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Right Shoulder pain Followup Full thickness rotator cuff tear Doing well post-op. Progressing as expected. icd10_description | 37 |
13 days post op RT Midfoot fusion > ORIF Rt Lisfranc Fx/Dislocation icd10_description | 19 |
Right Shoulder pain NP- RT clavicle Fx start PT, ice, nsaids icd10_description | 61 |
Right Hip pain RIGHT HIP PAIN Right hip mechanical symptoms, pain, and giving way. On x-rays, she has mild sclerosis. She has evidence of prior anterior femoral head and neck decompression with mild arthritis. The plan is for MRI evaluation as I do not have a good explanation for her mechanical symptoms and repeated fa... | 25 |
Left Shoulder pain New Patient Left Shoulder Mountain Bike Injury start PT Call if doesn't resolve icd10_description | 63 |
Left Shoulder pain Surgical neck fracture of the left Humerus Right carpal tunnel syndrome Plan Continue wearing shoulder immobilizer at all times Begin wearing wrist splint for right wrist RTC in 2 wks for exam and xrays icd10_description | 60 |
Deformity Eval Harness Adjustment Scheduled For wear harness as instructed icd10_description | 49 |
Pre Op left knee sx south Left knee early DJD with new medial meniscal tear icd10_description | 83 |
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 | 24 |
Right Shoulder pain Rt shldr pain, no xrays Right shoulder rotator cuff tendinosis, possible old SLAP tear given his mechanical symptoms. At this point in time, we will start physical therapy for stretching, strengthening, and scapular stabilization. He will call back if not improved. We discussed subacromial injection... | 37 |
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 | 25 |
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 |
Deformity Eval Follow Up Club Foot Foot Will Not Stay In Brace Continue brace if worsens my consider Afo icd10_description | 50 |
Leg pain left bka er follow up Plan -continue monitoring wound -continue compressive dressing -maintain knee extension and okay for gentle knee ROM -fu 2 weeks for repeat exam and 2V tibia/fibula -Rx for percocet PRN and recommended to wean off -continue gabapentin icd10_description | 82 |
Right Hip pain Follow Up Right Hip Post Fluoro Hip Injection significant improvement with injection, pain seems mostly from hip, activity as tolerated, call if pain worsens icd10_description | 16 |
Post Op, Tibia 4 wks post-op Lt BK Stable xrays . Plan -we discussed options for his wound including local wound care vs. surgical debridement and secondary closure. I feel that surgery will likely expedite his wound healing and his recovery. He is in agreement. Will schedule for next 2-3 days. -maintain knee extension... | 93 |
Finger pain New Patient Left Thumb Pain Possible Dislocation Golfing Suspected injury to the left radial collateral ligament Plan Begin wearing left thumb splint at all times except for hygiene purposes 15 mg Meloxicam daily Obtain MRI of the left thumb Return with MRI results icd10_description | 73 |
Right Hand pain Right SLAC wrist Right CMC osteoarthritis consistent with Eaton stage 4 's disease of right palm Plan Steroid injection to the right CMC joint Steroid injection to the right wrist Continue 15 mg Meloxicam daily RTC for exam 's disease of right palm Plan Steroid injection to the right CMC joint Steroid i... | 77 |
7 1/2 weeks Post op LT ankle scope, ligament reconstruction/ doing well > Lt Ankle Scope with debridement and Brostrom icd10_description | 24 |
Right Hip pain Right hip/thigh Osteoarthritis of the Right Hip. icd10_description | 16 |
Right Shoulder pain XRAYS HERE PAIN SINCE Possible carpal tunnel syndrome icd10_description | 3 |
Bilateral Knee pain New Patient Bilateral Knee Pain x 6 Months No Known Injury injection given, activity as tolerated icd10_description | 17 |
