Date:
Patient:
主诉 (zhǔ訴) (Chief Complaint):
Describe the patient’s main reason for presentation, typically involving:
Shoulder pain (often described as a deep ache or stiffness)
Limited range of motion in the shoulder (difficulty with reaching, overhead activities)
Night pain that may disrupt sleep
History of Present Illness:
Onset and duration of symptoms
Severity of pain (graded on a scale)
Location and character of pain (deep ache, sharp pain)
Functional limitations due to pain and stiffness (dressing, reaching, activities of daily living)
Past medical history (trauma to the shoulder, previous surgeries, diabetes)
Past treatments for shoulder pain (medications, physical therapy)
Physical Examination:
Vital signs (temperature, heart rate, blood pressure, respiratory rate) – May be normal unless pain is severe.
General examination: Assess for overall health and posture.
Shoulder examination:
Active range of motion (painful and limited in all directions – flexion, abduction, external rotation)
Passive range of motion (may be slightly more than active due to examiner assistance)
Palpation of tenderness around the shoulder joint capsule
Special tests for shoulder impingement (may be positive)
Imaging Studies (may be ordered to rule out other causes of shoulder pain):
X-ray: May show some narrowing of the joint space in later stages but is often normal.
MRI scan (less commonly ordered): May reveal inflammation and thickening of the shoulder capsule.
Assessment:
Diagnose adhesive capsulitis (frozen shoulder) based on clinical presentation (pain, stiffness, and limited range of motion).
Consider the stage of adhesive capsulitis (freezing, frozen, thawing) based on symptom progression.
Identify potential underlying causes (trauma, diabetes).
Plan:
Pain Management:
Medications: Over-the-counter pain relievers (NSAIDs, acetaminophen) or prescription medications for stronger pain control.
Ice therapy for inflammation reduction.
Physical Therapy: Crucial for regaining range of motion and improving function. Therapist will focus on gentle stretching, strengthening exercises, and modalities like ultrasound or electrical stimulation.
Corticosteroid injection: May be injected into the shoulder joint to reduce inflammation, especially in the early stages (freezing phase).
Surgery (rarely needed): Arthroscopic capsular release may be considered in severe cases with minimal improvement despite conservative measures.
Progress Notes:
Document response to treatment, including changes in pain level, range of motion, and functional abilities.
Monitor for side effects of medications.
Describe adherence to physical therapy exercises and progress made.
Adjust the plan as needed based on the patient’s response.
Prognosis:
Adhesive capsulitis is a self-limiting condition, but recovery can take 1-2 years. Early diagnosis, physical therapy, and pain management are essential for a good prognosis.
Disclaimer: This template is for informational purposes only and should not be used as a substitute for professional medical advice. A qualified healthcare professional can diagnose and develop a personalized treatment plan for adhesive capsulitis.