Abbreviations

aA== A=initial encounter, D=subsequent encounter, S=sequela

aaat with activities as tolerated

aacinject PROCEDURE: AC joint steroid injection
PRE-Procedure DIAGNOSIS: AC osteoarthritis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected shoulder was sterilely prepped with Betadine. A 1 mg of dexamethasone was drawn up into a 5 mL syringe with a 1 mL of 1% lidocaine and 1ml of marcaine. The patient was injected with a 1.5-inch 22-gauze needle into the AC joint. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

aankleinj
PRE-Procedure DIAGNOSIS: Ankle osteoarthritis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected Ankle was sterilely prepped with Betadine. A 1 mg of dexamethasone was drawn up into a 5 mL syringe with a 3 mL of 1% lidocaine. The patient was injected with a 1.5-inch 22-gauze needle. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

aanklent
CHIEF COMPLAINT:
RIGHT LEFT ankle/foot pain

HISTORY OF PRESENT ILLNESS:

Pain Severity: 3-7 /10
Pain location: ankle
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications, crutches, ice, tramadol, lortab

PHYSICAL EXAM:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: antalgic Coordination: normal
Ankle / foot Exam (Bilateral)
Inspection / Palpation LE (R/L): nontender
Dorsiflexion (R/L): 25º / 25º
Plantarflexion (R/L): 50º / 50º
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
Sensation: subjective normal distal sensation bilateral LE
Vasculature: LE Skin: No rashes, no lesions
Skin and lymph: appears normal in the affected extremity.

DIAGNOSTIC STUDIES;
Xray series of the ankle taken in the office today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

ASSESSMENT:

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered.

aanklesprain
CHIEF COMPLAINT:
RIGHT LEFT ankle/foot pain

HISTORY OF PRESENT ILLNESS:
Sustained a twisting injury to the foot and ankle. The ankle most likely was internal rotated and inverted. There has been pain and swelling in the ankle and foot since.
Pain Severity: 3-7 /10
Pain location: ankle
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: acute
Context: recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications, crutches, ice,

PHYSICAL EXAM:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: antalgic Coordination: normal
Ankle / foot Exam (Bilateral)
Inspection / Palpation LE (R/L): ankle tender and swollen diffusely
minimal ankle ROM without pain
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
Sensation: subjective normal distal sensation bilateral LE
Vasculature: Skin and lymph: appears normal in the affected extremity.

ASSESSMENT:
Ankle Sprain S93.409A

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered. We will begin treatment with rest, ice, compression, and elevation (RICE) with early controlled motion in a functional Ankle Brace or cam walker. We will also begin physical therapy to improve proprioception and strengthening of the peroneal muscles. They will follow up in 4 weeks

aatsrisks
We discussed the risks of surgery including but are not limited to: incomplete relief of pain, incomplete return of function, chondral injury, hemarthrosis / hematoma, DVT, joint stiffness, arthrofibrosis, recurrent tear, arthritis, infection, nerve or vascular injury, fluid extravasation, compartment syndrome, Complex Regional Pain Syndrome, synovial fistula, and the risks of anesthesia including heart attack, stroke and death.

abmri
We discussed the natural history and further diagnostic and treatment options. All questions were answered. There are significant symptoms and loss of function and they have not improved with appropriate prior conservative care. We will further evaluate with an MRI. They will follow up after the MRI for continued care.

abb
Bilateral

acmpat
CHIEF COMPLAINT:
RIGHT knee pain

HISTORY OF PRESENT ILLNESS;
She had a fall and twisted the knee. Since then she has noted anterior knee pain and crepitance. She feels the knee has locked a several times. There is nearly constant pain in the front of the knee. The pain is worse with stairs and prolonged sitting. They have not improved with prior conservative care. `
Pain Severity: 3-7 /10
Pain location: knee,
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications,

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Gait: antalgic Coordination: normal
Knee Exam
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): anterior knee pain with deep knee bend
Knee ROM (R/L): 0-120 / 0-120
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature:

DIAGNOSTIC STUDIES;
Xray series of the knee from today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

ASSESSMENT:
Chondromalacia Patella M22.40

PLAN:
We discussed the natural history and further treatment options. All questions were answered. We will begin with a course of formal physical therapy focusing on VMO strengthening as well as nsaids, PF brace and activity modifications. They will follow up in 4-6 weeks for continued care.

****************************************************(

actsnt
CHIEF COMPLAINT: RIGHT LEFT wrist pain

HISTORY OF PRESENT ILLNESS:
She has noted weakness in the hand and thumb, index and middle finger numbness and tingling at times. Occasional wrist and hand pain, night pain and numbness. Symptoms worse with driving, typing, prolonged grasping.
Pain Severity: 0-5 /10
Pain location: wrist,
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Previous treatment: nsaids, activity modifications,

PHYSICAL EXAM
Wrist Exam:
Inspection/Palpation: no tenderness, no thenar muscle atrophy.
+Durkins compression test
Equiviacal Phalens test
-Tinel’s sign
Symmetric wrist ROM
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

DIAGNOSTIC STUDIES;
Xray series of the wrist from today was personally evaluated by me and demonstrates:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

MRI: none

ASSESSMENT
Carpal Tunnel syndrome (CTS) G56.00 354.0

PLAN
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered. We will begin with conserative care with activity modifications, splints and NSAIDs. She will follow up in 4-6 weeks.

****************************************************

addd
degenerative disc disease

adepoim
Patient was given a 80mg depomedrol intramuscular steroid injection using strict sterile technique.

adeqnt
CHIEF COMPLAINT: Right Left wrist pain

HISTORY OF PRESENT ILLNESS:
Gradually worsening wrist pain over several months. 3-7/10 radial sided wrist pain. Worse with activity such as picking up heavy objects. Previous treatment: NSAIDs, no aspirations, no brace, no PT, no surgeries.

