AI Scribe for PM&R Physicians

SUBJECTIVE:
58-year-old male with 3-month history of progressive right shoulder pain and weakness. Reports difficulty raising arm overhead and pain at night interfering with sleep. Unable to perform overhead activities at work (construction). Previous trial of NSAIDs and home exercises with minimal improvement. Denies trauma, neck pain, or numbness.

Past Medical History: Type 2 diabetes, hypertension
Medications: Metformin, lisinopril, ibuprofen PRN
Social History: Active construction worker, right-hand dominant

OBJECTIVE:
General: Well-appearing, in no acute distress

Cervical Spine:
- ROM: full and pain-free in all planes
- Spurling's test: negative bilaterally
- No radicular symptoms

Right Shoulder Examination:
Inspection: mild atrophy of supraspinatus/infraspinatus fossae
Palpation: tenderness over greater tuberosity, AC joint non-tender

Range of Motion (degrees):
- Forward flexion: 110° (limited by pain, normal 180°)
- Abduction: 95° (limited by pain, normal 180°)
- External rotation: 45° (normal 90°)
- Internal rotation: reaches to L4 (normal T8)
- Painful arc between 60-120° abduction

Strength Testing (0-5 scale):
- Deltoid: 5/5
- Supraspinatus (empty can test): 3/5, painful
- Infraspinatus (external rotation): 4/5
- Subscapularis (lift-off test): 4/5

Special Tests:
- Neer impingement: positive
- Hawkins-Kennedy: positive
- Empty can test: positive, weak
- Drop arm sign: positive
- Speed's test: negative
- O'Brien's test: negative

Neurovascular: radial pulse intact, sensation normal C5-T1 dermatomes

Left shoulder: normal exam for comparison

IMAGING REVIEW:
Right shoulder MRI (reviewed):
- Full-thickness rotator cuff tear involving supraspinatus (2.5 cm retraction)
- Partial-thickness infraspinatus tear
- Moderate subacromial bursitis
- Mild AC joint arthropathy
- No evidence of labral pathology

ASSESSMENT:
1. Full-thickness rotator cuff tear, right shoulder - supraspinatus with retraction, partial infraspinatus tear
2. Secondary subacromial impingement syndrome
3. Functional limitation affecting work capacity

PLAN:
1. Surgical consultation discussed - candidate for arthroscopic rotator cuff repair given:
   - Tear size and retraction
   - Functional impairment
   - Failed conservative management
   - Patient age and activity level
   - Tissue quality adequate for repair

2. Pre-operative optimization:
   - Physical therapy: gentle ROM exercises to prevent stiffness, no strengthening
   - Continue NSAIDs, add tramadol 50mg TID PRN for pain control
   - Subacromial corticosteroid injection offered - patient deferred pending surgical decision

3. Post-operative rehabilitation planning discussed (if proceeding with surgery):
   - Phase 1 (0-6 weeks): passive ROM, sling immobilization
   - Phase 2 (6-12 weeks): active-assisted ROM, gentle strengthening
   - Phase 3 (3-6 months): progressive strengthening, functional exercises
   - Expected return to full duty: 6-9 months

4. Work status: light duty only - no overhead lifting, weight restriction 10 lbs

5. Functional goals:
   - Pain-free ROM
   - Return to full overhead activity
   - Return to construction work without restriction

6. Orthopedic surgery referral placed; follow-up in 2 weeks to review surgical decision and coordinate care