ICD-10 Chief Complaint:
There is pain in the wrist 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.
General Appearance: Well-nourished, well developed in no acute distress. Orientation: Oriented to person, place and time. Mood / Affect: Calm. Gait: normal Coordination: normal. Wrist Exam: Inspection/Palpation: Flexion(R/L): 55 / 55 Extension (R/L): 45 / 45. Normal cascade. Able to A-OK, hook horns, cross fingers, thumbs up. Subjective normal M/U/R distal sensation. 2+ Radial pulse. Skin and lymph appear normal
Xray series of the wrist from today including P/A, lateral and oblique views was personally evaluated by me and demonstrates: Fracture (s) and/or Dislocation(s): None . Alignment: Normal . Joint space(s): Normal . Soft tissues: Normal .
M25.432 Effusion, left wrist
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.