Pain Severity: 3-7 /10
Pain location: wrist
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: rare
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications, ice,

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
Wrist Exam (Bilateral)
Inspection / Palpation LE (R/L): tenderness along 1st extensor compartment / radial aspect of wrist
Postive Finkelstein's test
Flexion(R/L): 55 / 55 Extension (R/L): 45 / 45
able to A-OK, hook horns, cross fingers, thumbs up
subjective normal M/U/R distal sensation
2+ Radial pulse
Skin and lymph: appears normal in the affected extremity.

DIAGNOSTIC STUDIES;
Xray series of the wrist taken in the office today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

ASSESSMENT
DeQuervains tenosynovitis (727.04)

PLAN
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered. Plan conservative treatment for now including: activity modifications, Thumb keeper splint, NSAIDS and icing. Follow-up 4-6 weeks.

aelbownt
CHIEF COMPLAINT:
RIGHT LEFT Elbow pain

HPI:
Worsening pain and tenderness in the lateral elbow. Symptoms are worse with activity and motion. Pain has limiting daily activities and work. The pain has not improved with prior conservative care.

Pain Severity: 3-7 /10
Pain location: lateral elbow
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: several weeks
Pain night: rare
Timing: several weeks
Context:no trauma
Associated Symptoms: no numbness or tingling
Previous treatment: NSAIDS, activity modifications, ice, brace

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
Elbow Exam (Bilateral)
Inspection/Palpation UE (R/L): lateral epicondyle tenderness
No ulnar distribution numbness with elbow flexion for >30 seconds.
Lateral epicondyle pain with wrist extension against resistance
Elbow ROM (R/L): 0-130/ 0-130
Suppination (R/L): 80/80Pronation (R/L): 80/80
Elbow Stability (R/L): no varus or valgus laxity bilaterally
Biceps (R/L): 5/5 / 5/5 Triceps (R/L): 5/5 / 5/5
Wrist Extension (R/L): 5/5 / 5/5 Wrist Flexion (R/L): 5/5 / 5/5
Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally
UE Skin (R/L): no rashes or lesions bilaterally
Skin and lymph in affected extremity appears normal.

IMAGING:
Xray series of the elbow (3 views) from today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None.
Alignment: Normal .
Joint space(s): Normal.
Soft tissues: Normal .

aelbowpe
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: normal Coordination: normal
Elbow Exam (Bilateral)
Inspection/Palpation UE (R/L): lateral epicondyle tenderness
no ulnar distribution numbness with elbow flexion for >30 seconds.
Lateral epicondyle pain with wrist extension against resistance
Elbow ROM (R/L): 0-130/ 0-130
Suppination (R/L): 80/80Pronation (R/L): 80/80
Elbow Stability (R/L): no varus or valgus laxity bilaterally
Biceps (R/L): 5/5 / 5/5 Triceps (R/L): 5/5 / 5/5
Wrist Extension (R/L): 5/5 / 5/5 Wrist Flexion (R/L): 5/5 / 5/5
Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally
UE Skin (R/L): no rashes or lesions bilaterally
Lymph: appears normal in the affected extremity.

aff
F/U

affp
F/U as needed.

afootnt
CHIEF COMPLAINT:
RIGHT LEFT foot pain

HISTORY OF PRESENT ILLNESS:

Pain Severity: 3-7 /10
Pain location: foot
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications, ice, crutches

PHYSICAL EXAM:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: antalgic Coordination: normal
Ankle / foot Exam (Bilateral)
Inspection / Palpation LE (R/L): nontender
Dorsiflexion (R/L): 25º / 25º
Plantarflexion (R/L): 50º / 50º
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
Sensation: subjective normal distal sensation bilateral LE
Vasculature: Skin and lymph: appears normal in the affected extremity.

DIAGNOSTIC STUDIES;
Xray series of the foot taken today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal . Plantar and Achilles traction calcaneal spurs.
Soft tissues: Normal .

ASSESSMENT:

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered.

afx
fracture

afxrisks
We discussed the risks of surgery including, but not limited to: infection, nonunion, malunion, CRPS, deep vein thrombosis, pulmonary embolus, nerve or vascular injury, stiffness, incomplete relief of pain, incomplete return of function, need for further surgery and the risks of anesthesia including heart attack, stroke and death.

ahandnt
CHIEF COMPLAINT: RIGHT LEFT hand pain

HISTORY OF PRESENT ILLNESS:

Pain Severity: 3-7 /10
Pain location: hand,
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modifications,

PHYSICAL EXAM
Hand 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 in affected extremity

DIAGNOSTIC STUDIES;
Xray series of the hand dated today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

ASSESSMENT

PLAN
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.

ahipinj
PROCEDURE: Greater trochanteric bursa steroid injection.
PRE-Procedure DIAGNOSIS: Greater trochanteric Bursitis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected lateral hip was sterilely prepped with Betadine. A 2 mg of dexamethasone was drawn up into a 10 mL syringe with a 5 mL of 1% lidocaine and 5ml of marcaine. The patient was injected with a 1.5-inch 22-gauze needle. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

ahipnt
Chief Complaint:
Left Right hip pain

History of Present Illness
Presents for evaluation of hip pain.

