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Finger pain right thumb pain Intra-articular fracture at the base of the right thumb Plan ORIF right thumb proximal phalanx Return to clinic 2 weeks post op icd10_description | 72 |
shoulder pain start PT icd10_description | 37 |
Deformity Eval Follow Up Bilateral Club Foot Wear brace at night icd10_description | 50 |
Post Op, Right Knee pain Doing well post-op. Progressing as expected. icd10_description | 23 |
Left Wrist pain Left wrist pain left wrist tendinitis Possible scapholunate ligament injury Plan Begin Medrol Dosepak Obtain MR arthrogram of left wrist RTC with MRI results icd10_description | 73 |
Followup Osteoarthritis of knee 1 yr fu tka left Left total knee arthroplasty 1 year out, doing well. Views x3 of the left knee show stable component. Small lucency under the medial tibial plate. Otherwise, no changes. Follow up in 1 year's time with 3 views left knee. Otherwise, follow up as needed. icd10_description | 17 |
Right Hip pain Right Hip/Leg Pain And Numbness x 2 Months Sciatica vs radiculopathy right. Left lateral epicondylitis icd10_description | 28 |
Shoulder pain fu left shoulder Three months open reduction greater tuberosity fracture left proximal humerus. X-rays have shown fragmentation and displacement of the fracture fragment. He is progressing well but given his young age and physically demanding job, I have recommended MRI evaluation of the left shoulder to evaluate the rotator cuff. If he has a full thickness rotator cuff tear, this will need to be addressed acutely as it will be problematic if it is allowed to progress. He will follow up in 2 to 3 weeks' time. icd10_description | 61 |
Post Op, Left Ankle pain Left Lateral malleolus fracture. The fracture is healing well in good alignment. icd10_description | 82 |
Post Op, Left Hip pain Osteoarthritis of the Left Hip. icd10_description | 16 |
Right Knee pain Follow Up Right Knee Pain Post Physical Therapy Activity as tolerated icd10_description | 83 |
11 weeks post op LT foot fusion, gastrocnemius recession/ doing well > Lt Triple with Gastroc recession || Residual left clubfoot with planovalgus collapse Weak left post tib tendon Achilles contracture, left icd10_description | 50 |
Bilateral Knee pain bilateral knee pain Osteoarthritis of the Right knee. with MMT. Osteoarthritis of the left knee. icd10_description | 17 |
Bilateral Hand pain, Bilateral Foot pain Neuropathy, nerve pain..since last year Plan -We discussed these findings. She likely has a component of carpal/cubital tunnel syndrome and will order EMG/NCS to confirm. If confirmed will refer to Dr. for consider injections vs. surgery. Continue night splints for now. Will call with EMG/NCS results. -Discussed that neurontin is good medication for neuropathic foot pain and that good glycemic control can help to prevent worsening. Continue medical management per Dr. . Counselled patient regarding potential complications associated with diabetic neuropathy including nonhealing wounds, infection, amputation and systemic illness. -She inquired about pain medication and I suggested that neurontin is first line and that if this is not sufficient that increasing dose help. Could consider pain management referral at some point, if necessary. icd10_description | 40 |
Bilateral Knee pain New Patient Bilateral Knee Pain Old Injury Car Accident Lump On Right Heel 6 Months injection given Rt knee, activity as tolerated, achilles stretching, ice icd10_description | 31 |
Left Hand pain Left metacarpal base Buckle fracture Plan Begin wearing wrist splint at all times RTC in 2 wks for exam and xrays icd10_description | 72 |
Left Wrist pain Comminuted left distal radius fracture, displaced Plan ORIF left distal radius wearing wrist splint until surgery RTC 2 weeks post op icd10_description | 65 |
