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Wrist pain left wrist pain Left wrist lunate collapse, chronic scapholunate destruction, radiocarpal osteoarthritis Left middle and small trigger finger Plan Left wrist fusion RTC 2 weeks post op Left middle and small trigger finger Plan Left wrist fusion RTC 2 weeks post op icd10_description | 19 |
month follow up knee Possible R MMT, improved icd10_description | 83 |
Post Op, Right Ankle pain 6 wks post-op 20yo with right distal fibula fx s/p ORIF 6 weeks postop. Doing well, wound healed without signs of protection. Fx healing in stable alignment. Plan -progress WBAT, can transition out of boot -continue daily ankle ROM and progress to strengthening, discuss option for formal PT bu... | 82 |
Work Comp, Post Op, Left Foot pain check wounds draining Plan - in boot with crutches -referral to wound care to facilitate healthy wound healing ASAP. If he does not respond to this he need surgical debridement -continue ankle ROM -fu as scheduled for 3V foot -filled out PPR icd10_description | 88 |
Right Knee pain NP- RT knee injection given, activity as tolerated icd10_description | 17 |
Post Op s/p Left middle finger extensor repair Laceration to left middle and ring fingers Laceration of left middle finger extensor tendon Plan Referral to for gentle/aggressive ROM exercises and stretching, scar massage, and other modalities as indicated Continue scar massage use the left hand with 10 lb lifting restr... | 71 |
right knee follow up S/P R LFC ACI icd10_description | 83 |
Pre Op, Left Knee pain Left Anterior Cruciate Ligament tear. icd10_description | 83 |
Left Knee pain Followup Osteoarthritis of knee Anteromedial osteoarthritis of the Left knee. The symptoms have not improved with current treatment. icd10_description | 17 |
NP- LT foot and ankle pain/ no Xrays Lt subtalar inflammation icd10_description | 14 |
Bilateral Knee pain Gelsyn Injection #1 Bilateral Knees injection given, activity as tolerated icd10_description | 17 |
Post Op po 6 wks right distal bicep repair Six weeks out right distal biceps repair. He will follow up with me ' time. Continue to work with physical therapy. He has a very physically demanding job. My goal and hope is to have him back to work near the 12-week mark postoperatively. Follow up . icd10_description | 63 |
Right Wrist pain Follow Up Right Shoulder Pain/Right Wrist Pain Wear wrist brace at all times, ice nsaids, discussed shoulder surgery icd10_description | 61 |
Post Op Bilateral carpal tunnel syndrome s/p left release Left cubital tunnel syndrome s/p release Plan Begin scar massage of incision sites Continue taking antibiotics as prescribed RTC 1 wks for exam icd10_description | 3 |
Right Shoulder pain Right Rotator Cuff Tendonitis. with mild OA icd10_description | 63 |
Right Hand pain PIP dislocation of the right small finger Plan taped small finger to ring finger No lifting anything heavier than 10 lbs Use hand as tolerated Return to clinic in 4 wks for exam icd10_description | 73 |
Finger pain Right middle finger Osteoarthritis PIP joint right middle finger Middle finger PIP joint sprain Plan Begin wearing dynamic finger splint at all times for 2 weeks than transition to wearing at night only Continue 15 mg Meloxicam daily and PENNSAID Ice as needed RTC in 8 wks for exam icd10_description | 72 |
Post Op, Left Hip pain The prosthetic components are well positioned with no sign of loosening. icd10_description | 16 |
Left Knee pain Osteoarthritis of the left knee. icd10_description | 17 |
Left Hand pain CRPS of the left thumb Plan Begin desensitization training as instructed Return to clinic PRN icd10_description | 7 |
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... | 97 |
Leg pain 2 years post left femur surgery 14 yo M 2 years s/p IMN for left femur shaft fracture healed and doing well. Some persistent mild irritation medial distal thigh at level of interlocking screw. No signs of infection. Plan -discussed findings and treatment options. I feel that he benefit from removal of implants... | 78 |
Followup Chondromalacia of patella po 5 mos right knee scope 5 months out right medial patellofemoral ligament reconstruction - She continues to improve function. progress with activity as tolerated recommend focusing on quad strength. Follow-up on an as-needed basis or near the one year mark icd10_description | 22 |
Right Hip pain New Patient Right Hip Pain x 3 Months Right Hip Fracture With Repair Hip pain most likely due to DJD, patient does not wish hip revision, leg pain should respond to icing and NSAIDS icd10_description | 84 |
Right Knee pain Right Knee Gelsyn Injection #3 LOT # 1610016 injection given, activity as tolerated, series 3 finished icd10_description | 17 |