Pain Severity: 3-7/10
Pain location: hip
Exacerbating factors: activity. Ameliorating Factors: rest
Pain Duration: nearly constant
Pain night: occasional
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: none

Physical Exam
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: antalgic Coordination: normal
Hip Exam (Bilateral)
Inspection / Palpation LE (R/L):
Hip Flexion (R/L): 120º / 120º Hip Extension (R/L): 20º / 20º
Hip Adduction (R/L): 15º / 15º Hip Abduction (R/L): 40º / 40º
Hip IR (R/L): 5º / 5º Hip ER (R/L): 30º / 30º
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
Sensation: Subjective normal distal sensation bilaterally
Vasculature: 2+ dorsalis pedis pulse bilaterally
LE Skin: no rashes or lesions bilaterally
Lymph LE: no noted lymphadenopathy

Diagnostic Studies
A/P pelvis and A/P and lateral of the hip from today were personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

Assessment

Plan
We discussed the natural history and both operative and non-operative treatment options. All questions were answered.

ahpix
Occupation/Sports:
Date of Injury:
Involved Side:
History of Present Illness

Pain Severity: 3-7 /10
Pain location:
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: occasional
Timing:
Context:
Associated Symptoms:
Previous treatment:

aincts
Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

carpal tunnel syndrome

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: nerve compression symptom relief

We discussed the risks of surgery including, but not limited to: infection, incision breakdown, proximal pain, CRPS, deep vein thrombosis, pulmonary embolus, nerve or vascular injury, stiffness, incomplete relief of pain, incomplete return of function, need for further surgery and the risks of anesthesia including heart attack, stroke and death.

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

ainformedconsent
Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: pain relief

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

ainfx
We discussed the natural history and further diagnostic and treatment options. All questions were answered. We discussed operative treatment with fixation as well as conservative care and the risks and benefits and rehab course of each. After discussion they elected to proceed with surgery.

Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:
fracture

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: fracture healing

We discussed the risks of surgery including, but not limited to: infection, nonunion, malunion, CRPS, deep vein thrombosis, pulmonary embolus, nerve or vascular injury, stiffness, incomplete relief of pain, incomplete return of function, need for further surgery and the risks of anesthesia including heart attack, stroke and death.

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

ainkats
We discussed the MRI findings, natural history and further diagnostic and treatment options. All questions were answered. There are significant symptoms and loss of function and they have not improved with appropriate prior conservative care. We discussed knee arthroscopy and risks, benefits and rehab course. We discussed the limitations of arthroscopy in treating arthritis. After discussion they elected to proceed with surgery.

Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

meniscal tear
chondromalacia

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: pain relief

We discussed the risks of surgery including but are not limited to: incomplete relief of pain, incomplete return of function, chondral injury, hemarthrosis / hematoma, DVT, joint stiffness, arthrofibrosis, recurrent tear, arthritis, infection, nerve or vascular injury, fluid extravasation, compartment syndrome, Complex Regional Pain Syndrome, synovial fistula, and the risks of anesthesia including heart attack, stroke and death.

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

ainmeniscus
Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

meniscal tear, chondromalacia

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: pain relief

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

ainsats
We discussed the MRI, natural history and further diagnostic and treatment options. All questions were answered. There are significant symptoms and loss of function and they have not improved with appropriate prior conservative care. We discussed continued conservative care as well as shoulder arthroscopy and indicated procedures. We discussed the risks, benefits and rehab course. After discussed they elected surgery.

Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

Rotator cuff tendinosis
Adhesive capsulitis
biceps tendinosis
AC osteoarthritis

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: pain relief

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

aintha
We discussed the natural history and further diagnostic and treatment options. All questions were answered. There is significant arthritis which is limiting quality of life. We discussed further treatment options including: Activity modification, Exercise: low-impact excercise including isokinetic and isotonic strengthening improves symptoms, function and cartilage glycosaminoglycan content, Cane/walker, Acetaminophen / NSAIDs, Glucosamine sulfate / Chondroitin Sulfate supplements. Weight loss also reduces risk of OA progression and improves symptoms and function and was discussed and recommended. Should conservative treatment fail the main treatment options is hip replacement and we discussed the risks and benefits of this. We do an anterior muscle sparing approach which generally speeds recovery and decreases the need for hip precautions post-operatively. After discussion they elected to proceed with hip replacement.

Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

hip arthritis

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: pain relief

We discussed the risks of surgery including but not limited to: periprosthetic infection, periprosthetic fracture, leg length discrepancy implant loosening and wear, need for revision surgery, incomplete relief of pain, incomplete return of function, nerve or vascular injury, joint stiffness or instability, deep vein thrombosis, pulmonary embolus, tendon rupture, and the risks of anesthesia including heart attack, stroke and death. After discussion they elected to proceed with surgery.

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

aintka
Informed Consent
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

knee arthritis

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: pain relief

We discussed the risks of surgery including but not limited to: periprosthetic infection, periprosthetic fracture, implant loosening and wear, need for revision surgery, incomplete relief of pain, incomplete return of function, nerve or vascular injury, joint stiffness or instability, deep vein thrombosis, pulmonary embolus, tendon rupture, and the risks of anesthesia including heart attack, stroke and death. After discussion they elected to proceed with surgery.

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

ajntrisks
We discussed the risks of surgery including but not limited to: periprosthetic infection, periprosthetic fracture, leg length discrepancy, implant loosening and wear, need for revision surgery, incomplete relief of pain, incomplete return of function, nerve or vascular injury, joint stiffness or instability, deep vein thrombosis, pulmonary embolus, tendon rupture, and the risks of anesthesia including heart attack, stroke and death. After discussion they elected to proceed with surgery.

akneeinj
PROCEDURE: Knee joint steroid injection.
PRE-Procedure DIAGNOSIS: Knee osteoarthritis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected knee was sterilely prepped with Betadine. A 1 mg of dexamethasone was drawn up into a 5 mL syringe with a 4 mL of 1% lidocaine. The patient was injected with a 1.5-inch 22-gauze needle. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

akneent
CHIEF COMPLAINT:
RIGHT LEFT knee pain

HISTORY OF PRESENT ILLNESS;
The knee is painful limiting function and activities. There is frequent swelling and stabbing pains in the knee which are worse with activity. The pain is mainly medial joint line and worsening over time.
Pain Severity: 5 /10
Pain location: knee
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: rare
Timing: chronic
Context: no recent injury
Associated Symptoms: catching, popping
Previous treatment: nsaids, activity modifications, PT

