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Right Shoulder pain Follow Up Right Shoulder Pain Post Physical Therapy Continue HEP. icd10_description | 25 |
Finger pain Follow Up Left Thumb Pain Patient Would Like An Injection schedule surgery icd10_description | 31 |
Post MRI/CT left knee mri follow up L MMT icd10_description | 83 |
Right Shoulder pain Right Rotator Cuff Tendonitis. The patient experienced significant improvement initially, but now the symptoms are returning. icd10_description | 63 |
Right Hand pain Right index finger metacarpal shaft fracture Plan Continue wearing removable splint Continue previous restrictions RTC in 2 wks for exam and xrays icd10_description | 72 |
Femur, Post Op 7.5 wks post-fx, parents concerned about ankle, would like xr 2.5yoF with left femur shaft fx s/p hip spica casting 7.. Stable alignment on xrays healed in acceptable alignment for age. Plan -okay to progress activity as tolerated -continue PT, expect mobility to improve with time -have previously discus... | 78 |
Knee pain po 3 mos acl Right knee ACL reconstruction, lateral meniscus repair. He is doing well. 12 weeks out - no squats - work on quads and hyper extension - f/u 4 weeks Before he goes to the . His gait and quad are much improved . icd10_description | 83 |
F/U LT ankle pain Left Peroneal Allograft with persistent anastamosis (prox/dist) pain | Left subtalar arthritis icd10_description | 32 |
Ankle pain LEFT ANKLE INJURY WC DOI Left ankle sprain. icd10_description | 89 |
6 days post op LT ankle scope 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 |
F/U RT ankle pain, doing better after injection Right subtalar inflammation icd10_description | 14 |
Left Knee pain, Left Ankle pain CAR ACC SOUTH XRAYS Anteromedial osteoarthritis of the Left knee. Left ankle sprain. icd10_description | 89 |
Left Hip pain Follow Up Left Hip Pain Patient Would Like An Injection Last Injection injection given Lt greater trochanter, activity as tolerated icd10_description | 16 |
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 ... | 83 |
Hip pain po 7 mos right hip scsope Seven months out revision right hip arthroscopy. Will progress with activity as tolerated and follow up as needed. icd10_description | 38 |
month follow up right shoulder S/P L shoulder scope deb, RCR, SAD, and biceps tenotomy icd10_description | 37 |
Post Op, Right Shoulder pain, Left Knee pain 11 wks post-op Plan -progress activity as tolerated without restrictions -continue shoulder ROM and progress to strengthening -fu Dr. regarding further evaluation of ongoing back pain -fu PRN icd10_description | 60 |
Post Op, Leg pain 3 weeks post right femur surgery 9yoM with right femur shaft fracture s/p flexible nailing 3 weeks postop. Stable alignment with early fracture healing on xrays . Plan --okay to slowly progress to WBAT with crutches at this point given degree of early healing --continue knee ROM --fu 4 weeks for 2V fe... | 78 |
Knee pain gelsyn #2 left knee/right knee steroid injection left knee OA and meniscal tears - gelsyn #2 steroid for right knee today icd10_description | 17 |
2 weeks post op RT distal ulna Fx ORIF Right distal ulna nonunion icd10_description | 65 |
Right Knee pain Right Anterior Cruciate Ligament tear. icd10_description | 83 |
MRI results bilateral foot New Patient Bilateral Foot Pain Since Lt plantar fasciitis icd10_description | 14 |
Bilateral Hand pain Bilateral carpal tunnel syndrome, worse on the right Plan Right endoscopic carpal tunnel release RTC 2 weeks post op icd10_description | 3 |
F/U LT knee, surgery Activity as tolerated. Call if worsens. icd10_description | 17 |
Finger pain Right ring finger Right middle trigger finger, resolved Right ring trigger finger, resolving Plan Avoid heavy lifting of the right hand for next few weeks RTC PRN icd10_description | 31 |
Knee pain left knee po tka 6 wks reb by Dr. Six weeks out left total knee arthroplasty, doing well. Will continue with physical therapy. She has the option of following up with me in 6 to 8 weeks, but she will also be visiting her daughter in and follow up with her surgeon, Dr. , at that time. icd10_description | 17 |
