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Pre Op Right carpal tunnel release Bilateral carpal tunnel syndrome Plan Right endoscopic carpal tunnel release Discontinue aspirin a week before surgery RTC 2 weeks post op and schedule left carpal tunnel release icd10_description | 3 |
Left Knee pain xrays here got kicked in knee L inferior patella avulsion fracture icd10_description | 84 |
Right Knee pain Right Knee Pain Glesyn Injection #2 LOT # 1610016 injection given, activity as tolerated icd10_description | 17 |
Right Elbow pain NP- RT arm pain, dislocation/ Xrays in Medstrat Plan -discontinue spling -continue sling -start gentle daily elbow flexion/extension -fu 2 weeks for repeat exam and 2V elbow icd10_description | 66 |
Finger pain 6 months post left thumb surgery Assessment Left thumb CMC osteoarthritis, status post CMC arthroplasty revision Plan Continue home ROM exercises Return to clinic for exam icd10_description | 18 |
19 1/2 weeks post op LT achilles tendon repair/ doing better Left Achilles/Haglund/FHL + Peroneus Brevis repair icd10_description | 38 |
Bilateral Shoulder pain NP- Bilateral shoulder pain start PT shoulder. discussed that shoulder not causing leg or back pain and should have these evaluated by PMD icd10_description | 37 |
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 | 40 |
Post Op pop 6wks right hand orif 17yo LHD M s\p ORIF 4th and 5th MC shaft fxs 6 weeks postop. Healing without signs of infection. Plan -progress activity as tolerated without restrictions -fu 6 weeks for 3V hand icd10_description | 72 |
Shoulder pain FU RIGHT SHOULDER Right greater tuberosity fracture non displaced Right biceps tendinitis Plan Should avoid active flexion/abduction of the right arm Continue 15 mg Meloxicam daily Continue to PT for passive gentle ROM RTC in 2 wks for exam and shoulder xrays Plan Should avoid active flexion/abduction of ... | 60 |
Shoulder pain PO 3MOS RIGHT SHOULDER 12 weeks out massive rotator cuff repair. Is doing well will start strength with physical therapy. PT f/u 6 weeks and hopeful return to very demanding job icd10_description | 37 |
Finger pain, Right Wrist pain Left small finger Right wrist sprain Left small finger proximal phalanx fracture Plan Continue right wrist splint Left hand fracture brace to be worn at all times except for hygiene purposes Return to clinic for repeat examination and x-rays icd10_description | 73 |
Knee pain gelsyn #2 left knee Left knee mild patellofemoral osteoarthritis. She was given a steroid injection and will continue the physical therapy activities as a home program. She will follow up on an as-needed basis. She was also given a handout for viscosupplementation for possible injections in the future if need... | 17 |
Deformity Eval Harness Adjustment Right Clubfoot Casting #5 Scheduled For cast changed, wear harness as instructed icd10_description | 50 |
Right Hip pain 6.5 mos post-op 73yoM now 6 months postop right THA for displaced femoral neck fx. Had likely occult femoral neck fx but could not get MRI due to pacemaker and CT was normal. Had another fall vs. displacement of his fx and was admitted to with displaced femoral neck fx. Has multiple cardiac issues. Hip d... | 21 |
11 days post op LT ankle scope, achilles lengthening > Rt Ankle scope + Brostrom + Gastroc icd10_description | 24 |
Left Ankle pain 4.5 months post left ankle surgery 56yoF with left tibial pilon and distal fibula fracture s/p ORIF and exfix removal nearly 6 months postop. Wounds healed without issue . Xrays show continued fracture healing in stable alignment. Some concern for delayed fibula healing radiographically but clinically a... | 82 |
Left Wrist pain Left 's tenosynovitis Left wrist pain Left TFCC injury Left wrist pain Left TFCC injury Plan Continue attending for ultrasound and iontophoresis along with previous exercies Discontinue meloxicam Begin topical anti inflammatory naproxen as prescribed Return to clinic icd10_description | 31 |