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Gait: antalgic Coordination: normal
Knee Exam
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): medial joint line tenderness, +Mcmurray
Knee ROM (R/L): 0-130 / 0-130
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature:

DIAGNOSTIC STUDIES;
Xray series of the knee was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

ASSESSMENT:
Internal derangement of the knee
Knee pain

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered.

akneepe
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Gait: antalgic Coordination: normal
Knee Exam Bilateral
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): non-tender bilaterally
Knee ROM (R/L): 0-130 / 0-130
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature: Skin and lymph: appears normal in the affected extremity.

alatepinj
PROCEDURE: Lateral epicondylitis injection.
PRE-Procedure DIAGNOSIS: Lateral epicondylitis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected elbow was sterilely prepped with Betadine. A 1 mg of dexamethasone was drawn up into a 5 mL syringe with a 1 mL of 1% lidocaine and 1ml of marcaine. The patient was injected with a 1.5-inch 22-gauze needle into the lateral epicondyle. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

alll
Left

alumbarnt
CHIEF COMPLAINT:
Low back pain

HISTORY OF PRESENT ILLNESS;

Pain Severity: 3-7 /10
Pain location: back,
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications, crutches, ice, tramadol, lortab

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Gait: antalgic Coordination: normal
Skin and Lymph: appears normal
Tenderness: none
Flexion: 90
Extension: 30
Lateral Bend(R/L): 30 /30
Rotation (R/L): 45 / 45
L2 (iliopsoas / mid anterior thigh sensation)= 5/5 : normal
L3 (quadriceps / distal anterior thigh sensation)= 5/5 : normal
L4 (tibialis anterior / patellar reflex / medial ankle sensation)= 5/5 : 2+ : normal
L5 (EHL / dorsal foot sensation)= 5/5 : normal
S1 (Peroneals / Achilles reflex / lateral ankle sensation)= 5/5 : 2+ : normal
No quad tightness
Waddell Signs: -tenderness, -simulation, -distraction, -regional disturbances, -overreaction
Clonus (R/L): - / -
Babinski (R/L): - / -
Seated SLR(R/L): - / -
Supine SLR (R/L): - / -
Dorsalis pedis (R/L): 2+ / 2+
Babinski reflex (R/L): - / -

DIAGNOSTIC STUDIES;
Xray series of the lumbar spine were personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

ASSESSMENT:

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered.

ameniscalnote
CHIEF COMPLAINT:
RIGHT LEFT knee pain

HISTORY OF PRESENT ILLNESS;

Pain Severity: 3-7 /10
Pain location: knee,
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: popping and locking sensations
Previous treatment: activity modfications, nsaids, ice, PT, injections

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Gait: antalgic Coordination: normal
Knee Exam
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): medial joint line tenderness, +mcmurray, mild effusion
Knee ROM (R/L): 0-120 / 0-120
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature:

DIAGNOSTIC STUDIES;
Xray series of the knee dated was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): none.
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

ASSESSMENT:
Internal derangement of the knee

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered. The symptoms and physical exam are most consistent with meniscal tear and have failed to improve with prior conservative care. We will further evaluate the knee with an MRI. They will follow up after the MRI for continued care.

anttknee
Occupation/Sports:
Date of Injury:
Involved Side: Right Left

CHIEF COMPLAINT:
pain

HPI:

Pain Severity: 3-7 /10
Pain location:
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: several weeks
Pain night: rare
Timing: several weeks
Context:no trauma
Associated Symptoms: no numbness or tingling
Previous treatment: none

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Gait: antalgic Coordination: normal
Knee Exam Bilateral
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): non-tender bilaterally
Knee ROM (R/L): 0-130 / 0-130
Knee A/P Stability (R/L): Lachman (0+/0+); Posterior Drawer (0+/0+)
Knee M/L Stability (R/L): Varus (0+/0+); Valgus (0+/0+)
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation bilaterally
Vasculature: Skin and lymph: appears normal in the affected extremity.

IMAGING:
X-RAY series of the affected knee was personally evaluated by me and demonstrates:
Fracture (s) and/or Dislocation(s): None.
Alignment: Normal .
Joint space(s): Normal.
Soft tissues: Normal .

ASSESSMENT:

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered.

aolecburs
CHIEF COMPLAINT:
RIGHT LEFT Elbow pain

HPI:
They have noted an increasing swelling around the elbow. It has gotten very large. There is not much pain and it is not limiting them very much.

Pain Severity: 0-3 /10
Pain location: elbow
Modifying factors: none.
Pain Duration: several weeks
Pain night: rare
Timing: several weeks
Context:no trauma
Associated Symptoms: no numbness or tingling
Previous treatment: none

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
Elbow Exam (Bilateral)
Inspection/Palpation UE (R/L): large olecranon bursal swelling
Elbow ROM (R/L): 0-130/ 0-130
Suppination (R/L): 80/80Pronation (R/L): 80/80
Elbow Stability (R/L): no varus or valgus laxity bilaterally
Biceps (R/L): 5/5 / 5/5 Triceps (R/L): 5/5 / 5/5
Wrist Extension (R/L): 5/5 / 5/5 Wrist Flexion (R/L): 5/5 / 5/5
Intrinsics (R/L): 5/5 / 5/5
Sensation: Subjective normal median, ulnar, radial and axillary sensation bilaterally
Vasculature: 2+ radial pulse bilaterally
UE Skin (R/L): no rashes or lesions bilaterally
Skin and lymph in affected extremity appears normal.