10 weeks post op LT ankle medial malleolus Fx ORIF/ doing well Left Medial malleolus fracture with widening of medial clear space/syndesmosis injury > ORIF med malleolus with ORIF of syndesmosis icd10_description | 82 |
Bilateral Hip pain Right labral tear with mild OA icd10_description | 16 |
17 weeks post op LT ankle Peroneus Brevis tendon repair > LT Scope/ATF&CF Brostrom/Peroneus Brevis repair icd10_description | 25 |
Post Op POST OP LEFT SHOULDER S/P L RCR and SAD icd10_description | 37 |
Right Wrist pain right wrist injury Plan -will order MRI to rule out TFCC tear -will call with results, if MRI is abnormal will refer to Dr. icd10_description | 25 |
month follow up L RCR, SAD, biceps tenotomy icd10_description | 37 |
Right Shoulder pain New Patient Right Shoulder/Upper Arm Weakness Activity as tolerated Call if Worsens icd10_description | 37 |
follow up right knee Right knee chondrocalcinosis with possible recurrent LMT icd10_description | 83 |
Bilateral Shoulder pain Full thickness left rotator cuff tear, moderate osteoarthritis of glenohumeral joint with labral tear Biceps tendonitis bilaterally with left biceps subluxation Right subacromial impingement and Inferior labral tear Plan Obtain intra-articular injections of bilateral shoulders Begin PT of bilateral shoulder for rotator cuff strengthening Return to clinic in 6 wks for exam icd10_description | 37 |
MONTH FOLLOW UP LEFT KNEE S/P L LMR icd10_description | 83 |
F/U LT ankle pain/ wants to go back to work Sx> LEFT Peroneal tendon tenodesis () icd10_description | 32 |
Femur, Post Op 7.5 wks post-fx, parents concerned about ankle, would like xr 2.5yoF with left femur shaft fx s/p hip spica casting 7.. Stable alignment on xrays healed in acceptable alignment for age. Plan -okay to progress activity as tolerated -continue PT, expect mobility to improve with time -have previously discussed potential for growth disturbance and limb length inequality with parents -fu 6 weeks for repeat exam icd10_description | 25 |
Bilateral Knee pain New Patient Bilateral Knee Pain Old Injury Car Accident Lump On Right Heel 6 Months injection given Rt knee, activity as tolerated, achilles stretching, ice icd10_description | 17 |
Followup Rotator cuff syndrome po 5 mos left shoulder 5 months out left shoulder arthroscopy with debridement and extensive debridement of the labrum and posterior glenoid cartilage. Rotator cuff was intact, and he underwent a subpectoral biceps tenodesis. Injection at last visit helped significantly along with physical therapy. He is not doing well continue to work on strength and follow-up on an as-needed basis icd10_description | 26 |
Finger pain 3 months post left thumb surgery Laceration to left thumb Left thumb digital nerve injury Collateral ligament injury Open fracture distal phalanx of thumb Plan Steroid injection to thumb Continue neoprene thumb spica splint Begin naproxen day and night No use left hand RTC in 6 wks for exam icd10_description | 71 |
Followup Knee pain bilateral knee pain Right knee pain secondary to osteoarthritis. She is not a good surgical candidate. I discussed with her a steroid injection . She has been following up at the university with endocrinology and reports that she has been told that she can no longer have steroid injections. Regarding the left knee, stable total knee components with no abnormalities of the hip. Pes bursitis. We will try topical treatment. I do not think she will tolerate her brace well. She does use a walker for function. X-rays , AP pelvis, show mild hip arthritis. No changes in prior hardware. Right femur shows a healed stress fracture with no changes in hardware. Bilateral knees right knee shows medial joint line sclerosis and joint space narrowing and left knee shows a stable total knee. She will follow up as needed. icd10_description | 17 |
Right Shoulder pain NO XRAYS L distal biceps chronic strain/tendinopathy icd10_description | 37 |