Post Op, Hip pain 12.5 po 76yoF with right IT femur fx treated at outside facility about . Referred to me by Dr. for further evaluation and to discuss treatment options. She was scheduled for conversion to THA but 1 week before she fell again and fractured her femur below her nonunion around her IMN. She is now 12 week... | 78 |
Post Op/Xrays Left Foot Pin Removal > Left Rheumatoid forefoot reconstruction icd10_description | 20 |
Followup Shoulder joint pain 6 mos right shoulder Right shoulder 6 months out right superior capsular reconstruction. He is now off steroids and is improving his autoimmune dermatomyositis. Views x3 of the right shoulder show mild humeral head elevation which is consistent with that elevation that was prior before surg... | 25 |
Post Op, Right Ankle pain 6 wks post-op 27yoM with right trimalleolar ankle fx and chaput (syndesmosis) fx ORIF with removal of articular osteochondral fragments 6 weeks postop. Wounds healed without signs of infection. Plan -okay to progress to WBAT in boot -continue daily ankle ROM -Rx for PT -fu 6 weeks for 3V ankle... | 82 |
Pre Op, Left Knee pain Left Medial Meniscus Tear. icd10_description | 83 |
Wrist pain right wrist injury Right scapholunate ligament disruption Plan Right scapholunate ligament reconstruction RTC 2 wks post op icd10_description | 73 |
Post Op, Right Foot pain 14 wks post-op 44yoF with right talar neck and calcaneus fx s/p ORIF 14 weeks postop. Also had avulsion fx of superior peroneal retinaculum s/p repair. Wounds healed without signs of infection. Hx of chronic pain related to neuropathy. Had seen pain specialist and no longer taking opioids. Frac... | 88 |
Right Knee pain MRI Rt knee results Patella-femoral arthralgia of the Right knee. vs less likely plica icd10_description | 22 |
Post Op, Left Shoulder pain 2 Week Post Op/Suture Removal Left Shoulder Scope sutures d/c'd, start PT, out of brace as tolerated icd10_description | 19 |
Post Op PO 6MOS TKA Right total knee arthroplasty, 6 months out. Views x3 of the right knee show well positioned right total knee arthroplasty without any changes or issues. There is a small piece of bone at the lateral joint line next to the poly. It does not seem to be causing discomfort when I palpate in this area i... | 17 |
Right Hip pain Probable healed nondisplaced greater trochanteric fx with mild bursitis icd10_description | 34 |
Post Op, Left Hip pain Post Op/Xrays Left Total Hip Activity a, tolerated Xray 5 months icd10_description | 16 |
Left Shoulder pain Left shoulder osteoarthritis Plan 15 mg Meloxicam daily as needed RTC when ready to proceed with surgery, in the mean time please call our office with any questions or concerns icd10_description | 25 |
8 weeks post op RT foot 5th MT Fx/ 12 weeks post op RT 2nd and 3rd hammertoes RIGHT 2nd/3d HTs with MTP contractures without MTP instability LEFT 2nd HT 2nd MTP instability [> Left 2nd CPR//Angular deformity correction] [> Right 2nd & 3d HT/MTP] icd10_description | 88 |
Bilateral Knee pain NP- Bilateral knee pain start PT, ice, NSAIDs, recheck 6 weeks icd10_description | 23 |
Hip pain right hip pain/low back pain Plan -okay to progress WBAT -duplex US to rule out DVT RLE, if positive recommend going to to have treatment initiated -fu 1 month for repeat clinical evaluation -Rx for PT for gait training, ROM, stretching and progressive strengthening back and lower extremityes icd10_description | 92 |
follow up left knee w/c L ACL/MCL tears icd10_description | 83 |
Post MRI/CT Possible strain of the right biceps tendon Right subacromial impingement, s/p SX Right subacromial impingement syndrome Incomplete right rotator cuff tear Plan Obtain ultrasound guided injection to the right biceps tendon Continue 15 mg Meloxicam daily RTC in 4 wks for exam Right subacromial impingement, s/... | 37 |
month follow up right shoulder Plan -We discussed these findings and treatment options. She is actually doing a little better clinically after PT but still has limited AROM and persistent pain. She likely has some degree of fibrous union. We discussed treatment options again , including continued nonoperative managemen... | 60 |
