text stringlengths 40 2.35k | labels int64 0 100 |
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Left Knee pain Left Anterior Cruciate Ligament tear. icd10_description | 83 |
Finger pain Rt thumb pain, locks, swelling Right thumb trigger finger Plan Right trigger finger injection to A-1 pulley of thumb Return to clinic in 6 wks for exam icd10_description | 31 |
Followup Rotator cuff syndrome 9MOS RIGHT SHOULDER SCOPE 9 months out large rotator cuff repair, distal clavicle excision, and biceps tenotomy Continued Pain in the biceps area. Subacromial injection . She denies any focal biceps pathology. We will see how she does follow-up on an as-needed basis icd10_description | 37 |
Right Foot pain F/U RT foot pain Wean boot, start PT icd10_description | 89 |
Right Elbow pain 4 weeks post right elbow fracture Plan -discontinue casting and progress activity as tolerated -fu PRN -discussed potential but low likelihood for growth disturbance icd10_description | 60 |
Right Hip pain F/U RT hip pain, THR Hamstring and gluteal strain, ice, nsaids, gentle stretching icd10_description | 16 |
Left Wrist pain Distal radius fracture left wrist Ulnar styloid fracture left wrist Plan Transition out of wrist brace as you feel comfortable Use NSAIDs for pain Ice and elevate for pain RTC in 4-6 wks for final exam and xrays icd10_description | 65 |
Bilateral Hand pain, Right Shoulder pain Assessment Bilateral intrinsic tightness, improving Right shoulder subacromial impingement, improving Bilateral middle finger trigger finger, resolved Plan Continue NSAIDs PRN Continue hand therapy Continue home hand stretching exercises Return to clinic for repeat evaluation ic... | 31 |
Bilateral Hip pain Osteoarthritis of the Left Hip. Osteoarthritis of the Right Hip. The patient experienced significant improvement initially, but now the symptoms are returning. icd10_description | 16 |
5 weeks post op LT ankle scope, procedure/ having a lot of pain, wants pain management referral Sx > Lt Ankle scope + Brostrom || Left anterior ankle impingement syndrome icd10_description | 32 |
Right Knee pain NP- RT knee pain, no Xrays injection given, activity as tolerated icd10_description | 17 |
post op right knee S/P R knee scope lateral release and debridement of fat pad, cyclops, and MFC icd10_description | 22 |
Finger pain, Post Op 8days post-op..Lt small finger s/p Left small finger flexor tendon repair and Open fracture of left small finger proximal phalanx Joint stiffness of the left small finger Plan Begin scar massage Continue with , begin working on extension Continue 15 mg Meloxicam daily No lifting heavier than 5 lbs ... | 72 |
Leg pain 4 months post op right femur 74yoF with right periprosthetic supracondylar femur fracture s/p ORIF . Had failure off hardware (broken plate) after fall and incomplete healing of her fracture now s/p revision ORIF with RIA autograft 4 months postop. Stable xrays with continued healing , incisions healed without... | 48 |
Right Shoulder pain Right Shoulder pain and weakness. Probable Right RC Tear. icd10_description | 37 |
Right Hip pain Right hip Trocanteric Bursitis. with mild OA icd10_description | 34 |
Post Op Bilateral cubital tunnel syndrome, s/p right cubital tunnel release, Left cubital tunnel release Bilateral carpal tunnel syndrome, s/p right endoscopic carpal tunnel release, Left endoscopic carpal release Bilateral middle finger trigger fingers s/p right middle finger A-1 pulley release Plan Begin scar massage... | 31 |
Right Ankle pain 8 mos post-op Plan --progress activity as tolerated --NSAIDs PRN --MMI --filled out PPR icd10_description | 82 |
Post Op 2 weeks post op LT ankle Fx ORIF, surgery Plan -NWB RLE in cast -fu 6 weeks for cast removal and 3V ankle -Will advance weightbearing at that point -recs conveyed to facility icd10_description | 89 |
NP- Bilateral shoulder pain injection given, activity as tolerated icd10_description | 19 |
shoulder, LT knee pain, No Xrays injection given LTknee, activity as tolerated, start PT Rt shoulder icd10_description | 63 |
Right Hand pain Assessment Right carpal tunnel syndrome Plan Obtain EM of right UE Take ibuprofen when needed Return with EMG results icd10_description | 3 |
Post Op Bilateral cubital tunnel syndrome, s/p right cubital tunnel release, Left cubital tunnel release Bilateral carpal tunnel syndrome, s/p right endoscopic carpal tunnel release, Left endoscopic carpal release Bilateral middle finger trigger fingers s/p right middle finger A-1 pulley release Plan Begin scar massage... | 3 |
w/c post op right knee R ACLR, MMR, PLM icd10_description | 23 |