Knee pain bilateral knee pain An 11-year-old girl with mild patellofemoral laxity bilaterally and patellofemoral syndrome. She will work with physical therapy for some proximal chain strengthening. They will follow up ' time. Views x3 of to bilateral knees show open physes and well positioned patella and a trochlear groove. Normal patellar groove depth and no abnormalities on x-ray. icd10_description | 22 |
Post Op, Left Elbow pain 1 week post left elbow surgery 6yoF with left type 3 SCH fx s/p CRPP 7 days postop. Preop PIN nerve palsy (neuropraxia). Plan - in cast with sling at all times except for hygeine -fu 2-3 weeks for cast removal, 2V left elbow and pin removal if sufficient healing -discussed PIN palsy and recommend continued monitoring, I expect improvement with time icd10_description | 67 |
Finger pain left thumb Left thumb ulnar collateral ligament injury Plan Continue left thumb spica splint at all times even at night Light duty at work with 2lb lifting restriction RTC in 4 wks for exam icd10_description | 66 |
Ankle pain left ankle injury Left ankle sprain. Will work with physical therapy. Progress with activity as tolerated. Views x3 of the left ankle show normal bony alignment and normal syndesmosis with a small amount of soft tissue swelling over the lateral distal aspect of the ankle. Follow up as needed. icd10_description | 89 |
Right Hip pain 4 month post injury Plan -progress activity as tolerated without restrictions -continue PT for shoulder ROM and generalized conditioning -We discussed natural hx of shoulder arthritis and options including conservative management vs. shoulder arthroplasty. She is concerned about surgery given her cardiac history. She is not interested in surgery for her shoulders at this point. -fu PRN icd10_description | 58 |
Right Hand pain Right fracture of the small finger Plan Begin wearing right exos boxer's fracture brace RTC in 1 wks for exam and xrays icd10_description | 72 |
NP- Bilateral foot arthritis, referred by Dr. / no recent Xrays Peripheral neuropathy, non-diabetic- severe Clawtoe (1st IP)- hammertoes, L> icd10_description | 5 |
Right Knee pain, Post MRI/CT Follow Up Right Hip Pain MRI Results Refer to Dolm Possible Hip ATS icd10_description | 25 |
Right Knee pain small mass just below Rt knee Osteochondroma posteromedial right tibia icd10_description | 0 |
Post Op po 8 wks acl 7 weeks out right ACL reconstruction lateral meniscus repair. f/u 6 weeks - Avoid deep squatting. icd10_description | 83 |
Post MRI/CT Right wrist sprain Left wrist pain, probable prominent hardware Right subscapularis tear tendon, biceps tendonitis, and subluxation Plan Right subacromial space injection Continue wearing right wrist splint as needed along with anti inflammatories Continue meloxicam for one more month Continue at home PT exercises for the right shoulder RTC for exam icd10_description | 37 |
Bilateral Hand pain Post EMG Left shoulder subacromial impingement syndrome Bilateral carpal tunnel syndrome Bilateral cubital tunnel syndrome Lateral epicondylitis, right Plan Bilateral carpal tunnel injections given Wrist splints bilaterally to be worn at all times Return to clinic in 6-8 weeks for exam icd10_description | 3 |
Left Elbow pain 8 months post left elbow surgery Plan -discussed treatment options at this point again with interpreting spanish. I feel that he would benefit now from removal of implants including the broken screw. We discussed that if he has no gross motion after implant removal then we be able to leave his radial head as is. If there is motion present at the fracture during surgery then I recommend a radial head resection to prevent. I do not feel that he would need a radial head arthroplasty at this point as his other associated injuries are well healed. I will also perform excision of his exostosis in an effort to improve his ROM. -We discussed risks of further surgery including neurovascular injury, worsening stiffness, continued pain and risks of general anesthesia. -will schedule surgery and obtain worker's comp authorization -filled out PPR icd10_description | 65 |