Bilateral Hand pain Assessment Bilateral carpal tunnel syndrome Right ring trigger finger Bilateral thumb CMC arthritis Plan Repeat bilateral carpal tunnel injections Repeat right ring finger A1 pulley injection Repeat right middle finger MP joint injection with 0.5 cc Dex Begin 100 mg of celebrex Return to clinic icd1... | 18 |
Deformity Eval Harness Adjustment Wear harness as instructed icd10_description | 49 |
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 |
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 |
Post Op, Knee pain 2 wks post-op Plan -NWB RLE in hinged knee brace from 0-40 deg -NWB LLE in boot -finish lovenox for DVT prophylaxis -fu 2 weeks for repeat 2V right knee (plateau view and lateral) and 3V left foot icd10_description | 88 |
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 | 25 |
Right Foot pain NP- RT foot pain Rock Climbing Injury Xrays At Tahoe Forest Rt 3d & 4th prox metatarsal fractures without intraarticular displacement icd10_description | 88 |
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... | 20 |
Bilateral Wrist Pain And Right Shoulder Pain Right wrist sprain Left wrist pain, probable prominent hardware Right shoulder bicep tendonitis and subacromial impingement Plan Rest, ice, and 15 mg Meloxicam daily 2 weeks then as needed for right wrist wearing right wrist splint Begin at home PT exercises for the right sh... | 37 |
Right Wrist pain Right carpal syndrome, s/p release 's tenosynovitis Plan Continue with Referral to for lateral epicondylitis, dequervain's and iontophoresis and other indicated modalities Plan Continue with Referral to for lateral epicondylitis, dequervain's and iontophoresis and other indicated modalities Begin topic... | 3 |
Right Elbow pain Right Elbow Pain x 2 Months Old Injury Get MRI, protective activity, ice, NSAIDs icd10_description | 63 |
Post Op, Left Knee pain Followup Rupture of anterior cruciate ligament Doing well post-op. Progressing as expected. icd10_description | 83 |
Right Shoulder pain Right shoulder pain Subacromial impingement syndrome Biceps tendinitis Right shoulder labral tear Plan Right shoulder arthroscopy with labral repair with possible open biceps tenodesis Begin taking vitamin C RTC 2 weeks post op and consideration of referral to for desensitization training of the sho... | 37 |
Finger pain Lt thumb Metacarpal base Intra-articular fracture of the right thumb, malunion Plan Begin wearing thumb spica brace at all times Obtain CT scan of right thumb Return to clinic with CT scan icd10_description | 72 |
knee pain, referred by Return to PT, exacerbation of chondromalacia from fracture, no other structural abnormalilties icd10_description | 22 |
month follow up left knee S/P L knee scope LBR icd10_description | 23 |
Post Op, Left Knee pain Doing well post-op. Progressing as expected. icd10_description | 83 |
Post Op Assessment Bilateral carpal tunnel syndrome, s/p endoscopic releases bilaterally Plan Continue scar massage daily Return to activities as tolerated Continue Meloxicam Return PRN icd10_description | 3 |
Deformity Eval New Patient 15 Month Old Male Concerns About Bilateral Great Toe Curling In And no obvious hip abnormality. Curling toes under be part of development, no structural abnormalities, continue to observe, return at age 2 if has not improved. icd10_description | 20 |
Right Wrist pain Right wrist pain, improving Right scapholunate ligament tear Plan Continue with 15 mg Meloxicam daily Continue wrist brace as needed with strenuous activities Return to clinic for repeat evaluation Right wrist pain, improving Right scapholunate ligament tear Plan Continue with 15 mg Meloxicam daily Con... | 73 |
Post MRI/CT, Right Knee pain improving at this time, call if not improving for PT icd10_description | 22 |
F/U RT ankle pain, doing better after injection Right subtalar inflammation icd10_description | 33 |
Right Wrist pain Assessment Left FCR tendinitis, improving Left Extensor digitorum communis tendinitis Left Radiocarpal arthritis Right FCR tendinitis Plan Continue wrist splints as needed Continue wrist stretching exercises Continue with for stretching exercises No NSAIDs PO per your primary physicians instruction Ret... | 40 |
Post Op, Left Knee pain Doing well post-op. Progressing as expected. icd10_description | 23 |
