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Right Elbow pain Bilateral carpal tunnel syndrome, s/p release Right cubital tunnel syndrome, s/p release Right olecranon bursitis Plan Ice and elevate right elbow as needed Continue ibuprofen as needed Continue wearing elbow sleeve for at least 2 weeks RTC 6 weeks for repeat exam and for the evaluation of the left arm... | 34 |
bil elbows 12 weeks out right radial head open reduction and internal fixation. She is working with physical therapy. Left radial head fractures healed nonoperative management. The right elbow lacks terminal flexion and extension she will continue this but she has good functional motion. Progressive activity as tolerat... | 65 |
Right Knee pain F/U RT knee Continue HEP icd10_description | 22 |
Work Comp, Right Shoulder pain New Patient Right Shoulder Injury At Work WORK COMP MRI RDC shoulder SLAP and RC tendinopathy, schedule surgery icd10_description | 61 |
Pre Op left knee preop Left knee lateral and medial meniscus tear. MRI was reviewed. Complex tears of the lateral and medial meniscus. Mild cartilage wear. weightbearing 4 views of the left knee show preserved joint space. No significant sclerosis, osteophytes, or joint space narrowing. She has failed physical therapy.... | 83 |
Post Op, Bilateral Ankle pain 12 wks post-op Plan -Progress activity as tolerated without restrictions -fu PRN Plan -Progress activity as tolerated without restrictions -fu PRN icd10_description | 82 |
MRI results LT foot Lt peroneal tendon tear icd10_description | 89 |
Post Op, Right Knee pain Followup Osteoarthritis of knee The right knee prosthetic components are well positioned with no sign of loosening. Osteoarthritis of the left knee. icd10_description | 17 |
Post Op, Right Elbow pain 2 Week Post Op/Suture Removal Right Right Bicep Tendon Repair start Rom 60-90° Wear brace icd10_description | 63 |
Finger pain left thumb po 2 mos s/p Left thumb arthroplasty Plan Continue stretching exercises Continue hand therapy with for ROM improvement RTC in 6 wks for exam icd10_description | 18 |
Left Hip pain Osteoarthritis of the Left Hip. icd10_description | 16 |
Followup Osteoarthritis of knee bilateral knee pain Bilateral knee osteoarthritis. Both have prior ACL reconstructions. She has arthritis more extensive in the right knee than the left. Views x4 of the bilateral knees show joint space narrowing, osteophytes of the medial and lateral joint space and the patellofemoral j... | 17 |
Post Op/Xrays Left Foot Pin Removal > Left Rheumatoid forefoot reconstruction icd10_description | 20 |
Pre Op Left wrist ganglion cyst Bilateral thumb CMC arthritis Plan Obtain Left wrist MRI I will call with MRI results and evaluate surgery at this time icd10_description | 18 |
Pre Op PREOP RIGHT KNEE 5 months out first staged procedure bone grafting of 2 prior failed ACL reconstructions with posterior wall blowout. The plan is to proceed with revision ACL reconstruction next month . with allgraft .Right knee icd10_description | 83 |
Right Knee pain Doing well post-op. Progressing as expected. Stable and ratable from knee aspect icd10_description | 78 |
Right Foot pain Right 5th MT base fx icd10_description | 88 |
Ankle pain, Foot pain foot/ankle pain Recs -I discussed these findings in detail with the patient and her friend and that I do not know the exact cause of her symptoms. -I recommend that she continue the gabapentin and reestablish care with a pain management specialist and or spine surgeon to followup on her pending EM... | 4 |
Left Knee pain Followup Chondromalacia of patella Doing well post-op. Progressing as expected. icd10_description | 22 |
mri follow up right knee Right knee degenerative medial meniscus tear, physically demanding job. I discussed with him risks, benefits, and rationale. The plan is to proceed with arthroscopic surgery with partial medial meniscectomy. icd10_description | 83 |
None recorded. Bilateral carpal tunnel syndrome Plan Right endoscopic carpal tunnel release Return to clinic 2 weeks post op icd10_description | 3 |
Shoulder pain left shoulder pain Left shoulder rotator cuff strain. I reviewed x-rays from the hospital. They show some mild arthritis. No sign of any fracture or dislocation. I have recommended a prescription for physical therapy. If not improved, he will follow up in 5 to 6 weeks for re-evaluation and likely injectio... | 37 |
13 days post op RT ankle fusion Rt Ankle Fusion (redo)>> RIGHT Ankle severe post traumatic osteoarthritis with indeterminate infection (remote) CRPS (Dr. )- Pain meds by his office (discussed in detail on several visits pre op) icd10_description | 7 |