6 weeks post op / having pain Rt TAA Lt TAA icd10_description | 99 |
2 day post op 1st MTP fusion, 2-5 hammertoes > Left Rheumatoid forefoot reconstruction icd10_description | 39 |
Right Elbow pain 3 months post right elbow, surgery was in Right Capitulum fracture s/p ORIF Right Radial head fracture s/p ORIF Plan Referral to in for PT for elbow ROM RTC in 4 wks for exam icd10_description | 65 |
Finger pain, Left Wrist pain left thumb Left thumb CMC arthritis Left dequervain's tendonitis Plan Begin Medrol dose pak Begin wearing exos thumb spica splint Begin topical anti inflammatory Begin 500 mg naproxen after course of Medrol dose pak RTC in 6 wks for repeat exam icd10_description | 18 |
Deformity Eval New Patient 5 Day Old Male With Hip Dysplasia Harness Placed In Hospital wear harness as instructed icd10_description | 49 |
Right Knee pain no xrays patellar chondrosis icd10_description | 22 |
Left Shoulder pain Lt shldr results Bilateral RC tendonitis, now improving icd10_description | 63 |
2 weeks post op RT ankle scope RIGHT Ankle [} Ankle scope for anterior cicatrix and tenolysis of PL/ Tendons || RIGHT Ankle [] Anterolateral ankle impingement secondary to cicatrix band | Chronic lateral ankle instability | Dislocated Peroneal tendons without tear> Groove deepening procedure icd10_description | 24 |
Right Knee pain Right Knee Gelsyn Injection #3 LOT # 1610016 injection given, activity as tolerated, series 3 finished, call if pain doesnt resolve icd10_description | 17 |
Right Hand pain Bilateral CMC arthritis, worse on the right; improving Arthritis of right index and middle finger DIP joints Plan Begin wearing bilateral wrist splints at night and with over exertion of the wrists RTC PRN icd10_description | 14 |
Bilateral Hip pain Follow Up Bilateral Hip Pain Post Injection activity as tolerated , Call if worsens icd10_description | 34 |
Post Op Laceration to left middle and ring fingers Laceration of left middle finger extensor tendon Plan Sutures removed Begin scar massage Wear alumafoam splint at all times No lifting with left hand RTC 2 wks for exam with plan to begin gentle ROM icd10_description | 71 |
Pre Op right shoulder nnmc Large acute RCT icd10_description | 63 |
Right Knee pain Follow Up Right Knee Pain Post Gelsyn 3 Series Activity as tolerated Call if worsens icd10_description | 17 |
Left Knee pain Left Knee Gelsyn Injection #1 LOT # 1610016 injection given, activity as tolerated icd10_description | 17 |
NP- LT ring finger fracture wear splint, protective activity, recheck wound 1 week icd10_description | 72 |
Left Hip pain Follow Up Left Hip Pain Post Injection Fluoro Activity as tolerated. Call If worsens. icd10_description | 16 |
Post Op Right proximal humerus fracture, s/p ORIF with conventus cage Pain in left thumb Left thumb CMC arthritis Plan Referral to for custom splint Continue PT for thumb with ROM and strengthening Continue 15 mg Meloxicam daily Continue thumb splint to protect during day time but take off at night RTC in 4 wks for exam icd10_description | 18 |
Right Shoulder pain Follow Up/Xrays Right Shoulder Fracture Start Rom and strengthening icd10_description | 60 |
Left Knee pain The prosthetic components are well positioned with no sign of loosening. icd10_description | 99 |
Knee pain GELSYN #2 LEFT KNEE Bilateral knee osteoarthritis with good relief with viscosupplementation in the past. We will get authorization for this. , 4 views weightbearing bilateral knees show bone-on-bone arthritis with pencil-and-cup deformity of the medial joint line, sclerosis, osteophytes, mild sclerosis, and narrowing of the patellofemoral joint and lateral joint line. She will follow up for injections. icd10_description | 17 |