Right Knee pain Right Anterior Cruciate Ligament tear. icd10_description | 83 |
Bilateral Shoulder pain, Bilateral Knee pain wants knees and shoulder check B TKA icd10_description | 17 |
6 week follow up right leg wound check 54yoM with right open segmental Grade 3B tibia fracture s/p exfix, ORIF and soleus flap from crush injury. Dr. performed soleus flap and STSG in mid November. Ultimately patient decided that he did not want to pursue continued limb salvage and requested a BKA. Now s/p right BKA an... | 82 |
MRI results LT foot Lt peroneal tendon tear icd10_description | 24 |
Knee pain LEFT KNEE PAINFUL/ Left knee effusion. Aspirated . Clear fluid was sent for analysis. We had a long discussion. At this point, she does not want to proceed with right total knee arthroplasty. We will wait for the analysis on the fluid. She thinks she would like to proceed with a viscosupplementation trial of ... | 25 |
Right Foot pain Right fifth metatarsal base fracture Plan Resume all activities as tolerated RTC PRN icd10_description | 88 |
Left Hand pain 2 weeks post xiaflex s disease, contracture of left small, ring and middle fingers Plan Continue wearing custom extension splint at night RTC for repeat evaluation. icd10_description | 36 |
Left Knee pain Follow Up Left Knee Pain Patient Second Opinion Patient would benefit from patellectomy and reconstruction of extensor mechanism, will schedule with icd10_description | 22 |
month follow up left thumb thumb tip amputation icd10_description | 76 |
Left Shoulder pain Much better with PT icd10_description | 14 |
11 1/2 weeks post op Olecranon ORIF 11yoM with left displaced intraarticular olecranon fx s/p ORIF 11.5 weeks postop. Doing well. Fracture healed in good alignment. full elbow ROM Plan -progress activity as tolerated without restrictions -will schedule routine implant removal within the next 2 months -return for preop ... | 65 |
Post MRI/CT mri results bilateral shoulder Bilateral rotator cuff tears. The right is significant with supraspinatus and infraspinatus tear retracted past the glenoid, humeral head elevation, and articulation with the acromion. On the left, he has a supraspinatus tear which is 3.2 cm retracted, biceps tendon tear, and ... | 37 |
Post Op Right scapholunate ligament disruption s/p repair Plan Begin gentle finger extension and flexion Begin antibiotics Referral to for custom wrist splint Keep pin sites clean and dry RTC 1 wks for evaluation icd10_description | 73 |
Bilateral Shoulder pain Increase activity level. PT it no relief. icd10_description | 25 |
Right Hand pain right hand fracture Neck fracture of the small finger metacarpal Plan Begin wearing brace at all times RTC in 2 wks for exam with xrays icd10_description | 72 |
Post Op PO 6 WKS RIGHT KNEE Right knee patellofemoral osteoarthritis, large loose body removal - doing well at 6 weeks - f/u 6 weeks / prn icd10_description | 23 |
Followup Osteoarthritis of knee bilateral knee pain ants injections Bilateral quadriceps tendinosis and patellofemoral chondromalacia. Steroid injections of both knees .f/u prn icd10_description | 22 |
Right Forearm pain Soft tissue mass volar right forearm icd10_description | 53 |
Followup Osteoarthritis of knee PO 6 WKS LEFT TKA Left knee status post irrigation and debridement and poly exchange for a traumatic arthrotomy. She will continue on antibiotics. The IV antibiotics are supposed to go for 2 more weeks and then oral antibiotics for possibly 2 more months. I am going to see her at the 6-w... | 17 |
Shoulder pain PO 4 MOS RIGHT SHOULDER 4 months out right anterior and posterior Bankart repair.May do non-contact drills for the next month. He'll follow-up with me at that point he will be 5 months out. Doing well we will allow him to initiate contact icd10_description | 61 |
Pelvis pain Plan Plan --Okay to progress activity with AFO to improve mobility and prevent steppage gait --continue ankle ROM to prevent equinus contracture --continue to monitor sciatic nerve palsy, discussed with patient again that it will take a minimum of 1 year to determine his level of functional nerve recovery a... | 4 |