Right Elbow pain Right olecranon fracture, nondisplaced Plan Right long arm cast in roughly 45 degrees of flexion No lifting with the RUE Avoid activities that would compromise the fracture Return to clinic in 2 wks for exam and xrays icd10_description | 65 |
Right Foot pain EP- New problem RT foot pain/ no Xrays Achilles stretching. icd10_description | 33 |
Post MRI/CT Post EMG Right shoulder pain Right subacromial impingement syndrome Bilateral carpal tunnel syndrome, worse on the right Bilateral cubital tunnel syndrome, worse on the right Plan Right endoscopic carpal tunnel release and cubital tunnel release Continue home exercises for right shoulder RTC 2 weeks post op... | 3 |
Right Wrist pain Right ECU tendonitis icd10_description | 31 |
Right Hand pain, Right Wrist pain injured Plan -wrist brace for trapezium avulsion -continue early ROM and buddy taping -fu 3 weeks as scheduled for repeat exam icd10_description | 72 |
Left Knee pain Probable L MMT and/or LB icd10_description | 83 |
NP- Bilateral leg bowing, no Xrays Activity as touch. No intervention at this time. Call if worsens icd10_description | 54 |
Fracture Care LT wrist ' Fx, injury Protective activity X-ray 2 weeks icd10_description | 65 |
Right Knee pain 3 weeks post right knee surgery Plan -Continue NWB RLE x 8-12 weeks postop -continue knee ROM with PT -continue unlocked when out of bed -fu 5 weeks for 2V knee -recs conveyed to SNF icd10_description | 82 |
Right Shoulder pain Followup Strain of rotator cuff capsule Ganglion cyst right AC, currently asymptomatic icd10_description | 33 |
Shoulder pain RIGHT SHOULDER PAIN Bilateral shoulder subacromial impingement, rotator cuff tendinosis. He declined injections . He will work with physical therapy. If this is not improved over the next 6 to 8 weeks he will call, and the plan will be for an MRI arthrogram of the right shoulder. He was given a prescripti... | 37 |
Right Wrist pain, Post Op s fx right distal radius with ulnar styloid fx. The fixation hardware is in good position with no sign of failure. icd10_description | 65 |
Right Hand pain Right dupuytrens contractures of the right small and ring fingers Plan Schedule Xiaflex injections at your convenience Return to clinic for Xiaflex injections icd10_description | 36 |
Left Wrist pain Wants to talk about surgery Left SNAC wrist Plan Left wrist arthrodesis Return to clinic 2 wks post op icd10_description | 72 |
Left Shoulder pain, Post Op Post op LT clavicle surgery sutures removed, wear slilng, gentle shoulder rom, xray 2 weeks icd10_description | 60 |
Patient fell/ 3 days post op RT Subtalar fusion >Rt Subtalar Fusion icd10_description | 38 |
Finger pain left thumb Left thumb laceration Left distal tuft fracture of thumb Plan Begin using left hand as tolerated Begin washing hand once a day RTC in 4 wks for exam and xrays icd10_description | 71 |
month follow up left knee L PF chondrosis, probable unstable chondral lesion icd10_description | 22 |
Bilateral Shoulder pain bilateral shldr pain Right Rotator Cuff Tendonitis. Left Rotator Cuff Tendonitis. The patient experienced significant improvement initially, but now the symptoms are returning. icd10_description | 63 |
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 | 25 |
Right Knee pain Right knee lateral parameniscal cyst with probable occult LMT icd10_description | 35 |
follow up right wrist Left nondisplaced distal radius buckle fracture icd10_description | 65 |
Left Ankle pain 7 mos post-op Plan -progress activity as tolerated -continue ROM and progress to strengthening -fu 5 months for 3V ankle -continue compressive stockings. icd10_description | 34 |
Post Op, Right Foot pain Followup Open wound of foot 8.5 wks post surgery...at Wound clinic this am Plan -recommend return to surgery for debridement of her wound and wound vac therapy. be able to attempt secondary closure. I discussed in detail potential limitations to this option and feel that we should at least cons... | 9 |
Post Op 6 WEEKS POST OP RT FEMUR PELVIS 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 ... | 78 |
Post MRI/CT Post EMG Bilateral carpal tunnel syndrome, worse on the right Plan Right carpal tunnel release Continue wrist splints RTC 2 weeks post op icd10_description | 3 |
