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Left Shoulder pain, Post Op Type 2 SLAP left shoulder. Doing well post-op. Overuse in PT icd10_description | 61 |
Deformity Eval New 2.5 Year Old Male Left Foot Concerns Started Walking At 1.5 Years discussed casting versus surgical intervention. try stretching cast. start next week icd10_description | 33 |
Right Shoulder pain, Post Op, Right Hip pain 2 wks post-op Plan -continue NWB RUE with abduction brace at all times for now -WBAT RLE -PT/OT for mobilization/ADLs -fu 2 weeks for 3V right shoulder and 2V right hip icd10_description | 78 |
Right Hip pain Right Hip Pain x 1 Year No Known Injury injection given, activity as tolerated, stretching icd10_description | 34 |
Elbow pain right elbow pain Right elbow arthritis, questionable potential loose body, not having symptoms of it now. The pain is minimal. I told her I would not recommend a total elbow at this point. X-rays from an outside facility were reviewed. There is extensive arthritis and osteophytes of the ulnohumeral joint and... | 19 |
9 weeks post op LT ankle scope, procedure/ doing well > Lt ankle scope+Brostrom+peroneal repair Chronic left lateral ankle sprain icd10_description | 24 |
F/U LT ankle pain Left subtalar arthritis | Left Peroneal Allograft with persistent anastomosis (prox/dist) pain icd10_description | 32 |
Left Foot pain New Patient Left Foot Turning In And Walking With A x 1 Week No Known Injury No obvious structural abnormalities, call if doesnt resolve icd10_description | 54 |
Bilateral Hand pain Bilateral carpal and cubital tunnel symdrome Plan Begin 15 mg Meloxicam daily wearing wrist splints primarily at night Obtain Bilateral UE EMG RTC with EMG results icd10_description | 3 |
, Right Foot pain New Patient Concerns About Feet Turning In activity as tolerated, need surgical interventin at age 13-14, call with questions icd10_description | 21 |
Finger pain Bilateral thumb pain Bilateral trigger of the thumbs Plan Begin 15 mg Meloxicam daily every day for a month RTC in 6 wks for exam icd10_description | 31 |
Finger pain left middle finger Left middle trigger finger, resolving Plan Continue with Hand Therapy for gentle ROM, ultrasound, iontophoresis, desensitization Continue with for gentle ROM, ultrasound, iontophoresis, desensitization RTC in 8 wks for exam icd10_description | 31 |
right shoulder S/P R RCR, SAD, and biceps tenotomy icd10_description | 37 |
Right Elbow pain Right medial epicondyle apophysitis Plan begin light throwing, gradually within the next 2-3 weeks Continue gentle ROM exercises Take ibuprofen PRN RTC in 4 wks for exam icd10_description | 46 |
Finger pain Left ring finger Left ring finger triggering Plan Left ring trigger finger injection Continue 15 mg Meloxicam daily RTC in 6 wks for exam icd10_description | 31 |
fu left knee acl 5 mos 5 months out left knee ACL reconstruction with BTB autograft, doing very well. KT-1000 shows near symmetric exam.Return to play physical therapy. Follow-up in 10-12 weeks' time icd10_description | 23 |
5 1/2 weeks post op RT foot fusion RIGHT- Subtalar joint sprain, industrial related || Midfoot arthritis, Industrial aggravated [> Rt Triple Fusion] icd10_description | 33 |
Work Comp, Post Op, Right Ankle pain 6 weeks Post Op Right Ankle Scope WORK COMP/ doing well > Right ankle scope with extensive debridement + Os Trigonum excision. RIGHT Anterior ankle impingement secondary to cicatrix/exostosis --Posteromedial osteochondral lesion of tibia/talus--Symptomatic Os Trigonum icd10_descript... | 25 |
Post MRI/CT Open fracture of left small finger proximal phalanx Joint stiffness of the left small finger Plan Left small finger tenolysis with possible placement of rod. RTC 2 wks post op icd10_description | 25 |
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 | 17 |
Left Shoulder pain 4.5 months post op left humerus Displaced left proximal humerus fracture, s/p ORIF with conventus cage Plan Discontinue any heavy lifting and PT until CT scan results RTC with CT results icd10_description | 60 |
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 | 20 |
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 | 23 |
Right Ankle pain 8 mos post-op Plan --progress activity as tolerated --NSAIDs PRN --MMI --filled out PPR icd10_description | 60 |
Post Op s/p Right endoscopic carpal tunnel release and cubital tunnel release Right shoulder pain Right subacromial impingement syndrome Bilateral carpal tunnel syndrome, worse on the right Bilateral cubital tunnel syndrome, worse on the right Plan Begin scar massage Continue home exercises for right shoulder RTC in 4 ... | 3 |