Post Op, Left Knee pain 2 Week Post Op Left Total Knee Osteoarthritis of the left knee. Doing well post-op. Progressing as expected. icd10_description | 17 |
Pre Op PREOP LEFT HIP SCOPE A 26-year-old male injured left hip in the military during Seals training. The left hip MRI shows a labral tear and small CAM deformity. The right hip shows labral degeneration and acetabular chondromalacia. We discussed options. Ideally, he would have gotten better benefit from the intraart... | 25 |
9 weeks post op LT achilles tendon repair Left Achilles rupture, acute || Pre-op DVT. icd10_description | 84 |
Right Shoulder pain, Post Op Doing well post-op. Progressing as expected. icd10_description | 37 |
Post Op, Tibia 7 wks post-op Plan -progress to WBAT in boot, transition off of crutches and out of boot -Rx for PT to help with ROM, strengthening and gait training -fu 6 weeks for 2V tibia/fibula icd10_description | 82 |
Right Wrist pain Left wrist pain Plan Send to PAC MED for short wrist splint Continue PT for strengthening exercises Take ibuprofen for a course of 2 weeks as prescribed RTC in 4 wks for exam icd10_description | 25 |
Bilateral Knee pain New Patient Bilateral Knee Pain X 15 Years Has Been Getting Synvisc 1 Every 6 Months Bilateral knee patellofemoral chondromalacia, early arthritis. I reviewed x-rays with her . Views x4 weightbearing of the left knee show preserved joint space, mild sclerosis of the medial tibial plateau bilaterally... | 22 |
Left Hip pain Left Hip Pain x 4 Months Since Right Knee Surgery With Dr. injection given, activity as tolerated, start PT icd10_description | 34 |
Right Knee pain New Patient Right Knee Injury During Basketball Camp Activity as tolerated, ice. icd10_description | 80 |
Pre Op PREOP LEFT SHOULDER Left shoulder recurrent shoulder dislocation. I have discussed with the high likelihood of recurrent dislocation at over 90%. He is going to speak with his parents, he is going to speak with his position coach, and talk with the trainer. They are going to make some decisions about likely surg... | 24 |
Post Op, Tibia 12 wks post-op 29yoM with left tibial pilon and tibia shaft fx s/p ORIF and exfix removal 12 weeks postop. Wounds healed without signs of infection. Stable fracture alignment with continued healing on xrays . Improved ankle ROM. Plan --WBAT LLE and okay to transition out of boot --rec ankle brace to help... | 82 |
Left Knee pain Plan -okay to progress WBAT -unlocked brace -will order MRI to evaluate for ACL/MCL and meniscus tears -will call with MRI results, if he needs surgery will refer to colleague icd10_description | 83 |
Left Shoulder pain left shoulder Left shoulder subacromial impingement. The plan is to work with physical therapy. He was given a steroid injection . He will follow up ' time. If not improved he will call us, and the plan will be for MRI evaluation of the left shoulder. icd10_description | 37 |
Post Op Bilateral carpal tunnel syndrome s/p left release Left cubital tunnel syndrome s/p release Plan Continue scar massage of incision sites RTC 6 wks for exam icd10_description | 3 |
MRI results LT foot Lt peroneal tendon tear icd10_description | 25 |
Post Op po day 1 right knee Right knee patellofemoral osteoarthritis, large loose body - post op day 1 - PT and f/u 2 weeks icd10_description | 17 |
Bilateral Hip pain Left hip Trocanteric Bursitis. Right hip Trocanteric Bursitis. icd10_description | 34 |
Hand pain LEFT HAND ,RING FINGER Left ring retinacular cyst Plan Aspiration of the left ring retinacular cyst RTC in 6 wks for exam icd10_description | 53 |
Right Hip pain Follow Up Right Hip Pain Post Hip Injection Under Fluoro Schedule surgery icd10_description | 16 |
Pre Op, Left Knee pain Left Medial Meniscus Tear. with patellar chondromalacia icd10_description | 22 |
Finger pain Right ring finger, nail bed check Plan -continue finger ROM -progress activity as tolerated -fu 6 weeks to check nail plate -discussed possibility of developing dystrophic finger nail to right finger that require surgical nail plate ablation -filled out PPR icd10_description | 25 |
Post Op left knee left ACl auto hamstring PT - f/u 4 weeks - focus on quads and full extension icd10_description | 23 |
Leg pain Suspected left toddler's fracture Plan Left long leg waterproof cast applied RTC in 2 wks for exam with xrays out of cast icd10_description | 82 |
Left Foot pain 9 days post I&D 17yoM with left foot fractures of 4th and 5th MT bases and 5th MT neck. Some concern initially for midfoot instability but anatomic alignment on CT from and MRI ruled out Lisfranc ligamentous injury. Has open lateral full thickness foot wound s/p excisional debridement and VAC . Wound hea... | 88 |
