ICD-10 Chief Complaint:
HPI:
There is pain in the shoulder which has progressed to the point that it limits activity and sleep. It is affecting daily activities. There has not been improvement with conservative care.
Physical Exam:
General Appearance: Well-nourished, well developed in no acute distress. Orientation: Oriented to person, place and time. Mood / Affect: Calm. Gait: normal Coordination: normal. Shoulder Exam (Bilateral). Inspection/Palpation UE (R/L): Non-tender bilaterally. Active FE (R/L): 160 / 160 Passive FE (R/L): 160 / 160. External Rotation at side (R/L): 45 / 45 Internal Rotation (R/L): Cross Arm (R/L): neg / neg Neer Impingement Test (R/L): neg / +. Hawkins Test (R/L): neg / + Scapulothoracic motion (R/L): 2:1 / 2:1. O’Brien's Test (R/L): neg / + Apprehension (R/L): neg /neg. Abduction (R/L): 5/5 / 5/5 ER(R/L): 5/5 / 5/5 IR (R/L): 5/5 / 5/5. Biceps (R/L):5/5 / 5/5 Triceps (R/L):5/5 / 5/5 Intrinsics (R/L): 5/5 / 5/5. Sensation: Subjective normal m/u/r/ax sensation, <2 sec distal cap refill. Skin and lymph: appears normal in the affected extremity. Age approp cervical ROM without symptoms.
Diagnostic Studies:
Left Shoulder X-ray series of affected extremity from today including Grashe view, supraspinatus outlet view, axillary view and Zanca views were personally evaluated by me and demonstrate: Acromion: type II. Acromioclavicular Joint: mild acromioclavicular joint space narrowing with hypertrophic changes in the distal clavicle. Glenohumeral joint: the joint space is relatively well preserved. Acromiohumeral interval is greater than 7mm. Scapulohumeral line is intact. Greater tuberosity: mild sclerotic changes
Assessment:
M25.412 Effusion, left shoulder
Plan:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.
Category:
- Musculoskeletal System
ICD-10:
M25.412
ICD:
M25
Side:
- Left
ICD-10CM Year:
2019