Right Hip pain 4 month post injury Plan -progress activity as tolerated without restrictions -continue PT for shoulder ROM and generalized conditioning -We discussed natural hx of shoulder arthritis and options including conservative management vs. shoulder arthroplasty. She is concerned about surgery given her cardiac... | 19 |
Post Op, Right Ankle pain Right Lateral malleolus fracture. The fracture is healing well in good alignment. icd10_description | 82 |
Post Op po 2wks right elbow 21 week out right thommy john and ulnar nerve transposition - left hamstring autograft- PT sutures out - f/u per surgeon icd10_description | 3 |
Right Knee pain no xrays pain since wrist arthritis icd10_description | 25 |
Right Foot pain New Patient Right Foot Injury Stepped Wrong Xrays At weight bearing as tolerated in boot, elevate, ice, xray 4 weeks icd10_description | 82 |
Post Op, Right Ankle pain 7 wks post-op 49yoF with right trimalleolar ankle fx s/p ORIF 7 weeks postop. Wounds healed without issues . Fractures healing in stable alignment. Plan -Progress to WBAT and transition out of boot -continue daily ankle ROM, discussed option for PT but she declined, shown strengthening exercis... | 82 |
MRI reuslts RT ankle Severe right ankle sprain Osteochondral lesion of lateral talar dome, right icd10_description | 89 |
Left Hand pain Mass of the left hand 's tendonitis left hand, improving Plan Referral to for stretching and iontophoresis Begin medrol to help with inflammation Continue wearing the wrist splint at all times Begin topical anti inflammatory Return to clinic in 6 wks for exam icd10_description | 31 |
Post Op left knee S/P L PMM and chondroplasty icd10_description | 83 |
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. ... | 60 |
Right Wrist pain New Patient Right Wrist Injury Fell Off Bike Xrays At Right wrist pain Plan Use wrist splint as needed Ibuprofen as needed for pain RTC PRN icd10_description | 25 |
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 Continue scar massage for right thumb RTC in 2 wk with xrays icd10_description | 31 |
Bilateral Hip pain Right labral tear with mild OA icd10_description | 24 |
Finger pain right thumb Carpal tunnel syndrome right hand Thumb CMC arthritis right hand Left hip pain Plan 15 mg Meloxicam daily Continue thumb splint RTC in 6 wks for exam and consider injection at this time icd10_description | 25 |
Right Elbow pain Little league elbow right elbow icd10_description | 46 |
Post Op 2wks left tka Two weeks out left total knee arthroplasty, doing well. We will transition to outpatient physical therapy. He will follow up ' time. icd10_description | 17 |
wrist Fx, 1 week post closed reduction Plan -NWB RUE in cast with sling for comfort -fu 3 weeks for cast removal and 2V wrist icd10_description | 65 |
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... | 36 |
Post Op, Tibia 6 wks post Lt BKA, 9 days post debridement of incision Plan -continue NWB LLE -continue compressive dressing and changes as needed -maintain knee extension and okay for gentle knee ROM -fu pain management -continue gabapentin -I encouraged him to pursue followup with behavior health services regarding co... | 98 |
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 2-3 months for exam 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 | 17 |
Finger pain Left middle finger Left middle finger osteoarthritis at IP joints. Plan Left middle finger PIP joint injection Continue anti inflammatories as needed Continue therapy with RTC in 6 wks for exam icd10_description | 14 |
Left Shoulder pain, Post Op Doing well post-op. Progressing as expected. icd10_description | 93 |
Right Hip pain 3.5 months post right hip surgery 59yoM now 3 months postop revision right THA acetabulum component. Stable xrays . Wound healed without signs of infection. Doing very well clinically. Plan --okay to progress activity as tolerated --continue posterior hip precautions --fu 3 months for AP pelvis icd10_des... | 94 |
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 |
Work Comp, Left Elbow pain NP- LT elbow pain injection given, activity as tolerated, wear brace as instructed, stretching program, ice massage icd10_description | 39 |
Followup Adhesive capsulitis of shoulder fu shoulder pain,wants to discuss surgery Left shoulder with rotator cuff tendinosis. Exam findings consistent with mild adhesive capsulitis and an MRI that shows a SLAP tear. She continues to have mechanical symptoms, pain, and limitation. She has failed physical therapy. The l... | 37 |
Post Op, Right Knee pain Post Op/Xrays Right Total Knee Aggressive Rom, entire PT. Recheck motion 6 weeks icd10_description | 17 |
Post Op s/p Right reverse total shoulder Right rotator cuff tear, s/p arthroscopy Right AC joint arthritis, s/p arthroscopy Right biceps tendinitis, s/p arthroscopy Plan Begin scar massage Continue with PT for active/passive ROM as tolerated No lifting heavier than 10 lbs and no pushing up from a seated position Contin... | 37 |