ASSESSMENT:
Olecranon bursitis M70.20

PLAN:
We discussed the natural history and further treatment options. All questions were answered. We will begin with conservative care with activity limitations, avoiding any pressure on the area and a Heelbo elbow pad. They will follow up in 4-6 weeks.

aopiodpo
The patient will be prescribed an opioid post-op. The risks/benefits/alternatives of this medication were discussed in detail with the patient. The risks discussed included, but were not limited to dependency, addiction, and diversion. The patient was instructed on the expectations and how to use the medication. Condition-specific opioid alternatives for pain control were discussed, however due to the severity of pain and/or inability of non-opioid therapy to provide adequate relief the decision has been made to proceed with limited treatment with an opioid medication. I have utilized the CSMD to review the patient’s recent controlled substance prescription history and I find it appropriate to prescribe a controlled substance as part of the post-operative pain regimen.

aorthoviscinj
Procedure Note:
PROCEDURE: Knee joint orthovisc injection.
PRE-Procedure DIAGNOSIS: Knee osteoarthritis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected knee was sterilely prepped with Betadine. A orthovisc injection was prepared. The patient was injected with a 1.5-inch 22-gauze needle in the knee using and inferior lateral approach. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

apexm
HEENT: atraumatic, normocephalic, PERRLA, EOMI. Neck: supple, no thyromegaly, no adenopathy, no JVD. Chest: equal expansion, lungs clear to auscultation bilaterally without rales, rhonchi or wheezes. Cardiovascular: Heart RRR without MRG. Abdomen: NABS, non-tender, non-distended. Rectal Exam: deferred.

apexm1
HEENT: atraumatic, normocephalic, PERRLA, EOMI. Neck: supple, no thyromegaly, no adenopathy, no JVD. Chest: equal expansion, Abdomen: non-tender, non-distended.

apfinj
PROCEDURE: Plantar fascia steroid injection.
PRE-Procedure DIAGNOSIS: Plantar fasciitis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected heel was sterilely prepped with Betadine. A 1 mg of dexamethasone was drawn up into a 5 mL syringe with a 1 mL of 1% lidocaine and 1ml of marcaine. The patient was injected with a 1.5-inch 22-gauze needle. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

apfnt
CHIEF COMPLAINT:
RIGHT & LEFT foot pain

HISTORY OF PRESENT ILLNESS:
She has pain in both feet. It is worse when she lays down and also when she gets up and moving. She has pain in both of her heels with is so severe she feels like she will cry.
Pain Severity: 3-7 /10
Pain location: foot
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications,

PHYSICAL EXAM:
General Appearance: Well-nourished, well developed in no acute distress
Orientation: Oriented to person, place and time. Mood / Affect: Calm
Gait: antalgic Coordination: normal
Ankle / foot Exam (Bilateral)
Inspection / Palpation LE (R/L): tenderness in plantar fascia reproduces symptoms.
Dorsiflexion (R/L): 25º / 25º
Plantarflexion (R/L): 50º / 50º
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally
Sensation: subjective normal distal sensation bilateral LE
Vasculature: Skin and lymph: appears normal in the affected extremity.

DIAGNOSTIC STUDIES;
Xray series of the foot taken today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: pes planus .
Joint space(s): mild joint narrowing diffusely .
Soft tissues: Normal .

ASSESSMENT:
Plantar Fasciitis M72.2
Pes Planus M21.40

PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered. We will begin with conservative care with: Plantar fascia-specific stretching and massage by dorsiflexing the MTP joints while palpating the area of maximal tenderness a total of ten times per session, >3 sessions per day, viscoelastic heal inserts, naproxen and night splints. She will follow up in 4-6 weeks for continued care.

apoankle
HPI: The patient presents in followup from surgery. Pain has gradually improved. No fevers, no chills. Overall they are happy with the outcome thus far. PHYSICAL EXAM: Alert and oriented x3, well-nourished, well-developed, no acute distress. Calm affect. Incision is healing well in the affected extremity. . Subjective normal distal sensation. Less than 2-second distal capillary refill. IMAGING: 3 views of the ankle taken in the office today demonstrate bimalleolar ankle fracture reduced with plates and screws in place. ASSESSMENT: Status ORIF ankle fracture PLAN: Currently doing well. Was placed into a fracture boot and will continues with activity restrictions. F/u in 4-5 weeks.

apoctr
HPI:
The patient presents in followup from surgery. Has been gradually improving.

PHYSICAL EXAM:
Alert and oriented x3, well-nourished, well-developed, no acute distress. Calm affect. Incision is healing well in the affected extremity. Subjective normal distal sensation. Less than 2-second distal capillary refill.

IMAGING:
none

ASSESSMENT:
Status post Carpal Tunnel Release

PLAN:
Currently doing very well. Sutures were removed. Placed in cock-up wrist brace for 2 weeks. May gradually resume activities as tolerated. Follow up in 6-7 weeks or as needed for continued care.

apodrfx
HPI:
The patient presents in followup from surgery. Pain has gradually improved. No fevers, no chills. Overall they are happy with the outcome thus far.

PHYSICAL EXAM:
Alert and oriented x3, well-nourished, well-developed, no acute distress. Calm affect. Incision is healing well in the affected extremity. . Subjective normal distal sensation. Less than 2-second distal capillary refill.

IMAGING:
Wrist films demonstrate distal radius and ulnar styloid fracture reduced with Volar plate and screws in place.

ASSESSMENT:
Status ORIF distal radius fracture

PLAN:
Currently doing well. Placed into a SAC and given cast care instructions. F/U in 4 weeks.

apodrfx2
HPI:
Has been in a short arm cast and has been gradually improving.

PHYSICAL EXAM:
Alert and oriented x3, well-nourished, well-developed, no acute distress. Calm affect. Incision is largely healed. Mild stiffness. Subjective normal distal sensation. Less than 2-second distal capillary refill.