Left Elbow pain Left lateral epicondylitis Plan Continue 15 mg Meloxicam daily Continue left wrist splint as much as possible day and night RTC 6 wks for repeat evaluation icd10_description | 39 |
FOLLOW UP LEFT KNEE R TKA icd10_description | 17 |
Pre Op Subacromial impingement syndrome Right rotator cuff tendinopathy Plan Right shoulder labral repair and biceps tenodesis with possible rotator cuff repair Return to clinic 2 weeks post op Right rotator cuff tendinopathy Plan Right shoulder labral repair and biceps tenodesis with possible rotator cuff repair Return to clinic 2 weeks post op icd10_description | 37 |
Followup Arthritis of wrist right wrist pain- no better Assessment 6 months status post right scaphoidectomy with capitolunate fusion Plan Right wrist joint injection Return to clinic for exam icd10_description | 19 |
None recorded. Fracture at the base of the right small finger, displaced Fracture of the right scaphoid, non displaced Plan Continue wearing thumb exos splint for 2 more weeks Continue to work with light duty for work RTC in 4 wks for exam and final xrays icd10_description | 72 |
Left Wrist pain Complex regional pain syndrome, resolving Left wrist tendonitis, resolving Plan Begin wearing left wrist splint at night Begin Begin Medrol Dosepak to help with inflammation RTC in 6-8 wks for exam icd10_description | 7 |
Right Ankle pain rolled ankle Er Plan -We discussed treatment options and I recommend ORIF given that cast did not reduce ankle . We discussed general risks of surgery including infection, general risks of anesthesia, implant prominence, etc. She expressed understanding and wants to figure out her options for insurance as she currenlty has none. -continue NWB RLE in cast with crutches -continue elevation -will try to coordinate and schedule surgery for next week icd10_description | 82 |
Post MRI/CT fu mri results ref by Dr. Acute injury with left knee ACL tear, possible tibial impaction fracture, MCL strain, and medial and lateral meniscus tears. A large hemarthrosis was aspirated , 30 mL were removed. He was given a steroid and local injection. He has a knee brace that was given to him by Dr. . He will work on range of motion and work on physical therapy. I have recommended using the crutches. He return to sedentary work next week. We will re-evaluate ' time and see where he is doing at. I had a discussion with him regarding ACL reconstruction and surgery for his meniscus tears. He currently would like to see how he does at work without surgery. We will re-evaluate ' time. icd10_description | 23 |
Post Op, Right Ankle pain 2 Week Post Op/Suture Removal Right Ankle Haglunds Resection sutures d/c'd, start WB in boot , recheck 4 weeks icd10_description | 38 |
mon th follow up right shoulder S/P R RCR, SAD, and biceps tenotomy with post-op stiffness icd10_description | 37 |
Post Op Right small and left ring trigger finger s/p release Plan Continue scar massage No restrictions Continue naproxen PRN RTC in 6 wks icd10_description | 31 |
Right Knee pain New Patient Right Knee Swelling Not Sure How Long MRI Scheduled For No intervention needed. Cancel MRI. Call with worsening pain. icd10_description | 35 |
19 1/2 weeks post op LT achilles tendon repair/ doing better Left Achilles/Haglund/FHL + Peroneus Brevis repair icd10_description | 38 |
F/U LT ankle scope, procedure/ having pain and swelling, feels he cannot drive for work yet > Lt ankle scope+Brostrom+peroneal repair Chronic left lateral ankle sprain icd10_description | 38 |
15 1/2 weeks post op LT achilles tendon repair/ doing great Left Achilles rupture, acute || Pre-op DVT. icd10_description | 89 |
Bilateral Knee pain Follow Up Bilateral Knee Pain Patient Would Like Injections Last Injections injection given, activity as tolerated icd10_description | 17 |