Knee pain GELSYN #1 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 |
Right Elbow pain Plan -we discussed treatment options including NSAIDs, bracing, activity modification, injections and formal PT -prefers Rx for ibuprofen and brace for now -fu PRN if symptoms persist or worsen icd10_description | 39 |
Right Knee pain NO XRAYS knee DJD icd10_description | 17 |
Deformity Eval Bilateral Foot Cast removal Feet have corrected well, no more need for casting. Parents shown strecthing program, recheck 3 weeks. icd10_description | 24 |
Knee pain 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 knee a... | 83 |
Right Hand pain, Right Wrist pain /Hand Pain x 20 Years Fall Increasingly Worse Since Fall Injections Helped Very Little Suspected prior scapholunate ligament injury Right radioschapoid osteoarthritis with scapholunate ligament widening Right thumb CMC osteoarthritis consistent with Eaton stage 3 Plan Begin 15 mg Melox... | 19 |
Left Wrist pain, Post Op 12 wks post fx Plan -progress activity as tolerated -fu PRN icd10_description | 65 |
Bilateral Knee pain Bilateral Knee Gelsyn Injections #3 LOT # 1610016 x2 injection given, activity as tolerated, series 3 finished, call if doesnt resolve icd10_description | 17 |
Left Shoulder pain Compression fx left humeral head with minimal displacement icd10_description | 60 |
Left Forearm pain, Right Foot pain Scooter injury Plan -we discussed findings and I recommend nonoperative managament for all of his fractures. -okay for WBAT in boot -can transition out of boot when comfortable -fu 5 weeks for 3V foot icd10_description | 88 |
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 | 17 |
follow up right wrist R thumb CMC pain 's release icd10_description | 31 |
Left Knee pain, Right Hip pain left hip pain, right knee Right knee lateral collateral ligament strain. This will improve with time. Left hip strain and tight IT band with underlying femoroacetabular impingement. Views x3 right knee are normal in appearance. No acute abnormalities. AP pelvis and the lateral of the left... | 25 |
Knee pain left knee pain Left knee end-stage osteoarthritis bone on bone of the medial compartment and patellofemoral joint. He has failed steroid injections, activity modifications, and available over-the-counter medications and would like to proceed with a total knee arthroplasty. x-rays, 4 views weightbearing of the... | 17 |
Post MRI/CT Post EMG Right carpal tunnel syndrome Thoracic Outlet Syndrome Plan Continue right wrist splint Continue PT for shoulder and include neck stretching for Thoracic Outlet Syndrome RTC in 6 wks for exam icd10_description | 28 |
Shoulder pain LEFT SHOULDER PAIN Left shoulder subacromial impingement and rotator cuff tendinosis. MRI confirms the same. She will start with physical therapy. Regarding the left hip prior FAI treatment and hip arthroscopy, the plan is for a left hip injection prior to her hiking trip. She will follow up on an as-need... | 25 |
Right Hand pain Right hand 's Plan Monitor for new or worsening symptoms, call the office with any questions or concerns Return to clinic in wks for exam icd10_description | 36 |
6 days post op RT 1st MTP fusion, 2-5 hammetoes > Rt Forefoot reconstruction || Severe bunion, dislocated MTP joints with chronic synovitis and hammertoes (Right foot more symptomatic than left) icd10_description | 89 |
fu emg results Bilateral carpal tunnel syndrome, worse on the right then the left Plan Right endoscopic carpal tunnel release RTC 2 weeks post op icd10_description | 3 |
Post Op s/p right endoscopic carpal tunnel release Bilateral carpal tunnel syndrome, worse on the right then the left Plan Begin scar massage Return to clinic for exam Bilateral carpal tunnel syndrome, worse on the right then the left Plan Begin scar massage Return to clinic for exam icd10_description | 3 |
2 weeks post op LT tibia derotation osteotomy Left Internal Tibial Torsion, severe [> derotational osteotomy] Right Internal Tibial Torsion, moderate icd10_description | 21 |
Bilateral Hip pain Chronic low back, SI pain with possible mild right hip pathology icd10_description | 28 |
Right Hand pain Hand pain, right Plan Take mobic as needed Continue at home stretching exercises and massage RTC in 6 wks for exam icd10_description | 40 |
Left Shoulder pain mri L RCT icd10_description | 63 |
Post Op Tear of ulnar collateral ligament of right thumb, s/p surgical repair Plan Continue splinting at all times for 2 more weeks, then begin weaning out of brace as tolerated No lifting heavy of the right hand Continue in scar massage Continue with ROM exercises and begin working on grip strength Take NSAIDS PRN RTC... | 66 |