IMAGING:
Wrist films demonstrate distal radius and ulnar styloid fracture reduced with Volar plate and screws in place and early callus

ASSESSMENT:
Status ORIF distal radius fracture

PLAN:
Currently doing well. Placed into a fracture brace and will continue activity limitations and home ROM exercises. F/U in 4 weeks.

apodrfx3
HPI:
Has been in OT and gradually improving. Some stiffness, but overall making good progress with the wrist.

PHYSICAL EXAM:
Alert and oriented x3, well-nourished, well-developed, no acute distress. Calm affect. Incision is healed. Minimal stiffness. Subjective normal distal sensation. Less than 2-second distal capillary refill.

IMAGING:
Wrist films demonstrate distal radius and ulnar styloid fracture reduced with Volar plate and screws in place and callus formation

ASSESSMENT:
Status ORIF distal radius fracture

PLAN:
Currently doing well. May progress with activities as tolerated and continue home exercise program. F/U in 8 wks.

apohand
HPI:
The patient presents in followup from surgery. Pain has gradually improved. No fevers, no chills. Overall they are happy with the outcome thus far.

IMAGING:
none

ASSESSMENT:
Status

PLAN:
Currently doing very well. May gradually increase activities. Follow up in 6-7 weeks or as needed for continued care.

apoknt
HPI:
The patient presents in followup from surgery. Pain has gradually improved. No fevers, no chills. Overall they are happy with the outcome thus far.

PHYSICAL EXAM:
Alert and oriented x3, well-nourished, well-developed, no acute distress. Calm affect. Incision is healing well in the affected extremity. Range of motion 0-120. Subjective normal distal sensation. Less than 2-second distal capillary refill.

IMAGING:
none

ASSESSMENT:
Status post knee arthroscopy, partial menisectomy, chondroplasty.

PLAN:
Currently doing very well. May gradually resume normal activities as tolerated. Follow up in 6-7 weeks or as needed for continued care.

apoknt2
HPI:
Progressing with PT and the knee is improving. Has gradually started normal activities.

IMAGING:
none

ASSESSMENT:
Status post knee arthroscopy, partial menisectomy, chondroplasty.

PLAN:
Currently doing well. May progress with HEP and normal activities as tolerated. Follow up in 7 weeks or as needed for continued care.

apokntpt
HPI:
The patient presents in followup from surgery. Pain has gradually improved, but still has some stiffness and weakness in the knee

IMAGING:
none

ASSESSMENT:
Status post knee arthroscopy, partial menisectomy, .

PLAN:
Currently doing very well. We will start a course of PT. May gradually resume normal activities as tolerated. Follow up in 6-7 weeks or as needed for continued care.

aportc
History of Present Illness
Presents in follow up for the shoulder. Has been in the sling and gradually improving. Pain gradually improving.

PHYSICAL EXAM:

Shoulder Exam ( )
Inspection/Palpation UE (R/L): incisions healing well.
pendulum shoulder ROM
Sensation: Subjective normal m/u/r/ax sensation,
Skin and lymph: appears normal in the affected.
Age approp cervical ROM without symptoms.

DIAGNOSTIC STUDIES;
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 I
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.

ASSESSMENT:
s/p Rotator cuff repair, Subacromial Decompression, biceps tenodesis

PLAN:
Doing well. Continued PT and activity restrictions. Follow up in 6-8 weeks.

aportc2
History of Present Illness
She has been progressing with PT and feels she is improving.

PHYSICAL EXAM:

Shoulder Exam ( )
Inspection/Palpation UE (R/L): incisions healed
AFE=145, ER=30
Sensation: Subjective normal m/u/r/ax sensation,
Skin and lymph: appears normal in the affected.
Age approp cervical ROM without symptoms.

DIAGNOSTIC STUDIES;

ASSESSMENT:
s/p Rotator cuff repair, Subacromial Decompression, biceps tenodesis

PLAN:
Doing well. Continue PT and advance to HEP and gradually increase activity level. Follow up in 6-8 weeks.

aportc3
History of Present Illness
The patient has continue with HEP and resume normal activities. The shoulder is doing very well and not limiting activities.

PHYSICAL EXAM:

Shoulder Exam ( )
Inspection/Palpation UE (R/L): incisions healed
AFE=160, ER=45
Sensation: Subjective normal m/u/r/ax sensation,
Skin and lymph: appears normal in the affected.
Age approp cervical ROM without symptoms.

DIAGNOSTIC STUDIES;

ASSESSMENT:
s/p Rotator cuff repair, Subacromial Decompression, biceps tenodesis

PLAN:
Doing well. May continue with full activities as tolerated. We discussed natural history of the rotator cuff and they will benefit from maintaining a home Rotator cuff exercise program. F/U in 8 wks or as needed.

aportcprn
History of Present Illness
Has been progressing with HEP and feels continues to be gradually improving. The shoulder is no longer limiting daily activities.

PHYSICAL EXAM:

Shoulder Exam ( )
Alert and oriented x3
Inspection/Palpation UE (R/L): incisions healed
AFE=160, ER=45
Sensation: Subjective normal m/u/r/ax sensation,
Skin and lymph: appears normal in the affected.
Age approp cervical ROM without symptoms.

DIAGNOSTIC STUDIES;

ASSESSMENT:
s/p Rotator cuff repair, Subacromial Decompression, biceps tenodesis

PLAN:
Doing well. We discussed the post op course and natural history of Rotator cuff injuries and surgery. Progress with PT and with activities as tolerated. F/U as needed.

apostopnote
HPI:
The patient presents in followup from surgery. Pain has gradually improved. No fevers, no chills. Overall they are happy with the outcome thus far.

PHYSICAL EXAM:
Alert and oriented x3, well-nourished, well-developed, no acute distress. Calm affect. Incision is healing well in the affected extremity. Post op appropriate Range of motion. Subjective normal distal sensation. Less than 2-second distal capillary refill.

