Please feel free to either copy and paste the template below, or you can download it at the link below.
Let me know if you have any updates or corrections.
**Start of Template**
Assessment: The patient presents with shoulder pain, limited range of motion, and discomfort during overhead activities. The differential diagnosis includes rotator cuff injury, adhesive capsulitis (frozen shoulder), shoulder impingement syndrome, osteoarthritis, and referred pain from cervical spine issues.
Plan: Educate the patient about the common causes of shoulder pain and the importance of activity modification. Recommend non-pharmacologic treatments such as physical therapy, gentle stretching, and ice application for pain relief. For pharmacologic management, prescribe NSAIDs: ibuprofen 400-600 mg orally every 6-8 hours as needed (max 2400 mg/day) or naproxen 250-500 mg orally every 12 hours as needed (max 1000 mg/day), with acetaminophen as an alternative if NSAIDs are contraindicated. Schedule a follow-up in 4-6 weeks to reassess pain and mobility. If symptoms persist or worsen, consider imaging studies (e.g., X-ray or MRI) and discuss further treatment options such as corticosteroid injections or referral to an orthopedic specialist. Instruct the patient to report any new symptoms such as significant swelling or inability to move the shoulder.
**End of Template**