Shoulder pain right shoulder pain Right shoulder rotator cuff strain, mild scapular dyskinesia. The plan is to work with physical therapy and take a break from throwing. He return to throwing in 4 to 6 weeks if he is not having any pain. He will follow up on an as-needed basis. If symptoms persist or he develops mechan... | 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 Knee pain New Patient Left Knee Pain x 1 Year Due To Several Falls CT Scan At Banner In Echos injection given, activity as tolerated, recheck 6 weeks icd10_description | 17 |
Right Forearm pain Flexor Carpi Ulnaris Tendinitis Possible right cubital tunnel syndrome Plan Begin wearing wrist splint at all times until next visit 15 mg Meloxicam daily take for 4 weeks Obtain EMG of right UE RTC with EMG results icd10_description | 39 |
Right Shoulder pain long time, no specific injury Right impingement syndrome Right biceps tendinitis Plan Right steroid injection to subacromial space Begin PT for right shoulder RTC in 6 wks for exam icd10_description | 37 |
Left Foot pain Left foot buckle fracture at the base of the first metatarsal Plan Begin pediatric walking boot RTC in 2 wks for exam and xrays with possible transition out of boot icd10_description | 88 |
Post MRI/CT Right tear of the rotator cuff, disruption of the supraspinatus and subscapularis tendons Plan Right subacromial injection Right shoulder arthroscopy with rotator cuff repair and revision subacromial decompression Return to clinic when ready to proceed with surgery Plan Right subacromial injection Right sho... | 37 |
Post Op po 7 wks left knee Left knee patellofemoral chondromalacia with acute injury from accidents. At the time of surgery, there were grade 3 changes of the patella. She has been given an injection with a steroid . Leaving the office , she felt good. She had questions about long term. The plan is to manage this sympt... | 22 |
Left Wrist pain left thumb Assessment Right trigger thumb, s/p A1 pulley release 's syndrome of left thumb Left thumb tendinitis Plan Continue splinting PRN for the left hand Continue 15 mg Meloxicam PRN Follow up in 8 wks for repeat exam icd10_description | 31 |
Followup Osteoarthritis of knee fu after euflexxa injections bilateral knees Right knee bone-on-bone medial joint arthritis, patellofemoral joint moderate arthritis. Views x4 weightbearing of the right knee show bone-on-bone findings of the medial compartment with osteophytes and sclerosis along with osteophytes and sc... | 17 |
Left Elbow pain fell a couple times this 45yoM with left supracondylar humerus fracture nonunion with associated broken implants. Possibly some ulnar neuritis. Plan --We discussed these findings in detail. I feel that he wound benefit from nonunion repair with removal of his broken implants. We need to rule out potenti... | 60 |
Shoulder pain FU LEFT SHOULDER WANTS TO DISCUSS SURGERY I have reviewed images . MRI shows complete cartilage loss of the glenohumeral joint with mild rotator cuff tearing. X-rays show the same without glenohumeral elevation. icd10_description | 19 |
Right Shoulder pain Follow Up Right Shoulder Scope Symptoms worsening, no relief with PT, get new MRI icd10_description | 37 |
F/U LT TAA Left Posterior tibial tendinitis Left TAA () Prior left peroneal tendon reconstruction, remote. icd10_description | 99 |
Right Shoulder pain, Post Op Right Rotator Cuff Tear. Doing well post-op. Progressing as expected. icd10_description | 37 |
Bilateral knee pain injection given, activity as tolerated icd10_description | 17 |
hip pain, left leg Does not seem to have any pain from hip joint, mild djd on xray, pain generator most likely from lumbar spine. icd10_description | 28 |
Right Elbow pain Right lateral epicondylitis Plan Referral to Hand Therapy for ultrasounds and other modalities indicated for lateral epicondylitis Continue right wrist splint at all times Avoid lifting objects in ways that cause pain Begin topical anti inflammatory RTC in 6 wks for exam icd10_description | 39 |
Right Wrist pain Fell on Plan --we discussed treatment options including conversion to cast with better mold/reduction vs. ORIF. We discussed risks and benefits of both options. I feel that ORIF would be most definitive means of maintaining acceptable fracture alignment. We discussed risks of surgery including infectio... | 65 |
Post Op s/p left endoscopic carpal tunnel release Bilateral Carpal tunnel syndrome; worst on the left Plan Begin scar massage Continue with course celebrex Discontinue aleve while taking celebrex take tylenol for pain RTC in 4 wks for exam Bilateral Carpal tunnel syndrome; worst on the left Plan Begin scar massage Cont... | 3 |
Right Knee pain Doing well post-op. Progressing as expected. icd10_description | 83 |
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