Right Knee pain A 17-year-old male with RIGHT ACL tear, medial meniscus and bucket-handle tear, likely radial component. I discussed with the patient and his grandmother, who is his guardian , ACL reconstruction with BTB autograft and medial meniscus repair versus partial medial meniscectomy. They understand risks, ben... | 23 |
Post Op 6 week post-op right ankle/foot 44yoF with right talar neck and calcaneus fx s/p ORIF 6 weeks postop. Also had avulsion fx of superior peroneal retinaculum s/p repair. Wounds healing without signs of infection. Hx of chronic pain related to neuropathy. Seen pain specialist and takes norco daily for pain. Fractu... | 84 |
Right Foot pain New Patient Right Foot Injury In Stepped Off A Ramp And Twisted WBAT in boot, Xray 4 weeks icd10_description | 88 |
month follow up right knee knee industrial injury with first-time patellar dislocation icd10_description | 83 |
Left Hip pain Left Hip Pain x 2 Weeks No Known Injury Xrays At Saint Mary's protective activity. Avoid deep flexion. icd10_description | 25 |
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... | 60 |
3 weeks post injury, RT wrist Plan -okay for activity as tolerated in cast -routine cast care -fu 3 weeks for cast removal and 2V forearm -discussed potential for refracture icd10_description | 65 |
Right Shoulder pain Followup Full thickness rotator cuff tear Partial vs small full thickness RC tear. Recovering from cervical fusion icd10_description | 37 |
Left Ankle pain Osteoarthritis of the Right knee. The patient experienced significant improvement initially, but now the symptoms are returning. Asymptomatic cyst left ankle icd10_description | 17 |
Left Elbow pain Avulsion fracture of the left olecranon with triceps disruption Plan Left triceps repair RTC 2 weeks post op icd10_description | 32 |
follow up left knee Doing well post-op. Progressing as expected. icd10_description | 83 |
Left Elbow pain Assessment Left lateral epicondylitis Plan Left lateral epicondylitis injection Renew Hand Therapy for lateral epicondylitis exercises including ultrasound and iontophoresis No use of left arm 15 mg Meloxicam RTC in 4 wks for exam icd10_description | 39 |
Hand pain RIGHT RING FINGER TRIGGER FINGER X 4 MOS Right ring trigger finger Plan Right ring A-1 pulley steroid injection RTC in 6 wks for exam icd10_description | 31 |
Right Wrist pain Right ganglion cyst Possible right carpal tunnel syndrome Plan Begin wearing right wrist splint 15 mg Meloxicam daily Return to clinic in 6-8 wks for exam icd10_description | 33 |
follow up left ring finger L ring trigger finger, resolved icd10_description | 31 |
Post Op PO 6WKS RIGHT TKA Some calf tenderness, motion better with PT icd10_description | 17 |
Pre Op proep right knee Right knee medial and lateral meniscus tear, prior lateral meniscus inside out repair with complex tear and displaced fragment into the notch, questionable propagation of a medial meniscus tear without displacement right now. I discussed with him treatment options. My recommendation would be kne... | 83 |
Right Wrist pain 3 months post right wrist surgery Assessment Right TFCC injury, s/p surgical repair and s/p broken pin removal Right thumb CMC arthritis Plan Continue scar massage Referral to for desensitization training and other modalities as indicated 15 mg meloxicam Return to clinic for repeat exam icd10_descripti... | 24 |
Left Ankle pain, Left Foot pain The fracture is healing well in good alignment. icd10_description | 88 |
Bilateral Shoulder pain Right shoulder impingement Left shoulder osteoarthritis Plan Obtain intra-articular injection of the left shoulder Continue PT for the right shoulder Continue taking anti inflammatories RTC in 6 wks for exam icd10_description | 37 |
Post Op 6 week post left humerus 63yoF with left periprosthetic humerus fracture at tip of shoulder hemiarthroplasty s/p ORIF 6 weeks postop. Wound healed without signs of infection. Good shoulder/elbow ROM. Fracture healing. Plan -okay to progress activity as tolerated -continue shoulder, elbow ROM, declined referral ... | 60 |
