Er, this is… ah yes, Michael Abbott, forty years old, came in today complaining of, um, left shoulder pain… it’s been going on for about, well, maybe four, five weeks, can’t quite remember exactly, but he says it’s been worse in the last ten days. No, uh, no trauma as such, but he did start doing some DIY at home and, uh, was painting the ceiling for two days straight which might be related. Pain’s mostly at the front, sometimes a bit into the upper arm, and he says he feels it when, um, reaching up into cupboards or putting on a jacket. On exam, I found reduced abduction, painful arc around ninety degrees, and tenderness over the bicipital groove. Rotator cuff strength seems okay but there’s mild discomfort on resisted supination. I’m thinking biceps tendinopathy. I’ve advised him to ease off overhead work, start some isometric biceps loading, and we’ll review in… let’s say two weeks.
Subjective:
Michael Abbott reports left shoulder pain persisting for approximately 4-5 weeks, with a recent worsening over the last ten days. He mentions no specific trauma but has been engaged in DIY activities at home, including painting the ceiling continuously for two days, which may be related to his symptoms. The pain is primarily situated at the front of the shoulder, occasionally radiating into the upper arm. Symptoms exacerbate when reaching upwards or when putting on a jacket.
Objective:
Upon examination, Michael exhibits reduced abduction and a painful arc around ninety degrees. There is noted tenderness over the bicipital groove. Rotator cuff strength is adequate, but there is mild discomfort on resisted supination. These findings suggest possible biceps tendinopathy.
Assessment:
The clinical presentation and symptoms are indicative of biceps tendinopathy, likely exacerbated by recent overhead activities.
Plan:
Michael has been advised to reduce overhead activities and commence isometric biceps loading exercises. A follow-up appointment is scheduled in two weeks to review progress and adjust the treatment plan as necessary.
From those notes and from other details contained within his Physiodiary record, Physio-AI produced the following with just a few mouse clicks:
Demonstration Practice
21 The Street
Anytown
Telephone: 0123 456789
10/08/2025
Dr John Smith
21 The Street
Anytown
123456
John@smith.com
Mr Michael Abbott DoB: 1st Jan 1985
Dr Smith,
I am writing to summarise the treatment plan for Michael Abbott, who presented with persistent left shoulder pain that has been increasing in severity over the past four to five weeks. Michael reported that the pain began without specific trauma but noted that it might be related to recent DIY activities, including painting the ceiling, which involved repetitive overhead movements.
During the physical examination, it was observed that Michael has reduced shoulder abduction with a painful arc around ninety degrees and noticeable tenderness over the bicipital groove. Although his rotator cuff strength appears adequate, there is mild discomfort during resisted supination. Based on these findings, the assessment suggests biceps tendinopathy, likely exacerbated by his recent overhead activities.
To manage his symptoms, Michael has been advised to limit overhead activities. He has also been instructed to begin isometric biceps loading exercises to strengthen the affected area. We have scheduled a follow-up appointment in two weeks to monitor his progress and make any necessary adjustments to his treatment plan.
Please feel free to contact me if you require further information or have any recommendations regarding Michael's ongoing care.
Kind regards
Fred the Physio
Demonstration Practice
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