Post Op Scaphoid and Lunate edema, right Wrist pain, right Right carpal tunnel syndrome s/p release Plan Continue splint Begin 15 mg Meloxicam daily Begin scar massage No lifting heavier than 2lbs with right hand RTC 3 wks for exam icd10_description | 25 |
Post Op s/p left reverse total shoulder Left shoulder pain Left Rotator cuff tear Left Shoulder arthritis Plan Continue PT for active and passive ROM exercises and strengthening No restrictions with the left arm Return to clinic 6 wks for exam and xrays Left shoulder pain Left Rotator cuff tear Left Shoulder arthritis Plan Continue PT for active and passive ROM exercises and strengthening No restrictions with the left arm Return to clinic 6 wks for exam and xrays icd10_description | 19 |
Finger pain rt middle..injured in the middle of night..NNMC ER Plan -start early ROM and buddy taping -fu 4 weeks for repeat exam icd10_description | 73 |
EP- LT hip pain Plan -I discussed these findings with the patient. We discussed that he does have signs of a small degree of wear, which is not unexpected after 17 years. He is asymptomatic and I feel that we can continue to monitor this radiographically. He is in agreement. -fu 1 year for AP pelvis and 2V left hip, sooner if he develops any issues. icd10_description | 99 |
3 weeks post op LT 1st MTP fusion, 2-5 MT head resection > Left Rheumatoid forefoot reconstruction icd10_description | 39 |
Pre Op SX RIGHT SHOULDER S/P R SLAP repair with biceps tendinitis icd10_description | 37 |
Post Op, Knee pain 2 wks post-op Plan -NWB RLE in hinged knee brace from 0-40 deg -NWB LLE in boot -finish lovenox for DVT prophylaxis -fu 2 weeks for repeat 2V right knee (plateau view and lateral) and 3V left foot icd10_description | 88 |
Post Op 2.5 months post right carpal tunnel release Right shoulder pain Bilateral carpal tunnel syndrome, s/p right endoscopic release Right subacromial impingement Plan No restrictions with her right hand Monitor for new or worsening symptoms of the right shoulder Recommend repeat evaluation with Dr. for exam icd10_description | 37 |
8 weeks post op RT foot 2nd and 3rd hammetoes RIGHT Severe bunion with indeterminate degree of arthritis (1st MTP) Severe 2-4 hammertoes with MTP instability [>> Rt 1st MTP fusion/HTs 2-5 w/ MTP] > Rt 2nd and 3d metatarsal head excisions icd10_description | 20 |
Left Forearm pain, Right Wrist pain, Fracture Care 4 WKS POST INJURY Plan -discontinue casting -Rx for wrist brace LUE -fu 4 weeks for cast removal and 2V right forearm, 2V left wrist icd10_description | 65 |
Left Hand pain 1–left thumb CMC pain 2–left wrist pain 3–Concern for left scapholunate ligament injury 4-left trigger thumb Plan Repeat left thumb CMC injection Left thumb trigger finger injection Obtain MRI of the left thumb and wrist RTC for the evaluation of the left thumb icd10_description | 25 |
Post Op, Left Ankle pain Post Op Left Ankle Scope WBAT inBoot. Start PT. icd10_description | 89 |
Left Wrist pain Left wrist synovitis, possible scapholunate injury Plan Left steroid injection to wrist joint Continue Left wrist splint Ice as needed Begin 15 mg Meloxicam daily RTC PRN icd10_description | 73 |
Right Foot pain Right big toe Right great toe nail avulsion Plan Wear shoes when participating in activities RTC in 6-8 wks for exam icd10_description | 87 |
Followup Osteoarthrosis of the carpometacarpal joint of the thumb fu thumb wants to discuss surgery Left Carpal tunnel syndrome Left thumb CMC arthritis Plan Left thumb CMC arthroplasty with stablyx implant Return to clinic 2 weeks post op icd10_description | 3 |
Discuss RT 1st MTP fusion, 2-5 hammertoes scheduled for F/U bilateral foot pain/ lab results Severe bunion, dislocated MTP joints with chronic synovitis and hammertoes (Right foot more symptomatic than left) icd10_description | 20 |
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