Subjective:
VAS: 6/10
Aggravated by: Reaching overhead and sleeping on the right side.
Eased by: Rest and ice.
Social Hx: Patient is a builder and works full time.
Mandatory Questions:
Night/Constant/Bilateral Pain/Weight Loss: No night pain, no constant pain, unilateral pain, no weight loss.
Dizziness/Vertigo/Drop attacks/Nausea: Denies.
Dysphasia/Dysarthria/Swallow/Oro-facial: Denies.
Vision/Diplopia/Nystagmus: Denies.
Increased sweating/Night sweats: Denies.
Power loss/Numbness/Pins & needles: Reports some numbness in the hand.
Headaches/Migraine: Denies.
Prolonged steroids/Osteoporosis: Denies.
Anti-coagulants: Denies.
Sleep disturbance: Reports difficulty sleeping due to pain.
Cough/Sneeze: Denies.
Metal Implants: Denies.
Scans/X-rays:
X-rays taken 2 weeks ago showed mild AC joint arthrosis.
Past Medical History/Previous Injury:
No previous shoulder injuries. Patient had a fractured wrist 5 years ago.
Patient Valued Outcome:
Patient wants to return to work without pain.
Objective Assessment:
Posture: Forward head posture, rounded shoulders.
Movements: Painful active and passive range of motion in abduction and external rotation.
Impingement Tests: Positive Neer's and Hawkins-Kennedy tests.
Capsular Tests: Limited external rotation.
Scapular Control: Scapular dyskinesis noted.
AC Joint Tests: Positive AC joint compression test.
1st Rib: Negative.
SC Joint: Negative.
Palpation: Tenderness over the supraspinatus tendon and AC joint.
Neck: No referred pain from the neck.
ULTTs: Negative.
Thoracic: No thoracic involvement.
Elbow: No elbow involvement.
Other: No other findings.
IMPRESSION:
Right shoulder impingement syndrome with AC joint arthrosis.
PLAN:
Advise on activity modification, ice, and pain relief. Commence with shoulder rehabilitation exercises.
TREATMENT:
Soft tissue massage to the shoulder muscles. Shoulder mobilisations. Education on posture.
Home Exercise Programme:
Pendulum exercises, scapular retractions, and external rotation exercises.
Advice given:
Advised on activity modification, ice application, and posture correction.
Plan for Next Day:
Review patient's progress and adjust the treatment plan as needed. Provide further education on home exercises.
