Name: Sarah Jenkins
Thank you for referring Sarah who was seen in the Shoulder clinic today.
Diagnosis:
Right Rotator Cuff Tendinopathy with secondary impingement.
Left Bicipital Tendinopathy.
Plan:
Continue physiotherapy with focus on rotator cuff strengthening and scapular stabilisation.
Review in clinic in 6 weeks with a view to consider subacromial corticosteroid injection if symptoms persist.
Sarah Jenkins, a 45-year-old right-handed office worker, presented to the clinic today experiencing chronic right shoulder pain for the past six months, which has been progressively worsening. She works as a data analyst and spends most of her day at a computer, which exacerbates her symptoms. Her primary reason for the visit is persistent pain and reduced range of motion, particularly with overhead activities. She enjoys gardening and swimming, both of which are currently limited due to her shoulder pain. She attended the appointment alone.
She also reports occasional sharp pain radiating down her left arm, which is worse with lifting objects.
Her functional limitations include difficulty with dressing, reaching overhead to cupboards, and a significant impact on her ability to perform her job duties and engage in her hobbies.
To date, she has undergone a course of non-steroidal anti-inflammatory drugs (NSAIDs) prescribed by her general practitioner and has completed eight sessions of physiotherapy focusing on general shoulder mobility and strengthening, with limited improvement.
Past Medical History:
Sarah has a past medical history of essential hypertension, well-controlled with medication. There is no significant family history of musculoskeletal conditions. She is a non-smoker and consumes alcohol socially. She reports no known allergies.
Medications:
Amlodipine 5mg once daily.
Paracetamol 500mg as required.
On Examination:
1. Cervical spine movement was full and pain-free, with chin to chest range of 45 degrees and lateral rotation to both sides of 80 degrees, symmetrical bilaterally.
2. General shoulder inspection revealed no overt swelling, bruising, or muscle wasting on either side.
3. Right shoulder range of motion showed external rotation of 60 degrees, internal rotation to T10, and forward flexion of 140 degrees with a painful arc of abduction between 90 and 120 degrees, consistent with stiffness rather than frozen shoulder. The left shoulder had full, pain-free range of motion.
4. Palpation over the right AC joint was mildly tender. Palpation along the long head of biceps tendon in the bicipital groove was significantly tender on the left, but non-tender on the right.
5. Resisted supination of the forearm on the left produced pain in the bicipital groove. Speed's test was positive on the left, eliciting pain in the bicipital groove. Yergason's test was also positive on the left, reproducing pain and detecting instability.
6. Rotator cuff assessment on the right showed 4/5 strength with pain during the belly press test for subscapularis, 4/5 strength with pain on resisted external rotation for infraspinatus, and 3/5 strength with significant pain on the empty can test for supraspinatus. Left rotator cuff assessment was 5/5 strength for all tests with no pain.
7. Impingement provocation tests on the right revealed a positive Neer's sign and a positive Hawkins-Kennedy test, both eliciting significant pain.
8. The Scarf test for AC joint pathology was negative on the right, despite mild tenderness on palpation.
Radiology findings from a recent plain film X-ray of the right shoulder showed no acute bony pathology or significant degenerative changes.
A comprehensive discussion was held with Sarah regarding her symptoms and the findings from the examination. The options for future management, including further physiotherapy, potential corticosteroid injections, and surgical intervention were explained, detailing the risks and benefits of each. She was provided with an opportunity to ask questions and expressed understanding of the proposed plan.
Investigations planned: Magnetic Resonance Imaging (MRI) of the right shoulder to further assess the rotator cuff and other soft tissue structures. Ultrasound scan of the left shoulder to assess for bicipital pathology.
Treatment planned: Continuation of current physiotherapy regimen, with specific exercises targeting rotator cuff strengthening and scapular stability. Consideration of subacromial corticosteroid injection for the right shoulder if symptoms do not improve following MRI results and continued physiotherapy.
Many thanks again for the referral.
