: Schedule follow-up appointment in one week. Continue home exercises. Avoid aggravating activities.