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S40.012A Contusion of left shoulder, initial encounter

ICD-10 Chief Complaint:

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
S40.012A Contusion of left shoulder, initial encounter
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered. 





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