Post Op, Right Foot pain 4 wks post-op 22yoM with right foot nailgun injury and open 1st-3rd metatarsal fxs and retained foreign body s/p removal of foreign body and I&D 4 weeks postop. Wound healed without signs of infection. Plan -okay to progress activity as tolerated -transition to normal shoe -fu 4 weeks for 3V fo... | 88 |
follow up left hip L hip hemiarthroplasty icd10_description | 78 |
Finger pain Left middle finger Trigger finger left middle finger Radial sagittal band rupture of left middle finger MP joint Plan Schedule left middle A-1 pulley release icd10_description | 40 |
4 days post op 2-4 hammertoes > HTs+MTPs icd10_description | 20 |
F/U RT knee pain, wants injection 68 yo M with right IT femur fx s/p IMN 2., doing well from that. Has right knee osteoarthritis, severe radiographically but clinically doing pretty well. Injected right knee with kenalog again. Plan -progress activities as tolerated -continue bracing PRN -fu PRN, if interested in repea... | 17 |
Left Ankle pain Left ankle sprain Plan Send to PAC med and begin wearing ankle brace and begin to WB Referral to PT for ankle ROM, stability, and strengthening RTC in 4 wks for exam icd10_description | 89 |
9 weeks post op LT ankle scope, procedure/ doing well Sx > Lt Ankle scope + Brostrom || Left anterior ankle impingement syndrome icd10_description | 24 |
Right Shoulder pain Follow Up Right Shoulder Pain Post Injection/PT Continue strengthening. Call if worsen icd10_description | 37 |
Followup Rotator cuff syndrome po 3 mos right shoulder 12 weeks status post decompression and biceps tenotomy. Fallback East now with rotator cuff weakness unresolved with physical therapy. Concerning for rotator cuff tear. Plan for MRI evaluation. He is also following up with spine regarding his cervical degenerative ... | 37 |
Left Shoulder pain Followup Strain of rotator cuff capsule Left Rotator Cuff Tendonitis. The patient experienced significant improvement initially, but now the symptoms are returning. icd10_description | 63 |
Left Wrist pain, Post Op 2 wks post-op Left subacromial impingement 's contracture of left ring finger and right small finger Carpal tunnel syndrome bilaterally, s/p carpal tunnel release Cubital tunnel syndrome bilaterally, s/p cubital tunnel release Plan Begin scar massage at incisions sites Begin PT RTC for exam and... | 3 |
Right Foot pain Right 5th MT base fx. The fracture is healing well in good alignment. icd10_description | 88 |
Right Knee pain, Post MRI/CT Follow Up Right Knee MRI Results schedule surgery icd10_description | 83 |
Right Wrist pain Right distal radius fracture Plan Able to discontinue wrist splint RTC PRN RTC PRN icd10_description | 65 |
Post Op, Hip pain 12.5 po 76yoF with right IT femur fx treated at outside facility about . Referred to me by Dr. for further evaluation and to discuss treatment options. She was scheduled for conversion to THA but 1 week before she fell again and fractured her femur below her nonunion around her IMN. She is now 12 week... | 78 |
Bilateral Elbow pain New Patient Bilateral Elbow Pain x 1 Year Lateral epicondylitis ("Tennis Elbow") Left elbow. Olecranon spur on right icd10_description | 34 |
3 weeks post op 1st MT head I&D Plan -leave sutures for additional 2 weeks -fu 2 weeks for repeat wound check -continue wound care -DM management per PCP -no weightbearing through forefoot, continue unloader boot icd10_description | 1 |
Right Shoulder pain Right shoulder labrum tear Plan Repeat right sub acromial injection Ice for pain and inflammation RTC in 6 wks for exam icd10_description | 61 |
Finger pain right thumb Right thumb proximal phalanx salter harris I fracture Right index proximal phalanx salter harris I fracture Plan resume activities as tolerated RTC PRN Right index proximal phalanx salter harris I fracture Plan resume activities as tolerated RTC PRN icd10_description | 72 |