Finger pain Left thumb and middle finger Arthritis of the IP joint of left thumb Plan Begin 15 mg Meloxicam daily Continue thumb splint as needed before surgery Do not lift heavier than 10 lbs, have splint in place while at work Continue to wait for approval from Workers compensation for surgery RTC icd10_description | 14 |
Right Shoulder pain, Fracture Care Follow Up/Xrays Right Clavicle Fracture Recent Fall slightly worse displacement, no further intervention needed, xray 3 weeks icd10_description | 60 |
Right Hip pain The prosthetic components are well positioned with no sign of loosening. The right wrist fracture is healing well in good alignment. icd10_description | 78 |
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 |
Left Knee pain New Patient Left Knee Pain x 1 Month Xrays At Quad stretching Ice, NSAIDs icd10_description | 45 |
Finger pain Right index finger Right index finger MP joint swelling Right index finger osteoarthritis Plan Injection to right index MP joint Begin 15 mg Meloxicam daily Avoid compromising activities RTC in 6 wks for exam icd10_description | 19 |
Left Shoulder pain Left shoulder arthritis Plan Will speak with primary care physician for operative clearance Use sample PENNSAID as needed Recommend left reverse total shoulder replacement RTC in when ready to proceed with surgery icd10_description | 19 |
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... | 25 |
Knee pain fu left knee after PT Left ACL tear from industrial injury - he has been working full duty , prior repair done in early 2000s. Much improved with physical therapy. He will continue activity modifications and work on strength. The plan is to approach this nonoperatively. He will follow up on an as-needed basis... | 23 |
Followup Osteoarthritis of knee RIGHT KNEE NEW INJURY Bilateral knee osteoarthritis. The right is bone-on-bone of the lateral joint line. She is not a candidate for steroid. She would like to avoid total knee arthroplasty. She has done well with viscosupplementation in the past. We will schedule this at next visit. icd... | 17 |
Right Hand pain 2+ wks post-op Right index and middle finger carpometacarpal dislocations Right index finger metacarpal base fracture Traumatic laceration involving first web space and palm of the right hand Plan Instructed in gentle ROM exercises Return to clinic in 4 wks for exam and xrays Plan Instructed in gentle R... | 72 |
Finger pain 6 mo follow-up Laceration of left small finger nail bed, s/p nail bed repair Plan Continue activities as tolerated Return to clinic to further evaluate the nail growth icd10_description | 71 |
Right Ankle pain injured playing basketball 19yoM with right lateral ankle sprain. No obvious fracture seen on xrays from outside facility . Plan -We discussed treatment recs and expected timing for recovery -Okay for WBAT and will provide Rx for ankle brace -continue NSAIDs and consider adding tylenol PRN -discussed o... | 89 |
Right Shoulder pain New Patient Right Shoulder Pain x 1 Year Softball Player Recent MRI start pt, recheck 6 weeks icd10_description | 25 |
Shoulder pain fu left shoulder Left shoulder adhesive capsulitis,Continue to work with physical therapy. Work restrictions Remain the same work at side and in front, but she cannot do any overhead elevation, pushing, pulling, or lifting more than 5 pounds. I would not put her on any hour restrictions for work. I encour... | 37 |
Post Op, Right Hip pain 2 Week Post Op/Suture Removal Right Hip Hardware Removal Activity as tolerated icd10_description | 94 |
Post Op, Right Foot pain Incision looking good post right 3rd ray resection icd10_description | 42 |
8 weeks post op LT 4th and 5th toe dermadesis/ doing better > Lt 4th & 5th Dermodesis icd10_description | 20 |