Right Elbow pain Right medial and lateral epicondylitis Plan Begin medrol dose pak and the 15 mg Meloxicam daily shortly after Discontinue ibuprofen wearing right wrist splint Begin PT for medial and medial and lateral epicondylitis exercises with other modalities as indicated Return to clinic in 6 wks for exam icd10_d... | 39 |
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 |
Post Op po 2wks right tka Doing well 2 weeks out right total knee arthroplasty. Continue with physical therapy. Follow up ' time. icd10_description | 17 |
Right Shoulder pain New Patient Right Shoulder/Neck Pain x 1 Week No Known Injury start PT ice, Nsaids icd10_description | 63 |
Right Foot pain 6 wks post injury 12yoM with right 5th MT base fx (zone 1), healing 6 weeks into closed treatment. Plan -discontinue boot and progress activity as tolerated -fu 6 weeks for 3V foot icd10_description | 88 |
follow up right shoulder S/P R RCR and SAD with improving adhesive capsulitis icd10_description | 37 |
Finger pain Left middle finger Left middle finger ganglion cyst Plan Aspiration of the left middle finger ganglion cyst Return to clinic in 6 wks for exam icd10_description | 33 |
Knee pain RIGHT TIBIA FX 3 WKS Right buckle fracture of tibia and fibula icd10_description | 82 |
Bilateral Hand pain, Finger pain Bilateral carpal tunnel syndrome, worse on the left Bilateral index trigger finger Left thumb CMC arthritis consistent with Eaton stage 2 Plan Referral to for custom left thumb splint Obtain EMG of bilateral upper extremities Return to clinic with EMG results Bilateral index trigger fin... | 3 |
Post Op Left carpal tunnel release BIlateral carpal tunnel syndrome, s/p left carpal tunnel release Left trigger thumb, s/p release Right middle trigger finger Plan Right endoscopic carpal tunnel release Right A-1 pulley release of middle finger RTC 2 wks post op icd10_description | 3 |
Finger pain fu pinky finger Left small finger crush injury Left small finger distal phalanx fracture Plan Use a band aid as needed Resume activities as tolerated. RTC in 6 wk for exam final xrays icd10_description | 75 |
Post Op Assessment Left ring trigger finger, status post A1 pulley release Left carpal tunnel syndrome, status post endoscopic carpal tunnel release Right middle and ring trigger finger, status post right ring A1 pulley release Plan Monitor right ring finger for new or worsen symptoms Wash right hand wound 3x/day and c... | 3 |
Post Op Cubital tunnel syndrome, s/p release Mass on left wrist. Plan Continue in scar massage Resume activities as tolerated RTC for exam icd10_description | 53 |
Post Op, Left Hip pain Followup Osteoarthritis of hip Doing well post-op. Progressing as expected. icd10_description | 16 |
Left Wrist pain Right scaphoid waste fracture, non displaced Plan Send to PAC med for left wrist brace RTC in 2 wks for exam and xrays icd10_description | 72 |
Post Op 6 weeks post op right ankle 31 yo M with bilateral tibial pilon fxs, left open with talar dome fx s/p I&D and exfix. Now 16 months postop ORIF. Left side with syndesmosis ORIF. Doing well without signs of infection, all wounds healed. Limited bilateral ankle ROM right worse than left. still improving. Now 11 mo... | 88 |
Post Op Bilateral carpal tunnel syndrome, s/p release Right cubital tunnel syndrome, s/p release Plan Ice and elevate right elbow Continue ibuprofen as needed wearing elbow sleeve RTC 2 weeks for repeat exam icd10_description | 3 |
Elbow pain fu left elbow Left elbow supracondylar humerus fracture, type 1 extension type.Healed on all 3 views normal exam progressive activity follow-up as needed icd10_description | 60 |
5 weeks post op LT 2nd - 4th hammertoes > HTs+MTPs icd10_description | 20 |
Bilateral Knee pain Follow Up Bilateral Knee Pain Post Injections failed cortisone, try series icd10_description | 17 |
Finger pain 3 week post xiaflex s/p right xiaflex injections to right small and middle fingers Bilateral Dupuytren's with contractures of right small and middle fingers and left small and ring fingers Plan Begin ROM exercises of right hand Continue with custom splint primarily at night for the next 3-4 weeks RTC for ex... | 36 |
Bilateral Wrist pain New Patient Bilateral Wrist Pain/Carpal Tunnel Bilateral carpal tunnel syndrome Plan Begin wearing bilateral wrist splint at night only RTC in 6 wks for exam icd10_description | 3 |
Post Op WOUND CHECK RIGHT HAND FINGER 4.5 WEEKS 39yoM with right hand middle finger pain consistent with sprain at PIP joint, resolved. Right hand ring fingernail bed injury heald with nail plate growing in, some concern for dystrophic nail formation. Plan -continue monitoring for nail plate growth issues -discussed po... | 40 |
Right Knee pain films nnmc Plan -discussed treatment options including continued conservative treatment and option for TKA at some point. Injected knee with cortisone . Provided rx for hinged knee brace for additional stability -could consider TKA at some point if conservative treatment fails to provide sufficient reli... | 17 |