Kind regards
(Maintain a professional tone throughout the document. Use precise medical terminology throughout. Never invent or assume any patient details, assessments, plans, interventions, or clinical information. Use only the transcript, contextual notes, or clinical note as the source for all information. Always refer to the patient using their first name only. Never use Mr, Mrs, or Ms. Never use bullet points, dashes, or hyphens at the start of any list item. Always use a full stop at the end of each line within a list.)
(If this is a follow-up or review appointment, remove any reference to thanking the referrer and do not include an examination findings section.)
Name: [Patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write on a single line.)
[Opening line thanking the referrer and noting the patient was seen in the shoulder clinic today] (Only include if this is an initial referral appointment and explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this line entirely. Write as a full sentence in the format "Thank you for referring [patient's first name] who was seen in the Shoulder clinic today.")
Diagnosis:
[The clinician's explicitly stated diagnosis including whether the left or right shoulder is affected, written in full without abbreviation] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Never invent or infer a diagnosis. Always state explicitly whether the left or right shoulder is affected. List each diagnosis on a new line with a full stop at the end of each line. Do not use bullet points, dashes, or hyphens.)
Plan:
[The management plan including when the patient is next planned to be seen in clinic or whether they are discharged from follow-up] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Do not include post-operative surgical management. List each plan item on a new line with a full stop at the end of each line. Do not use bullet points, dashes, or hyphens.)
[A narrative summary of the presenting complaint or history including the patient's age, handedness, occupation, employment status, type of work, reason for visit, current issues, leisure interests and activities, and who attended with the patient if applicable] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
[Any other associated symptoms] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
[Functional limitations affecting the patient's daily life, work, or activities] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
[Treatment facilitated to date including medications, physiotherapy, or other interventions] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
Past Medical History:
[Relevant medical and surgical history, family history, social history, and allergies] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
Medications:
[Current medications] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. List each medication on a new line with a full stop at the end of each line. Do not use bullet points, dashes, or hyphens.)
On Examination:
(Only include this entire section if examination findings are explicitly mentioned in the transcript, contextual notes, or clinical note. If no examination findings are mentioned, omit this section entirely. Document all findings in narrative paragraph format following the numbered sequence below. For each step, describe the findings and compare to the contralateral side where appropriate. Omit any step that was not performed or explicitly mentioned.)
1. [Cervical spine movement assessment findings including chin to chest range and lateral rotation to both sides] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
2. [General shoulder inspection findings including the presence or absence of swelling, bruising, or muscle wasting] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
3. [Shoulder range of motion findings including external rotation, internal rotation, forward flexion, and the presence or absence of a painful arc of abduction, noting whether findings are consistent with frozen shoulder or stiffness] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
4. [Palpation findings over the AC joint and along the long head of biceps tendon in the bicipital groove, noting the presence or absence of tenderness] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
5. [Results of resisted supination of the forearm, Speed's test, and Yergason's test] (Only include if the long head of biceps was found to be tender on palpation and if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
6. [Rotator cuff assessment findings including the belly press test for subscapularis, resisted external rotation for infraspinatus, and the empty can test for supraspinatus, noting strength and pain response for each] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
7. [Results of impingement provocation tests including Neer's sign and Hawkins-Kennedy test, noting whether each was positive or negative] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
8. [Result of the Scarf test for AC joint pathology, noting whether positive or negative] (Only include if the AC joint was found to be tender on palpation and if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit this step entirely. Write as part of the narrative paragraph.)
[Radiology findings and any relevant interpretations] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
[A narrative account of the discussion held with the patient regarding options for future investigations and management of their shoulder symptoms] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format.)
[Investigations planned] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
[Treatment planned] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
[Any other relevant actions including counselling or referrals] (Only include if explicitly mentioned in the transcript, contextual notes, or clinical note, else omit section entirely. Write in full sentences in paragraph format. Do not use bullet points.)
"Many thanks again for the referral."
"Kind regards"