IMAGING:
none

ASSESSMENT:
Status post .

PLAN:
Currently doing very well. May gradually resume activities as tolerated. Follow up in 6-7 weeks for continued care.

apotha
HISTORY OF PRESENT ILLNESS;
Has been doing well. Progressing with PT.

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Hip Exam
Skin and lymph appears normal in the affected extremity
incision healing well. Post op appropriate ROM
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation
Vasculature:

DIAGNOSTIC STUDIES;
Xray series of the Hip from today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): THA in place with no loosening .
Soft tissues: Normal .

ASSESSMENT:
s/p THA

PLAN:
Doing well and may progress with physical therapy and activities as tolerated. Follow up in 7 weeks, sooner if any concerns arise.

apotha2
HISTORY OF PRESENT ILLNESS;
Has been doing well and gradually resuming normal activities. Progressing with PT.

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Hip Exam
Skin and lymph appears normal in the affected extremity
incision healed. symmetric ROM
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation
Vasculature:

ASSESSMENT:
s/p THA

PLAN:
Doing well and may progress with physical therapy and wean to home programs and progress with activities as tolerated. Follow up in 3 months sooner if any concerns arise.

apotha3
HISTORY OF PRESENT ILLNESS;
Has been doing well and gradually resumed normal activities. No pain or limitations related to the hip

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Hip Exam
Skin and lymph appears normal in the affected extremity
Near symmetric hip ROM
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation
Vasculature:

DIAGNOSTIC STUDIES;
Xray series of the Hip from today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): left THA in place with no loosening .
Soft tissues: Normal .

ASSESSMENT:
s/p THA

PLAN:
Doing very well. Will continue with full activities without restriction. We discussed natural history and long term outcome for hip replacement including wear. F/U in 6 months.

apotka

HISTORY OF PRESENT ILLNESS;
Has been doing well and working with PT and HEP.

PHYSICAL EXAM:
General Appearance: well-nourished, well developed in no acute distress
Orientation: oriented to person, place and time. Mood / Affect: calm
Knee Exam
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): incision healing well
post op appropriate ROM
no instability
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation
Vasculature:

DIAGNOSTIC STUDIES;
AP and lateral Xray series of the knee from today was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): TKA in place with no loosening .
Soft tissues: Normal .

ASSESSMENT:
s/p TKA

PLAN:
We discussed the post op course. Currently doing well. Will progress with PT and HEP. Follow up in 6-8 weeks.

apotka2
HISTORY OF PRESENT ILLNESS;
Progressing well with PT and the knee is doing well and improving.

PHYSICAL EXAM:
Knee Exam
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): incision well healed
ROM 0-120
no instability
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation
Vasculature:

DIAGNOSTIC STUDIES;
Xray series of the knee were personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): TKA in place with no loosening .
Soft tissues: Normal .

ASSESSMENT:
s/p TKA

PLAN:
We again discussed the post op course. May progress with activities and therapy as tolerated. and advance to HEP. F/U in 3 months

apotka3
Chief Complaint: TKA routine follow up

HISTORY OF PRESENT ILLNESS;
Has been doing well. The knee replacement has been function normally and the knee has not been limiting activities and is generally pain free.

ASSESSMENT:
s/p TKA

PLAN:
We discussed the natural history of knee replacement. May continue with activities as tolerated. F/U in 12 months.

apotka4
HISTORY OF PRESENT ILLNESS;
He has been doing well and the knee is not limiting function or activities. No complaints.

PHYSICAL EXAM:
Alert and oriented x 3. Calm affect.
Knee Exam
Skin and lymph appears normal in the affected extremity
Inspection / Palpation LE (R/L): non tender
ROM 0-120
no instability
Strength LE: 5/5 EHL, tibialis anterior, plantar flexion
Sensation: Subjective normal distal sensation
Vasculature:

ASSESSMENT:
s/p TKA

PLAN:
Doing very well. May continue with full activities as tolerated. We discussed the replacement and natural history. F/U in 12 months

apotsa
History of Present Illness
Presents in follow up for the shoulder. Has been in the sling and gradually improving. Pain gradually improving.

PHYSICAL EXAM:

ASSESSMENT:
s/p TSA, biceps tenodesis

PLAN:
Doing well. Start PT and continue activity restrictions. Follow up in 6-8 weeks.

****************************************************

apotsa2
History of Present Illness
Presents in follow up for the shoulder. Has been in PT and gradually improving. Pain gradually improving.

PHYSICAL EXAM:

Shoulder Exam ( )
Inspection/Palpation UE (R/L): incisions healed
AFE=100, ER=40
Sensation: Subjective normal m/u/r/ax sensation,
Skin and lymph: appears normal in the affected.
Age approp cervical ROM without symptoms.

ASSESSMENT:
s/p rTSA, biceps tenodesis

PLAN:
Doing well. Continue PT and gradually increase restrictions. Follow up in 3 months.

apotsa3
History of Present Illness
Presents in follow up for the shoulder. Has resumed full activities and the shoulder is painfree and not limiting activities.
PHYSICAL EXAM:

Shoulder Exam ( )
Inspection/Palpation UE (R/L): nontender
AFE=140, ER=40
Sensation: Subjective normal m/u/r/ax sensation,
Skin and lymph: appears normal in the affected.
Age approp cervical ROM without symptoms.

