Initial Shoulder Consultation

(Write this letter directly to the patient using "you" and "your" throughout. Write in full sentences using a conversational and professional tone. Never invent or infer any patient details, assessment findings, plan items, interventions, or management steps. Use only the transcript, contextual notes or clinical note as the sole reference for all information included in this letter.) Date of Consultation: [Date of consultation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Use format DD/MM/YYYY.) Patient Name: [Patient's full name] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely.) Patient Date of Birth: [Patient's date of birth] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Use format DD/MM/YYYY.) Diagnosis: [Document the clinician's explicitly stated diagnosis or diagnoses, including any associated details or qualifiers] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Never invent or infer a diagnosis. Write in full sentences addressing the patient directly.) Oxford Shoulder Score: [Oxford Shoulder Score total and any individual sub-scores or components, along with the date the score was performed] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note. If the score is mentioned, report it in the format "[score]/48". If the score is not mentioned, write "xx/48".) History: [Patient's age, hand dominance, occupation, and any sporting or physical activities relevant to the shoulder presentation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences addressing the patient directly.) [Description of the patient's shoulder symptoms including night pain, rest pain, ability to lie on the affected shoulder, sleep disturbance, pain score, and difficulty with overhead activities] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences addressing the patient directly.) [Description of any associated symptoms including neck pain and any pins and needles or altered sensation in the upper limb] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences addressing the patient directly.) [Relevant past medical history including any chronic conditions, previous surgeries, or significant medical events relating to the current presentation] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences addressing the patient directly.) Co-morbidities: [All co-existing medical conditions, relevant details for each condition, known allergies, and smoking status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each condition on a new line.) Clinical Examination: [Findings from the physical examination including observations, palpation findings, range of motion, special tests performed and their results, and any other relevant clinical findings] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences addressing the patient directly.) Investigations: [Diagnostic tests or procedures that have been performed or are pending, including imaging results, laboratory tests, or other relevant investigations, along with their findings or current status] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write as a list with each investigation on a new line.) Plan: [Proposed management strategy including treatments, referrals, medications, follow-up schedule, patient education, and any other planned interventions, with clear explanation of next steps and what is expected of the patient] (Only include if explicitly mentioned in the transcript, contextual notes or clinical note, else omit section entirely. Write in full sentences addressing the patient directly.)