F/U LT ankle pain/ injection did not help at all Surgery [] Left ankle scope with Kidner and dorsal TN spur excision icd10_description | 40 |
Post Op s/p External fixator of the small finger PIP joint Fracture and dislocation of the small finger PIP joint Plan Avoid getting the pin sites wet Return to clinic 2 weeks for exam and xrays Fracture and dislocation of the small finger PIP joint Plan Avoid getting the pin sites wet Return to clinic 2 weeks for exam... | 72 |
Post Op Right carpal tunnel release Right subacromial impingement Left SLAC wrist Right STT and radioscaphoid arthritis Bilateral carpal tunnel syndrome, worse on the right, s/p right release Plan Continue activites as tolerated Rest right shoulder and take meloxicam for relief RTC in 6 wks for exam Left SLAC wrist Rig... | 3 |
Arm pain Lt arm, fall Plan -Okay to discontinue splinting given benign exam and stable suspected fracture -fu 3 weeks for 2V forearm icd10_description | 65 |
Left Foot pain New Patient Left Foot Pain x 6 Months No Known Injury very mild deformity at this shoes, ice, NSAIDs icd10_description | 20 |
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 |
Post Op, Left Shoulder pain Followup Full thickness rotator cuff tear Doing well post-op. Progressing as expected. icd10_description | 14 |
Right Shoulder pain, Post MRI/CT MRI results RT shoulder injection given Rt glenohumeral joint, activity as tolerated, recheck 6 weeks icd10_description | 19 |
Right Foot pain Right fifth metatarsal base fracture, nondisplaced Plan Weightbearing as tolerated with the boot in place Able to work with boot in place Return to clinic for repeat evaluation and x-rays icd10_description | 88 |
Right Forearm pain Nondisplaced left distal 1/3 ulnar shaft fx icd10_description | 65 |
Knee pain fu after injections left knee/right knee fu Right knee patellofemoral arthritis with mechanical symptoms, questionable meniscal involvement. Given a steroid injection . The plan will be for MRI evaluation of the right knee. icd10_description | 17 |
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 Ankle pain Medial ankle OA vs painful hardware icd10_description | 19 |
Hip pain left hip pain fell Left hip strain. Views x2 of the left hip show normal alignment and preserved joint space. No sign of any fracture malalignment. Contusion and sprain. He will progress with activity as tolerated. If not improved over the next 10 to 12 weeks, he will contact us for further evaluation and will... | 79 |
Post Op, Right Hip pain Osteoarthritis of the Right Hip. Doing well post-op. Progressing as expected. icd10_description | 16 |
Left Wrist pain, Right Elbow pain Assessment Left trigger thumb, status post A1 pulley Left middle trigger finger Left wrist pain Right lateral epicondylitis Plan Continue with for left dequervain's and trigger finger exercises and right lateral epicondylitis Continue wrist splint Begin Medrol Dosepak to help with infl... | 25 |
Left Knee pain Left Knee Pain And Swelling Recent Dental Cleaning Oxford no sign infection, most likely mechanical irritation, ice, nsaids, call if swelling worsens, redness, fever, chills icd10_description | 17 |
Pre Op, Right Hip pain Osteoarthritis of the Right Hip. icd10_description | 16 |
Right Knee pain EP- RT knee pain, wants cortisone injection Failed cortisone. Try HA series. icd10_description | 17 |
Post Op, Left Ankle pain Lt ankle scope++peroneal repair Chronic left lateral ankle sprain Plan Continue to ice and elevate as needed 15 mg Meloxicam daily RTC with Dr. when available icd10_description | 38 |
Post MRI/CT Followup Current tear of lateral cartilage AND/OR meniscus of knee mri follow up left knee L ACL cyst icd10_description | 35 |
Right Elbow pain Plan -progress activity as tolerated without restrictions -fu PRN -discussed low likelihood but potential for growth disturbance icd10_description | 60 |
Right Hand pain Right index finger metacarpal shaft fracture Plan Continue previous restrictions RTC in 1 wks for exam and xrays icd10_description | 72 |
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