2 day post op 1st MTP fusion, 2-5 hammertoes > Left Rheumatoid forefoot reconstruction icd10_description | 20 |
Right Knee pain Right Knee Gelsyn Injection #3 LOT # 1610016 injection given, activity as tolerated. Series 3 injections finished, recheck 6 weeks icd10_description | 17 |
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 | 83 |
Right Ankle pain 36yoF with right tibial pilon fx s/p ORIF over 3 months postop. Wound healed without signs of infection. Xrays show abundant bridging callous formation and stable fracture alignment but all 3 proximal screws have broken. Fracture healing despite continued smoking. Plan -okay to progress activity as tol... | 82 |
Right Knee pain 8 months post right knee surgery Assessment s/p excision of substantial gouty tophus anterior to right patella and excision of patellar fracture fragment and repair of medial retinaculum. Gouty tophus right knee return to work with no restrictions RTC PRN return to work with no restrictions RTC PRN retu... | 82 |
Finger pain right ring and small Trigger fingers right ring and small fingers Plan Begin Medrol Dosepak with approval from ENT RTC in 6 wks for exam icd10_description | 31 |
Bilateral Knee pain Followup Osteoarthritis of knee Osteoarthritis of the left knee. Osteoarthritis of the Right knee. The symptoms have not improved with current treatment. icd10_description | 17 |
Post Op Complete transection of ulnar and median nerve Complete transection of the FCR Nearly complete transection of the FDS to the index finger Traumatic laceration at wrist Plan Referral to for custom splint must wear at night and is able to come out throughout the day for gentle ROM exercises Begin washing 2-3 time... | 32 |
Right Knee pain no xrays pain since wrist arthritis icd10_description | 83 |
Right Hand pain, Left Knee pain, Left Ankle pain Left patella fracture, mildly displaced Right wrist pain Plan Plan for ORIF left patella Continue wearing knee immobilizer; keep leg straight at all times Ice and elevate; ankle above knee and knee about the heart No lifting of patients; weightbearing as tolerated with i... | 82 |
Right Shoulder pain Followup Rotator cuff impingement syndrome Right Rotator Cuff Tendonitis. The patient experienced significant improvement initially, but now the symptoms are returning. icd10_description | 63 |
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 | 20 |
Right Hip pain Followup Osteoarthritis of hip rt hip annual f/u Doing well post-op. Progressing as expected.The prosthetic components are well positioned with no sign of loosening. icd10_description | 16 |
Left Knee pain Left knee injury Left meniscal tear Left knee pain Plan Steroid injection to the left knee Discontinue knee brace Continue with naproxen Return to clinic in 6 wks for exam icd10_description | 83 |
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 | 37 |
Left Hand pain LEFT HAND Fracture of the distal phalanx of the ring finger with percutaneous fixation Fracture to middle phalanx of the ring finger without current fixation Fracture of distal phalanx or middle finger with percutaneous fixation, severely comminuted Fracture of the distal aspect of the middle phalanx of ... | 72 |
Post Op PO 6WKS RIGHT KNEE 6 weeks out right knee scope with partial medial meniscectomy. doing well - no issues icd10_description | 83 |
Right Hand pain 5 months post right hand surgery Right small and ring finger proximal phalanx fractures Small finger metacarpal neck fracture Plan Renew hand therapy for aggressive ROM Return to clinic for repeat evaluation icd10_description | 72 |
Leg pain Right and left BKA follow up 52yoM with bipolar disorder and chronic pain. Hx of bilateral BKA after multiple surgeries by Dr. and Dr. . last surgery was in . Now s/p revision right BKA 9 months postop, doing well. Has left BKA site pain with distal ulceration. Plan -do not use prosthesis -recommend revision B... | 40 |
Right Knee pain Follow Up RIght Knee Scope ACL Recon ok to start running. Continue HEP icd10_description | 83 |
Right Shoulder pain, Post Op Post Op Right Shoulder Scope Continue PT. Recheck 6 weeks D/C brace icd10_description | 37 |
9 months post op LT foot fusion LEFT> Triple + rem deep hardware [] icd10_description | 40 |
Post Op 12 weeks post-op right ankle 26yoM with right bimalleolar ankle fx/dislocation, syndesmosis disruption and tibial pilon (chaput) fx s/p ORIF nearly 12 weeks postop. Wounds healed without signs of infection. Stable xrays with continued healing Plan -Progress WBAT and transition out of boot -Rx for ankle brace to... | 89 |
3 weeks post injury LT tibia 18moF now injured left leg. Found to be consistent with healing nondisplaced proximal tibia metaphyseal fracture. Plan -discontinue casting -progress activity as tolerated -discussed low likelihood but potential for growth disturbance -fu PRN icd10_description | 82 |