Right Knee pain Gelsyn Right Knee Injection #3 LOT # 1605018 injection given, activity as tolerated, series 3 injections finished icd10_description | 89 |
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 gr... | 22 |
Finger pain Right middle finger Laceration to left middle finger Laceration to digital nerve Tendonous mallet finger Plan Wear stack splint at all time for the next 4 weeks to improve extension Continue attending for left hand finger ROM, aggressive No lifting with left hand greater than 2 lbs Continue pain medications... | 71 |
None recorded. Plan -continue WBAT RLE -continue knee ROM -Rx for PT for knee ROM and strengthening, gait training -fu 2 months for 2V right femur icd10_description | 78 |
Left Wrist pain Left distal radial and ulnar shaft fracture Plan Cast removed RTC in 4 weeks for exam and xrays icd10_description | 65 |
Finger pain left index finger Avulsion fracture at the base of left index finger taped index and middle finger Monitor for new or worsening symptoms RTC in 6 wks for evaluation of ROM icd10_description | 72 |
Post Op, Right Knee pain Doing well post-op. Progressing as expected. icd10_description | 83 |
Post Op, Left Hip pain 11 days post-op Plan -WBAT LLE -continue posterior hip precautions -PT/OT for mobilization/ADLs -fu 4 weeks for AP pelvis and 2V left hip -recs conveyed to SNF icd10_description | 99 |
Knee pain fu 5 mos right knee Right clavicle fracture which is healed and stable, irritated from increased use; right knee now 5 months out removal of inferior patellar pole fracture and advancement of patellar tendon and is doing normal. . She will follow up on an as-needed basis. icd10_description | 82 |
Right Hip pain, Right Ankle pain NP- RT hip, RT ankle pain/ no Xrays Start PT icd10_description | 89 |
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_descrip... | 37 |
Left Elbow pain Plan -okay to progress activity as tolerated without restrictions -fu PRN -discussed potential for but low likelihood of growth disturbance icd10_description | 25 |
Leg pain Right Proximal tibia fracture Plan Cast removed Resume activities as tolerated RTC in 4 wks for exam and xrays icd10_description | 82 |
Left Shoulder pain Follow Up Left Shoulder Pain Post Physical Therapy Continue strengthening Call if worsens icd10_description | 63 |
Left Knee pain Followup Osteoarthritis of knee Anteromedial osteoarthritis of the Left knee. The patient experienced significant improvement initially, but now the symptoms are returning. icd10_description | 17 |
Hand pain right hand fx 2 wks po 2 weeks out fourth metacarpal closed reduction and pinning will follow up ' time for splint removal and 3 views out of splint icd10_description | 72 |
Post Op 4.5 weeks post op RT patella Fx ORIF 84yoF with right displaced patella fx s/p ORIF 4.5 weeks postop. Stable alignment on xrays, wound healing without signs of infection. Plan -WBAT RLE with brace locked in full extension -okay to start gentle ROM 0-60 deg in TROM brace -fu 2 weeks for ROM check and to advance ... | 82 |
Post Op 5 weeks post-op right foot and left ankle Plan -progress WBAT LLE and transition out of boot -Rx for PT for ankle ROM -fu 6 weeks for 3V left ankle icd10_description | 88 |
Left Wrist pain Remote left lunate fracture Scapholunate ligament tear Radioscaphoid arthritis Left severe rotator cuff arthropathy Plan Continue short wrist splint when needed, especially when using the walker Monitor for new or worsening symptoms of the left shoulder, call the office with any questions or concerns RT... | 73 |
Left Knee pain mri here w/c L ACL/MCL tears icd10_description | 83 |
Left Ankle pain 6 mos post-op 65yoF with left tibia/fibula shaft fx with plafond extension s/p ORIF 6 months postop. Fracture healed in stable alignment. Some mild foot pain with stable xrays and previously healed 2nd TMT fusion with stable implants and no obvious degenerative changes. Plan --progress activity as toler... | 82 |
Finger pain right thumb Carpal tunnel syndrome right hand Thumb CMC arthritis right hand Left hip pain Plan 15 mg Meloxicam daily Continue thumb splint RTC in 6 wks for exam and consider injection at this time icd10_description | 18 |
Leg pain 7.5 months post right tib fib surgery Assessment Open type I tib/fib fx, s/p ORIF and I&D of fracture site Plan Resume all activities RTC when ready for hardware removal icd10_description | 82 |
3 weeks post op LT 1st MTP fusion, 2-5 hammertoes LEFT Arthritic bunion> Fusion || Severe hammertoes 2-5 w/ MTP contracture || 2nd plantar plate tear> CPR [] S/p Right TAA icd10_description | 20 |
