Comprehensive Physiotherapy Assessment

Subjective

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1. Chief Complaint (CC):

Patient reports right shoulder pain following a skiing injury approximately six months ago. Pain intensity varies from 4/10 on typical days to 7-8/10 on worse days.

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2. History of Present Illness (HPI):

The injury occurred about six months prior during skiing. The patient experiences pain primarily when reaching behind the back, describing this movement as very painful and essentially not possible. Activities involving the arm positioned in front of the body are generally tolerated without significant pain. Resting the arm by the side alleviates symptoms. The patient notes occasional radiating pain with tingling sensations extending from the shoulder down into the right bicep. No clear numbness reported in fingers. Functional limitations include inability to reach behind the back and pain with certain shoulder movements. Patient provided video responses regarding weakness and overhead activity but specific details from videos are not included here.

 

3. Review of Systems (ROS – physiotherapy-focused):

- Musculoskeletal: Persistent right shoulder pain with aggravation on reaching behind the back; no reported swelling. - Neuromuscular: Reports tingling radiating from shoulder to right bicep; no numbness in fingers; no reported weakness though video responses were provided for assessment.

- No balance issues, fatigue, or shortness of breath reported. 4. Current Medications: No medications reported or documented.

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4. Current Medications: No medications reported or documented.

No medications reported or documented.