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
Avia
21 The Street,
Anytown
Policy number : 123-457-789 Claim/Auth No: AB/21 Amount Claimed: £85
Dear Sir/Madam,
I am writing to submit a claim for the treatment provided to Michael Abbott, who has been under my care for left shoulder pain diagnosed as biceps tendinopathy. The condition was likely exacerbated by repetitive overhead movements from recent DIY activities.
During the consultation on 10 August 2025, Michael reported increasing pain over the last few weeks, particularly when reaching upwards or dressing. Examination revealed reduced shoulder abduction and tenderness over the bicipital groove. His treatment plan includes limiting overhead activities and initiating isometric biceps loading exercises.
Please find enclosed the clinical notes and relevant documentation to support this claim. I kindly request reimbursement as per the terms of Michael's health insurance policy.
Thank you for your attention to this matter.
Kind regards
Fred the Physio
Demonstration Practice
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