Post Op RIGHT FEMUR FRACTURE HOSP FOLLOW UP 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 2 weeks postop femur and 12 days postop clavicle. Has right scapula fx and left 3rd MT fx treating nonop. ... | 78 |
Bilateral Hand pain Bilateral carpal tunnel syndrome Right thumb through middle trigger finger Plan Right endoscopic carpal tunnel release Return to clinic 2 weeks post op icd10_description | 3 |
Post MRI/CT Post EMG Bilateral carpal tunnel syndrome, worse on the right Plan Right carpal tunnel release Continue wrist splints RTC 2 weeks post op icd10_description | 3 |
Left Shoulder pain Followup Rotator cuff impingement syndrome Left Rotator Cuff Tear. Doing well post-op. Progressing as expected. icd10_description | 37 |
3 month follow up left tka L TKA icd10_description | 19 |
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... | 82 |
Left Knee pain New Patient Left Knee Pain Heard A Pop 10/2016 Protective activity, get MRI icd10_description | 23 |
Deformity Eval F/U hip dysplasia Activity as tolerated, xray at age 2 icd10_description | 49 |
Deformity Eval New Patient 10 Day Old Female With Hip Dysplasia Harness Placed In Hospital Wear harness as instructed icd10_description | 49 |
F/U Bilateral ankle pain, RT ankle is now pain free LT ankle 50-70% better with last injection, Bilateral elbows are pain free Talonavicular arthritis, left icd10_description | 19 |
Right Shoulder pain, Post MRI/CT MRI results RT shoulder injection given Rt glenohumeral joint, activity as tolerated, recheck 6 weeks icd10_description | 63 |
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... | 94 |
4 weeks post op 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 |
Shoulder pain left shoulder Left shoulder subacromial impingement, rotator cuff tendinosis. Will work with physical therapy. He also has back issues. I have recommended an evaluation with physical therapy for both. He will follow up for a left shoulder injection if not improved. icd10_description | 37 |
foillow up left ankle 5 month post op 86yoF with left displaced trimalleolar ankle fx s/p ORIF 5 months postop. Wounds healed without issues. Xrays show stable posterior ankle subluxation. Fractures healed with malunion but clinically doing well at this point without pain and weightbearing in normal shoe. Plan -We disc... | 82 |
Right Shoulder pain NO XRAYS L distal biceps chronic strain/tendinopathy icd10_description | 37 |
Shoulder pain LEFT SHOULDER PAIN X 3 WKS Left shoulder acute injury, concerning for SLAP tear, possible rotator cuff tear which would be surprising in a 43-year-old female but given her severe weakness and pain on range of motion and rotator cuff strength testing, the plan is for an MRI arthrogram with followup with re... | 37 |
Knee pain right knee pain Right knee end-stage osteoarthritis. Views x4 weightbearing of the right knee show bone-on-bone arthritis of the medial compartment with osteophytes and sclerosis. The lateral compartment shows osteophytes as well, and the patellofemoral joint shows narrowing with bone-on-bone findings and ost... | 17 |
Right Knee pain F/U RT knee Continue Quad stretching Call if worsens icd10_description | 45 |
Bilateral Shoulder pain Full thickness left rotator cuff tear, moderate osteoarthritis of glenohumeral joint with labral tear Biceps tendonitis bilaterally with left biceps subluxation Right subacromial impingement and Inferior labral tear Plan Obtain intra-articular injections of bilateral shoulders Begin PT of bilate... | 37 |
2 weeks post op RT ankle scope RIGHT Ankle [} Ankle scope for anterior cicatrix and tenolysis of PL/ Tendons || RIGHT Ankle [] Anterolateral ankle impingement secondary to cicatrix band | Chronic lateral ankle instability | Dislocated Peroneal tendons without tear> Groove deepening procedure icd10_description | 32 |
FOLLOW UP RIGHT RING FINGER ring fingertip traumatic amputation icd10_description | 76 |
Right Knee pain 6 month post right tibial plateau surgery Assessment Right lateral tibial plateau fracture with intra-articular extension that is comminuted, status post ORIF Plan Resume all activities as tolerated RTC PRN icd10_description | 82 |
Right Knee pain Right PCL avulsion fx, moderate OA icd10_description | 83 |
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