post op left knee left knee revision ACL - protocol and PT - doing well icd10_description | 23 |
Post MRI/CT Post EMG Carpal tunnel syndrome bilaterally Cubital tunnel syndrome on the left Plan Continue bilateral wrist splints as needed RTC after surger to his neck icd10_description | 3 |
Post MRI/CT mri follow up right knee quad tendinitis and medial compartment DJD icd10_description | 79 |
Right Knee pain Follow Up/Xrays Right Total Knee Right shoulder severe glenohumeral arthritis with collapse of the humeral head, injection - she wants to avoid surgery 10 months out right total knee arthroplasty without patellar resurfacing due to thin patella. Overall doing well. f/u prn icd10_description | 19 |
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... | 36 |
Followup Osteoarthritis of knee BILATERAL KNEE EUFLEXXA INJECTIONS #1 bilateral knee OA eulfexxa #1 - icd10_description | 17 |
Knee pain left knee pain Left knee degenerative medial meniscus tear. MRI confirms this. Mild arthritis . Views x4 today weightbearing left knee shows preserved joint space and small areas of sclerosis. He has failed years of conservative measures of this medial meniscus tear with mechanical symptoms. The plan is to pr... | 83 |
Pre Op, Right Knee pain Osteoarthritis of the Right knee with large MMT. Limited improvement with injection. icd10_description | 23 |
Post Op post op left knee L TKA icd10_description | 17 |
Post Op PO 3 MOS LEFT KNEE 11 weeks out left knee scope - still having aching discomfort - - steroid injection - will f/u after vacation gelsyn if needed icd10_description | 83 |
Bilateral Hand pain Bilateral carpal tunnel syndrome Plan RTC when ready to schedule right endoscopic carpal tunnel release icd10_description | 3 |
Right Knee pain Ongoing recurrent patellar pain with flexion activity icd10_description | 22 |
Bilateral Hip pain Left hip Trochanteric Bursitis. Right hip Trochanteric Bursitis. The patient experienced significant improvement initially, but now the symptoms are returning. icd10_description | 34 |
Post Op right soulder 11 days R RCR and SAD icd10_description | 37 |
Right Shoulder pain Right Rotator Cuff Tendonitis. icd10_description | 63 |
Deformity Eval LEft Clubfoot Cast Removal cast removed, good alignment, get MD ortho brace icd10_description | 50 |
follow up left knee S/P L PMM/PLM/LBR/chondroplasty icd10_description | 83 |
Finger pain Right middle finger Right ring trigger finger cyst v.s giant cell tumor of tendon sheath Plan Obtain MRI of right hand Return with MRI results icd10_description | 53 |
Right Shoulder pain 4 months post right shoulder surgery Right subacromial impingement, s/p SX Right subacromial impingement syndrome Incomplete right rotator cuff tear Plan Obtain MRI of right shoulder RTC with MRI results icd10_description | 37 |
F/U bilateral foot pain/ LT 1st MTP fusion 2-5 HT's, RT 1st MTP fusion 2-5 HT's > Right 1st MTP fusion/ Clayton/ Osteoclasis HTs LEFT 1st MTP fusion resection [] icd10_description | 39 |
Right Knee pain, Bilateral Ankle pain NP- Bilateral ankle pain, RT knee pain, Xrays at difficult to pinpoint due to spasticity, bracing would most likely worsen pain, ice, NSaids, rest recheck 4 weeks icd10_description | 83 |
Left Knee pain Left Anterior Cruciate Ligament tear. icd10_description | 83 |
Finger pain L ring finger..1 mo post injury Plan -start ROM -discussed option for OT but he prefers to start working on ROM on his own -fu 4 weeks for 2V right finger icd10_description | 72 |
Post Op, Right Ankle pain 2 wks post-op Plan -okay to progress activity as tolerated -fu PRN icd10_description | 82 |
4 1/2 weeks post op LT 5th MT Fx ORIF fracture Lt Accessory navicular icd10_description | 88 |
Left Knee pain mri here injured L recurrent MMT icd10_description | 83 |
Right Hand pain Right sided De Quervain's syndrome Right ring trigger finger Plan Right ring A-1 pulley injection Continue thumb spica splint Begin naproxen as needed RTC in 6 wks for exam icd10_description | 31 |
Left Shoulder pain Followup Rotator cuff impingement syndrome Left Rotator Cuff Tear. Doing well post-op. Progressing as expected. icd10_description | 37 |
Post Op Right proximal humerus fracture, s/p reverse total shoulder arthroplasty Right thumb trigger finger, s/p A1 pulley release Plan Continue physical therapy for one month for strengthening Continue scar massage for right thumb RTC with no xrays icd10_description | 31 |