Post Op Trigger finger of right ring finger, s/p release Middle finger retinacular cyst, s/p excision Right carpal tunnel syndrome, s/p release Plan Begin scar massage RTC in 4-6 wks for exam icd10_description | 3 |
Post Op, Left Foot pain, Left Elbow pain 2.5 wks p-op -I reassured her that her soreness and foot pain should improve with time -She will call if she fails to improve with her right foot and will refer to PT -Rx for tramadol PRN -fu PRN icd10_description | 88 |
Shoulder pain LEFT SHOULDER PAIN she reports she will not follow up with PT - I have recommended eval with her spine surgeon in also for eval of cervical spine icd10_description | 37 |
Left Hip pain f/u left hip Left hip trochanteric bursitis improved - left hip FAI - with labral tear - improved left hip But still experience mechanical symptoms and pain. We'll see how it improves will follow-up ' time pain not resolved or worsening plan would be to proceed with left hip arthroscopy icd10_description | 25 |
Bilateral Knee pain Gelsyn #2 Injections Bilateral Knees injection given, activity as tolerated icd10_description | 17 |
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 |
8 weeks post RT ankle scope, procedure, Peroneal tendon repair Right ankle- Chronic instability/Loose bodies/Large spurs /Indeterminate degree of osteoarthritis > Scope+Brostrom w/ InternalBrace+Removal Loose bodies icd10_description | 25 |
Bilateral Shoulder pain Doing well post-op. Essentially back to full function with both shoulders icd10_description | 10 |
Left Hip pain f/u left hip Left hip trochanteric bursitis improved - left hip FAI - with labral tear - improved left hip But still experience mechanical symptoms and pain. We'll see how it improves will follow-up ' time pain not resolved or worsening plan would be to proceed with left hip arthroscopy icd10_description | 25 |
Left Knee pain Left knee meniscal injury Plan Continue meloxicam Use knee as tolerated Wear knee brace as needed RTC in 6 wks for exam Plan Continue meloxicam Use knee as tolerated Wear knee brace as needed RTC in 6 wks for exam icd10_description | 23 |
Post MRI/CT Left wrist pain Left middle finger trigger finger Right thumb trigger finger Plan Begin exos wrist splint, with taking it off at night and occasionally throughout the day Continue taking advil PRN RTC in 4-6 wks for exam with plan to begin ROM exercises icd10_description | 31 |
Left Knee pain, Left Hip pain Follow Up Left Hip And Knee Pain Post Injection Knee Activity as tolerated. Call if worsens. icd10_description | 17 |
Bilateral Shoulder pain Increase activity level. PT it no relief. icd10_description | 25 |
Left Elbow pain prior surgery, unable to straighten arm, hurts Osteoarthritis of left elbow Elbow pain Elbow Contracture Plan Obtain MRI of elbow Begin 15 mg Meloxicam daily Begin at home exercises for supination improvement RTC with MRI results icd10_description | 24 |
Left Knee pain New Patient Left Knee Pain x 1 Month No Known Injury Xrays At start PT, ice, nsaids, weight loss icd10_description | 22 |
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 |
Left Hand pain, Post Op 6 wks post-op 16yoM with left 5th MC shaft fx s/p ORIF 6 weeks postop. Wound healed without signs of infection, fx healing in stable radiographic alignment. Plan -progress activity as tolerated without restrictions -fu 6 weeks for 2V hand icd10_description | 72 |
Post Op Assessment s/p Right endoscopic tunnel release s/p Right ring A-1 pulley release Trigger finger right ring finger Bilateral Lateral epicondylitis, worse on right BIlateral carpal tunnel syndrome Plan Begin scar massage Continue 15 mg Meloxicam daily No use of right hand for 2 weeks RTC in 2 wks for exam icd10_d... | 3 |
Follow Up Bilateral Ring Fingers Left ring trigger finger Right ring trigger finger Plan Repeat bilateral ring trigger finger injections Begin 15 mg Meloxicam daily RTC in 6 wks for exam icd10_description | 31 |