Right Hand pain Trigger finger of right thumb Suspected right carpal tunnel syndrome Plan Right thumb A1 pulley injection Obtain right UE EMG Return with EMG results icd10_description | 31 |
Leg pain Left, approx 1 mo, no known injury -MRI left knee to rule out meniscus tear potentially impeding ROM -Rx for PT for abductor and core stretching and strengthening -continue NSAIDs -will call with MRI results -consider aspiration/injection if needed depending on MRI findings -consider left hip MRA to rule out l... | 25 |
Post Op, Right Knee pain 2 Week Post Op Right Total Knee Staple Removal staples d/c, start outpatient pt icd10_description | 17 |
Post MRI/CT, Right Ankle pain Recs -We discussed these findings and potential causes again . She has not improved and her symptoms seem worse now. Will order MRI ankle to evaluate for ligamentous/tendon injury and MRI foot to rule out stress reaction. -continue walking boot for immobilization -okay for WBAT in boot -co... | 40 |
Post Op Right clavicle and right wrist s/p ORIF right clavicle and right distal ulna Plan Referral to OT located in for ROM exercises flexion, extension, pronation, supination, and aggressive strengthening and stretching Discontinue wearing wrist brace and use hand as tolerated No weight restrictions for right clavicle... | 65 |
follow up left leg had swelling went to er had ultra sound no clot S/P L PMM/PLM and chondroplasty with pes bursitis icd10_description | 83 |
2 weeks post op RT TAA Rt TAA Lt TAA icd10_description | 19 |
Followup Osteoarthritis of knee left knee tka L TKA icd10_description | 17 |
Right Knee pain ref by dr ep last seen films done last week knee DJD icd10_description | 17 |
Left Knee pain NP- LT knee pain start PT, ice, NSAIDS icd10_description | 22 |
Post Op PO 4 MOS REVISION ACL 4 months out hardware removal, revision ACL reconstruction, ORIF of femur fracture at the time of surgery. The plan is to wait for incorporation of bone graft and proceed with ACL reconstruction with likely allograft, possibly an Achilles allograft due to the large femoral defect from the ... | 23 |
follow up left knee Doing well post-op. Progressing as expected. icd10_description | 83 |
Right Hip pain F/U RT THA, surgery activity as tolerated, call with questions or problems icd10_description | 16 |
Post MRI/CT mri follow up right shoulder shoulder impingement with possible SLAP lesion 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 | 14 |
Knee pain fu 5 mos right knee Right clavicle fracture which is healed and stable, irritated from increased use; right knee now 5 months out removal of inferior patellar pole fracture and advancement of patellar tendon and is doing normal. . She will follow up on an as-needed basis. icd10_description | 60 |
Right Hand pain Right small trigger finger Right trigger thumb Plan Begin 15 mg Meloxicam daily Return to clinic in 6 wks for exam and possible injections icd10_description | 31 |
Bilateral Hand pain Right middle trigger finger Bilateral thumb CMC arthritis, worse on left Plan 15 mg Meloxicam daily Referral to for left custom thumb splint Continue right thumb spica splint RTC in 6 wks for exam icd10_description | 18 |
Right Shoulder pain, Post Op Doing well post-op. Progressing as expected. icd10_description | 14 |
Left Wrist pain 1st CMC OA left hand icd10_description | 18 |
MONTH FOLLOW UP LEFT SHOULDER L recurrent AC joint gangion cyst icd10_description | 19 |
Right Hip pain 8 months post right hip surgery Plan -progress activity as tolerated -continue posterior hip precautions -continue strengthening -fu 6 for repeat exam -filled out PPR, anticipate MMI at approx 1 year postop icd10_description | 99 |
Post Op Post op RT TKA, surgery Continue activity Xray 6 months icd10_description | 32 |
Finger pain Left thumb, right ring and middle Left thumb CMC arthritis Right index and middle trigger fingers Plan Right index and middle A-1 pulley releases RTC 2 weeks post op icd10_description | 31 |
Finger pain 5.5 months post left thumb surgery Laceration to left thumb Left thumb digital nerve injury Collateral ligament injury Open fracture distal phalanx of thumb Plan Left thumb IP joint fusion RTC post op icd10_description | 15 |
Right Knee pain Right Knee Gelsyn Injection #1 LOT # 1610016 injection given, activity as tolerated icd10_description | 17 |
Finger pain Left ring finger Left ring finger triggering, improving Plan Continue 15 mg Meloxicam daily RTC in 6 wks for exam icd10_description | 31 |
Post Op, Right Knee pain Post Op/Xrays Right Total Knee Continue strengthening icd10_description | 17 |
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