Read the case notes below and complete the writing task which follows.

Notes:

Patient Details:

• Mrs Nina Zim (DOB: 1/05/54)
• Married with four children

Medical History:

• 1990 Appendicectomy
• 2003 Fibroids: total hysterectomy
• 2007 Adenocarcinoma stomach (partial gastrectomy)
• 2011 Osteoarthritis cervical spine (OA CSP)

Referral:  By self

Physiotherapy Assessment – 3/08/1

Subjective Assessment

• 3-wk history interscapular & bilateral shoulder pain, gradual onset (no accident). Pain slowly
  getting worse. Aggravated when sitting at end of day and during night. Generally feels easier
  when moving.
• Pt walks at least 1/2 hour/day, 3x per week.
• Past history of neck pain – treated effectively by physiotherapy 10 months ago.
• No loss of weight.
• Not currently taking medication.
• X-ray in March 2012 – degenerative changes in CSP.

Objective Assessment

Posture: Stiff
Movement:

• CSP: *rotation L 60° slight pain
               rotation R > 70°
• Flexion normal
• Extension 50°
• Lateral flexion L 30°, R 30°
• Shoulder flexion L + R 150°
• External rotation L + R 70°
• Hand behind back R full range
• *Hand behind back L 1/2 range with pain
• Shoulder resisted movement: abduction no pain
                                                                external rotation no pain
                                                             * L internal rotation reproduced pain
                                                                 biceps no pain

Palpation:

• Tender C7/T1 spinous process
• Tender medial L shoulder (subscapularis tendon)

Treatment Day 1 (3/08/13)

• Passive movement (manual therapy) C7/T1
• Grade IV PA x 2 minutes
• Reassess: hand behind back pain eased
• Advice re sitting posture and use of lumbar roll

Treatment Day 2 (6/08/13)

• Subjective: Little change/maybe a little easier
• Objective: Hand behind back L pain end of range
• Treatment: Repeat Day 1. Added manual traction of the CSP & ultrasound

Treatment Day 3 (10/08/13)

• Subjective: Continuing to have problems especially at night. Unsettled & wakes. Very concerned because
                            of cancer 6 years ago.
                            Complaining more L sided arm pain > elbow
• Objective:     L shoulder pain reproduced with end of range hand behind back & resisted internal rotation =
                             ? subscapularis tendinitis
• Treatment:  Treat L shoulder
                              1. Ultrasound
                              2. Home advice re hot water bottle
                              3. Refer to own doctor

Writing task:

Using the information given in the case notes, write a letter of referral to Mrs Zim’s doctor. Address the letter to Dr Harold
Bone, Central Medical Clinic, Long Street, Stillwater.

In your answer:

• Expand the relevant notes into complete sentences
• Do not use note form
• Use letter format

The body of the letter should be approximately 180–200 words.