ASSESSMENT:
s/p rTSA, biceps tenodesis

PLAN:
Doing well. Continue with activities as tolerated. F/U in 12 months.

aptnsaids
We discussed the natural history and further treatment options. All questions were answered. We will begin with a course of formal physical therapy as well as nsaids and activity modifications. They will follow up in 4-6 weeks for continued care.

arrr
Right

artc
Rotator cuff tear

artr
Rotator cuff repair

asad
Subacromial Decompression

asai
Subacromial impingement

asainject
PROCEDURE: Subacromial steroid injection
PRE-Procedure DIAGNOSIS: rotator cuff tendinosis
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected shoulder was sterilely prepped with Betadine. A 2 mg of dexamethasone was drawn up into a 10 mL syringe with a 4 mL of 1% lidocaine and 4ml of marcaine. The patient was injected with a 1.5-inch 22-gauze needle into the subacromial space. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.
asats
Shoulder arthroscopy

ashouldernl
CHIEF COMPLAINT: LEFT shoulder pain

History of Present Illness
There is fairly constant 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.
Pain Severity: 3-7 /10
Pain location: shoulder,
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: 2-3 months
Context: no trauma
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modfications, exercise
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,
Skin and lymph: appears normal in the affected extremity.
Age approp cervical ROM without symptoms.

ASSESSMENT:
Left rotator cuff tendinosis / bursitis M75.52
Left biceps tendinosis M75.22
Left AC osteoarthritis M19.012
PLAN:
We discussed the natural history and further diagnostic and treatment options. All questions were answered.

ashoulderpe
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 / neg
Hawkins Test (R/L): neg / neg Scapulothoracic motion (R/L): 2:1 / 2:1
O'Brien's Test (R/L): neg / 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,
Skin and lymph: appears normal in the affected extremity.
Age approp cervical ROM without symptoms.

atennisent
ASSESSMENT:
Lateral epicondylitis (Tennis elbow) (726.32).

PLAN:
We discussed the natural history and further treatment options. All questions were answered. We will begin with conservative care with: (1)Cessation of offending activities. (2)Ice 20minutes 3-4x/day. (3)NSAIDs for 10-14 days and the as needed. (4)Counterforce brace placed over the forearm musculature. We will avoid immobilization/inactivity which can lead to disuse atrophy. Follow up in 4-6 weeks for continued care and to monitor response to conservative treatment.

atkarisks
Osteoarthritis of knees(715.16).
We discussed the natural history and further operative and non-operative treatment options including the risks, benefits and rehab course of each They have failed conservative care for the arthritis in the knee and have marked limitations in activity and quality of life. We discussed knee replacement including risks and benefits and rehab course of this and they elected to proceed.

Informed Consent Total Joint
We discussed the natural history, non-operative and operative treatments as well as no further treatment for:

knee arthritis

We discussed the risk, benefits and expected rehab course of each treatment option.

Surgical benefits: pain relief

We discussed the risks of surgery including but not limited to: periprosthetic infection, periprosthetic fracture, leg length discrepancy, implant loosening and wear, need for revision surgery, incomplete relief of pain, incomplete return of function, nerve or vascular injury, joint stiffness or instability, deep vein thrombosis, pulmonary embolus, tendon rupture, and the risks of anesthesia including heart attack, stroke and death. After discussion they elected to proceed with surgery.

The patient understands the risks and benefits of surgery and has elected to proceed with surgery.

atriggerinj
PROCEDURE: trigger thumb injection
PRE-Procedure DIAGNOSIS: trigger thumb
POST-Procedure DIAGNOSIS: same.
PROCEDURE: The patient was apprised of the risks and the benefits of the procedure and consented. The affected hand was sterilely prepped with Betadine. A 1 mg of dexamethasone was drawn up into a 5 mL syringe with a 1 mL of 1% lidocaine and 1ml of marcaine. The patient was injected with a 1.5-inch 22-gauze needle into the flexor sheath at the A1 pulley. There were no complications. The patient tolerated the procedure well. There was minimal bleeding. The patient will avoid overuse over the next few days. The patient was instructed to follow up with us if any unusual pain, swelling, or redness occurs in the injected area. The patient was given a followup appointment to evaluate response to the injection.

awalkerrx
Mobility limitations prevent mobility-related ADLs in the home. The patient is able to safely use a 4-prong cane which can sufficiently resolve the mobility deficit.

aworkcompn
After reviewing all the above documents, taking into account this examination, from a medical perspective, the injury that I am treating did not (more likely than not) occur or need treatment under the set of circumstances described.

aworkcomppren
It is more likely than not to a reasonable degree of medical certainly that the need for treatment is related to the patient’s pre-existing condition and not to the described injury. It is more likely than not to a reasonable degree of medical certainty that it would have needed this treatment even without the described injury.

aworkcomppprey
The injury as related to me by the patient, and from the job description and other documents referenced above, is more likely than not to a reasonable degree of medical certainty, the cause of the need for treatment even though the patient has had a significant pre-existing condition.

aworkcompy
The other documents and this examination support the conclusion that the injury I am treating is consistent with the nature of the injury described and to a reasonable degree of medical certainty more likely than not is necessary because of this injury.

awristnt
Occupation:
Sport:
Injury: none

CHIEF COMPLAINT: RIGHT LEFT wrist pain

HISTORY OF PRESENT ILLNESS:

Pain Severity: 3-7 /10
Pain location: knee,
Modifying factors: improved with rest, exacerbated by activity.
Pain Duration: constant
Pain night: constant
Timing: chronic
Context: no recent injury
Associated Symptoms: no numbness
Previous treatment: nsaids, activity modifications,

PHYSICAL EXAM
Tenderness:
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

DIAGNOSTIC STUDIES;
Xray series of the wrist dated was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

MRI: none

ASSESSMENT

PLAN
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.

axraynl
Diagnostic Studies:
Xray series of affected area was personally evaluated by me and demonstrates the following:
Fracture (s) and/or Dislocation(s): None .
Alignment: Normal .
Joint space(s): Normal .
Soft tissues: Normal .

axrsl
DIAGNOSTIC STUDIES;
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: normal