Left Wrist pain 6 months post left wrist surgery Assessment Left ulnar-positive variance with ulnocarpal abutment Left TFCC injury Status post wrist arthroscopy with open TFCC repair and ulnar shortening osteotomy Plan Resume all activities as tolerated RTC PRN icd10_description | 77 |
6 1/2 weeks post op RT foot bunionectomy, 2nd hammertoe correction > Rt Prox Bunion + 2nd HT/MTP icd10_description | 20 |
Post Op, Left Hip pain Doing well post-op. Progressing as expected. icd10_description | 16 |
Post MRI/CT Post EMG, ref by Dr. for left arm Left PIN palsy with EDC, EPL and ECU deficits s/p GSW to the left arm in Plan RTC PRN if he would like to pursue surgical treatment Plan RTC PRN if he would like to pursue surgical treatment icd10_description | 64 |
Right Hip pain The prosthetic components are well positioned with no sign of loosening. Incision now fully healed. Osteoarthritis of the Right knee. icd10_description | 17 |
Left Knee pain Left Knee Gelsyn Injection #2 LOT # 1610016 injection given, activity as tolerated icd10_description | 17 |
Right Knee pain MCA Plan -Recommend discontinuing knee bracing and starting knee ROM as tolerated -okay for WBAT -provided with compressive dressing -monitor abrasion and perform local wound care -offered fu appt but he prefers to fu at VA -fu PRN icd10_description | 92 |
Post MRI/CT Right wrist pain Right Dequervains tenosynovitis Scapholunate ligament tear Plan Recommend scapholunate ligament reconstruction, palmaris longus autograph, with wrist arthroscopy and TFCC debridement and repair RTC when ready to proceed with surgery icd10_description | 73 |
Pre Op preop right shoulder Right shoulder recent dislocation. MRI shows a small Hill-Sachs lesion, anterior labral tear, and posterior labral tearing as well. . Regarding the right shoulder, we discussed treatment options for a shoulder dislocation. He has not been cleared to return to sport. He would like to have the... | 61 |
Right Knee pain Followup Knee joint effusion Doing well post-op. Progressing as expected. icd10_description | 22 |
7 weeks post op RT great toe fusion/ doing well Right 1st MTP arthritis Sx> Rt 1st MTP Fusion icd10_description | 19 |
Right Shoulder pain, Post Op Doing well post-op. Progressing as expected. icd10_description | 19 |
F/U LT achiiles tendon pain/ 100% better with injection and physical therapy L> Achilles pain with left peritenon enlargement icd10_description | 33 |
Bilateral Shoulder pain Doing well post-op. Essentially back to full function with both shoulders icd10_description | 10 |
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 |
2 weeks post op LT ankle scope, Brostrom procedure Sx > Lt Ankle scope + Brostrom || Left anterior ankle impingement syndrome Left chronic lateral ankle ligament instability icd10_description | 25 |
Right Knee pain Follow Up Right Knee Pain Post Gelsyn 3 Series Activity as tolerated. Call if worsens. icd10_description | 17 |
Knee pain right knee pain Left knee complex lateral meniscus tear with perimeniscal cyst. This has been going on for 3 years. The plan is to proceed with left knee arthroscopy, partial lateral meniscectomy versus repair. I have discussed the rehab of both, and he is very comfortable with this. Regarding the right knee,... | 83 |
Post Op 6 week post-op left tibfib 29yoM with left tibial pilon and tibia shaft fx s/p ORIF and exfix removal 6 weeks postop. Wounds healed without signs of infection. Stable fracture alignment with early healing on xrays . Improved ankle ROM. Plan --TTWB LLE in boot --continue daily ankle ROM offered formal PT for ROM... | 82 |
Bilateral Ankle pain NP- Bilateral ankle for since no Xrays Activity as tolerated Call if worsens icd10_description | 89 |
Post MRI/CT mri follow up L knee MMT/LMT with mild underlying DJD icd10_description | 83 |
Post Op, Left Knee pain Followup Osteoarthritis of knee Doing well post-op. Progressing as expected. The prosthetic components are well positioned with no sign of loosening. icd10_description | 17 |
Post Op PO 8 WKS LEFT KNEE 7 weeks status post arthroscopywith Tx of subchondral femur fracture - f/u prn icd10_description | 17 |
Right Shoulder pain New Patient Right Shoulder Injury Bull Riding Wear brace, protective activity Xray3 week icd10_description | 60 |
Post Op Right scapholunate ligament disruption s/p repair and reconstruction Plan Remaining pins removed Continue gentle finger extension and flexion Continue antibiotics Continue with custom splint at all times RTC 3 wks for repeat evaluation and xrays icd10_description | 73 |
month follow up right knee R ACLR, PMM icd10_description | 83 |
