General Consultation Letter

Dear Referring Doctor,

Thank you for referring Linda Martin for severe pain in the left shoulder, neck, arm, and back, muscle weakness, and difficulty performing exercises. She was examined on 2025-10-23.

Linda Martin is a 78-year-old female who reports severe, stabbing, and constant pain localized to the left shoulder, neck, left arm, and lower back, with associated muscle weakness. The pain predominantly affects the arm and back of the neck, radiating down the arm below the elbow to the hand. She describes the pain as persistent for some time and worsening with movement and pressure, such as lying on the right side. She is able to perform pendulum exercises but finds them painful. The pain significantly limits her ability to perform exercises and daily activities, causing difficulty holding objects and covering herself in bed. She has a history of multiple surgeries and a previous rotator cuff injury. She lives independently with assistance from her daughter and granddaughter for shopping and household tasks. She uses a walker and avoids stairs for safety. She does not receive formal home care services and avoids visiting her daughter's house due to hazardous cement steps. She remains active at home, cooking, cleaning, and occasionally visiting neighbors for coffee. She has one pet dog. Family history is unremarkable for hereditary diseases or significant health conditions.

Current Medications:
Linda takes prescribed pain medication, three pills in the morning for pain control. She denies taking Tylenol.

Allergies:
None.

Observations:
Linda appeared sore and in pain during the examination. She described the pain as "like somebody stabbing me all the time." She demonstrated muscle weakness in the left upper extremity and was unable to independently apply or remove the TENS machine electrodes. She uses a walker and ambulates with assistance, though her gait is unsteady.

Vital Signs:
Not documented.

Physical Exams:
Musculoskeletal examination revealed tenderness and soreness in the left shoulder, neck, and back muscles. Neurological examination noted tingling sensation around the shoulder. No other abnormalities were documented.

Investigations:
None relevant.

Procedures:
TENS therapy electrodes were applied during the visit for electrotherapy to help with pain relief.

Assessment:
Linda Martin presents with chronic left shoulder, neck, arm, and lower back pain with associated muscle weakness, likely related to chronic pain and a previous rotator cuff injury. The pain is severe and limits her functional abilities. The clinical findings support this impression.

Diagnosis:
Chronic left shoulder, neck, arm, and lower back pain with muscle weakness.

Plan and Recommendations:
1. Chronic left shoulder, neck, arm, and lower back pain with associated muscle weakness: I have administered TENS therapy once weekly in clinic today. Linda was instructed to use the TENS machine at home with assistance from her daughter or caregiver, programming it for 20 minutes up to three times daily as needed. She was advised against using the TENS machine during sleep or at night. She was encouraged to continue pendulum and gentle range of motion exercises as tolerated and to begin gradual strengthening exercises once pain is controlled. We will monitor for improvement in muscle strength and function.

2. Safety concerns due to mobility limitations: Linda was advised to avoid stairs and hazardous environments. She was encouraged to use her walker for ambulation and coordinate with family for assistance with daily activities and transportation.

Follow-Up:
I will see Linda again in one week to assess pain control and functional status.

Thank you for involving us in this patient’s care.

Samuel Patel  
General Practitioner  
Regional Medical Center