Left Knee pain New Patient Left Knee Pain x Years Increased Pain x 3 Weeks Recent Xrays and MRI At injection given, activity as tolerated, recheck 6 weeks icd10_description | 17 |
Left Wrist pain no xrays trigger thumb icd10_description | 31 |
Left Wrist pain Left distal radius buckle fracture Plan Resume activities as tolerated, for first few weeks avoid compromising activites Ibuprofen PRN RTC PRN icd10_description | 65 |
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 |
Right Hand pain Post EMG Right radial tunnel syndrome Right meniscal tear Right wrist pain Right knee pain Plan Referral to for massage, nerve gliding, ultrasounds, and other modalities as indicated Continue wearing right wrist splint for the next month for rest Right knee injection Return to clinic for exam with possi... | 3 |
Pre Op, Right Knee pain Osteoarthritis of the Right knee with large MMT. Limited improvement with injection. icd10_description | 83 |
Finger pain Left thumb Left thumb CMC arthritis Plan Steroid Injection given to left thumb Continue meloxicam Continue thumb splint as tolerated RTC for exam icd10_description | 18 |
F/U bilateral foot and ankle pain/ two days after injection pain was worse, now 60% better Rt subtalar inflammation w/ ganglion || Lt plantar fasciitis icd10_description | 25 |
FOLLOW UP RIGHT SHOULDER Probable recurrent RCT icd10_description | 37 |
Tibia 6 mos post op Rt tibia Doing well. Plan -Progress activity as tolerated without restrictions -Continue PT and progress strengthening -fu 6 months for 2V tibia/fibula and 3V ankle, also standing AP pelvis (with shoes off) and standing AP/lateral of lumbar spine (with shoes off) icd10_description | 82 |
Followup Osteoarthritis of knee euflexxa injections #3 right knee Left shoulder with small rotator cuff tear with decent range of motion, some discomfort, and some mild weakness. PT helpful so far - if not improved over the next 6 weeks, we will discuss injection, possible surgical repair. icd10_description | 17 |
Post Op Left carpal tunnel syndrome, s/p carpal tunnel release Right carpal tunnel syndrome, s/p carpal tunnel release, resolved Plan Sutures removed No restrictions RTC in 4 wks icd10_description | 3 |
Left Shoulder pain New Patient Left Shoulder Pain Due To Several Recent Falls Xrays At injection given, activity as tolerated icd10_description | 19 |
Right Hand pain, Right Wrist pain Right wrist sprain Right wrist tendinitis Plan Begin wearing wrist splint at all times except for hygiene purposes No lifting with right hand 15 mg Meloxicam daily RTC in 4 wks for exam icd10_description | 39 |
Post Op, Tibia 8 wks post-op Plan -Progress activity as tolerated in unlocked, hinged knee brace, okay to transition out of brace PRN -continue knee and ankle ROM -consider PT in the future -fu 6 weeks for 2V tibia/fibula icd10_description | 83 |
Right Hand pain Ulnar sagital band disruption or right hand Hand pain, right Plan Right peritendinous injection to the right hand Continue at home stretching exercises and massage RTC in 8 wks for exam Hand pain, right Plan Right peritendinous injection to the right hand Continue at home stretching exercises and massag... | 40 |
Pre Op SX RIGHT SHOULDER SX Right shoulder supraspinatus and subscapularis calcific tendinitis. icd10_description | 37 |
Post Op po2wk right knee 1 4day out open patellar bipartite excision. Will work with PT follow-up 3 weeks time icd10_description | 52 |
Finger pain Right ring finger Right ring finger injury with nail damage Right distal phalanx fracture Plan Monitor for new or worsening symptoms RTC in 4 wks for exam icd10_description | 72 |
Bilateral Shoulder pain bilateral shldr pain Right shoulder end-stage osteoarthritis. No relief from injections and pain medications. Unfortunately, the only surgical treatment is that of a total shoulder arthroplasty. He is currently not a candidate for this. He is on dialysis waiting for kidney transplants. Reportedl... | 19 |
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