Right Wrist pain, Post Op Assessment Right wrist pain status post ORIF. Concern for possible tendon impingement on retained hardware of the volar wrist plate. s/p left DRUJ arthroplasty after distal radius fracture with heterotopic ossification and DRUJ autofusion. Significant heterotopic ossification over the volar as... | 29 |
EP- New problem, LT ankle pain since injury in 2004/ no recent Xrays Lt subfibular impingement icd10_description | 39 |
Left Elbow pain injured dirt bike riding Plan -NWB LUE -discontinue splint -sling for comfort -encouraged early elbow ROM -fu 3 weeks for 2V elbow icd10_description | 65 |
Left Shoulder pain Follow Up Left Shoulder Pain Would Like An Injection Last Injection injection given, activity as tolerated icd10_description | 60 |
Left Knee pain Left Knee Gelsyn Injection #1 LOT # 1610016 injection given, activity as tolerated icd10_description | 17 |
Followup Enthesopathy of hip region fu hip pain bilatearl hip OA - woul dlike inejctions icd10_description | 16 |
Right Knee pain Follow Up Right Knee Pain Post Injection Activity as tolerated. Call if worsens icd10_description | 17 |
Left Knee pain no xrays new injury L knee medial DJD with possible prepatellar bursitis vs patellar tendon lesion icd10_description | 17 |
Right Hip pain Hip strain vs low back injury icd10_description | 79 |
Right Foot pain New Patient Right Foot Injury Running RTO Rupture superficial flexor of toe versus contusion, no intervention needed, has good strength to mtp flexion, buddy tape for 4 weeks, call if pain doesnt resolve icd10_description | 32 |
NP- LT hand wound, dog bite 78yoM with dog bite laceration to left dorsal hand and forearm irrigated and loosely closed in ED last night. Has Rx for augmentin. Reportedly there was some concern for tendon involvement but has full function of finger extension . Plan -shown how to do daily dressing changes -finish Rx for... | 71 |
Followup Tear of medial meniscus of knee 7 MOS RIGHT KNEE SLAP tear and rotator cuff tendinosis. Improve with physical therapy Regarding his knee, with progressive cartilage wear and early osteoarthritis, steroid injection to help with symptoms before vacation follow-up as needed icd10_description | 83 |
follow up left knee S/P L PMM/PLM and chondroplasty with pes bursitis icd10_description | 83 |
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 |
Pre Op, Right Knee pain Pre Op Revision Right Total Knee RSM No growth on cultures from aspirate, labs returned to normal, plan knee reimplantation icd10_description | 17 |
2 days post op RT foot bunion and 2nd hammertoe corrections > Rt Prox Bunion + 2nd HT/MTP icd10_description | 20 |
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 | 60 |
Post Op/Xrays Left Foot Pin Removal > Left Rheumatoid forefoot reconstruction icd10_description | 11 |
Left Wrist pain Assessment Left ulnar neuritis Left distal radius fracture, healed with nonoperative treatment Left ulnar styloid nonunion Left thoracic outlet syndrome Plan Continue with PT for thoracic outlet syndrome and stretching of the neck Continue activities as tolerated Return to clinic in 2-3 months for exam ... | 3 |
9 weeks post op RT ankle scope/ has swelling at the end of the day > Rt ankle scope for extensive cicatrix icd10_description | 25 |
Finger pain Lt middle finger injury playing volleyball Mallet finger of the left middle finger Plan Begin wearing middle finger stack splint at all times RTC in 4 wks for exam icd10_description | 20 |
Right Ankle pain injured no xrays Plan -We discussed these findings and treatment options. She has tried various conservative treatment options over the last 6 months and her symptoms seem to be worsening. I recommend immobilization in boto and activity modification for now. Will order MRI to evaluate for achilles inse... | 39 |
Post Op PO DAY 1 RIGHT SHOULDER post op SCR - -doing well f/u 2 weeks icd10_description | 37 |
Post Op Trigger finger right small and ring fingers, s/p release Plan Instructed in scar message use right hand without restrictions RTC 4 wks for repeat evaluation icd10_description | 31 |
Shoulder pain right shoulder pain ref by Dr A 53-year-old active male with right shoulder near complete subscapularis tear, partial supraspinatus tear, and biceps tendon displacement. I have discussed with him treatment options, nonoperative and operative. He would like to watch the shoulder for a little bit and thinks... | 37 |
17 weeks post op RT 5th MT Fx ORIF, Peroneus Brevis tendon repair Right 5th MT avulsion non-union ORIF () | Right Tibial plateau ORIF () icd10_description | 88 |
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... | 19 |
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