Bilateral Hand pain Left wrist carpal tunnel syndrome Right thumb CMC arthritis Plan Begin 15 mg Meloxicam daily Obtain EMG of left UE RTC with EMG results icd10_description | 3 |
Bilateral Forearm pain Bilateral radial tunnel syndrome Plan Continue attending Hand Therapy for ultrasound and iontophoresis modalities Continue bilateral wrist splints at night and increased activity during the day Continue 15 mg Meloxicam daily Begin taking topical anti inflammatory 2-3 times a day RTC in 6 wks for ... | 3 |
Left Shoulder pain Left shoulder pain Subscapular bursitis Rule out rotator cuff tear or biceps/labral injury Plan Obtain of left shoulder RTC with MRI results icd10_description | 37 |
1 week post op LT foot fusion > Lt Triple fusion + gastroc recession || Bilateral (L>) tendoachilles contracture with subtalar and talonavicular arthritis icd10_description | 19 |
Post Op, Left Foot pain Dr pt..went to ER for redness and swelling. They did give her abx. Plan -continue NWB LLE in boot with crutches -finish course of abx as previously prescribed by IHS clinic -continue elevation -fu with Dr. as scheduled icd10_description | 11 |
Right Knee pain Follow Up Right Knee Pain injection given, activity as tolerated, call if worsens icd10_description | 17 |
Left Hip pain New Patient Left Hip Pain x 1 Month injection given Lt greater trochanter, activity as tolerated, stretching icd10_description | 16 |
Post Op, Right Knee pain Right MMT, LMT, mild OA. Doing well post-op. Progressing as expected. icd10_description | 83 |
MONTH FOLLOW UP RIGHT SHOULDER shoulder impingement, improved icd10_description | 37 |
Pre Op preop right shoulder Right shoulder SLAP or labral tear given his instability and mechanism injury. I am also concerned about a small radicular component. He has some radicular symptoms but does not have findings on exam. MRI confirms SLAP tear and partial RTC tear - he is at borderline age of SLAP repair vs ten... | 61 |
None recorded. Left shoulder rotator cuff arthropathy. She would like to continue with conservative management at this time. She is considering when to have a left total shoulder replacement. I have recommended that she have only 2 to 3 injections a year. I have discussed the complications of this. Views x3 of the left... | 19 |
Right Wrist pain New Patient Right Wrist Pain Second Opinion ORIF Hardware Intact Right Knee Pain Right cubital and carpal tunnel syndrome Right wrist pain Right knee pain Plan Obtain EMG of right UE Obtain MRI right knee RTC with EMG and MRI results Right wrist pain Right knee pain Plan Obtain EMG of right UE Obtain M... | 25 |
Left Shoulder pain, Left Knee pain NEW INJURY Possible L RCT icd10_description | 37 |
MONTH FOLLOW UP RIGHT KNEE knee DJD icd10_description | 17 |
Left Hand pain Left hand intrinsic tightness Complex regional pain syndrome, resolving Left middle finger trigger finger left medial epicondylitis Plan Continue at home exercises Continue Ibuprofen PRN Continue ROM exercises Return to clinic in 8 wks for repeat exam Complex regional pain syndrome, resolving Left middle... | 39 |
Left Knee pain mri report only L MMT icd10_description | 83 |
Hip pain FU LEFT HIP Left hip avascular necrosis with a subchondral impaction fracture. She is improving. I have encouraged her to not overdo it. She is to continue to work with the AlterG which has been very helpful for maintaining her motion helping with her RA but not overdoing the hip and causing pain. I would reco... | 38 |
Left Shoulder pain FILMS ON COMPUTER INJURED SMH ER Left knee DJD with traumatic aggravation. icd10_description | 17 |
Followup Rotator cuff syndrome fu 4mos po right shoulder 4 months out right anterior, posterior, and SLAP repair of the right shoulder. She is doing well.Follow-up in 2-3 months icd10_description | 61 |
Bilateral Hip pain, Right Knee pain 87yoF with right proximal humerus fracture being treated nonoperatively now . Also had right IT femur fx treated with IMN 13 months postop. Humerus fracture healed in stable alignment with good ROM. Right IT fx healed with some fracture settling but doing well. Left IT femur fx heali... | 78 |
Post Op 26yoM polytrauma and right femur shaft fx s/p IMN, left clavicle shaft fx s/p ORIF, also had left complex open distal radius/ulna fractures s/p I&D and ORIF by Dr. . Now 6.5 weeks postop femur and 6 weeks postop clavicle. Has right scapula fx and left 3rd MT fx treating nonop. Also had right femoral artery repa... | 88 |
Right Shoulder pain Followup Recurrent subluxation of shoulder - multidirectional Doing well post-op. Progressing as expected. icd10_description | 63 |
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