AI SOAP Notes Builder
Er, this is… ah yes, Michael Abbotts, 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:
Patient reports left shoulder pain that has persisted for approximately 4-5 weeks, with an increase in severity over the last ten days. He denies any specific trauma but mentions the onset of symptoms around the time he started DIY activities at home, including painting a ceiling for an extended period. The pain is primarily located at the front of the shoulder and sometimes radiates into the upper arm. It is particularly noticeable when reaching overhead into cupboards or putting on a jacket.
Objective:
Physical examination revealed reduced shoulder abduction and a painful arc at around 90 degrees. Tenderness was noted over the bicipital groove. Rotator cuff strength was within normal limits, though there was mild discomfort on resisted supination of the forearm.
Assessment:
The symptoms and examination findings suggest biceps tendinopathy, likely exacerbated by recent overhead activities.
Plan:
Recommended patient to avoid overhead activities and start isometric loading exercises for the biceps. Scheduled a follow-up appointment in two weeks to reassess the condition and progress with the management plan.