HPI:
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.
Diagnostic Studies:
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 .
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: 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
Assessment:
Sprain of other part of right wrist and hand
Plan:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.
Category:
- Injury
ICD-10:
S63.8X1A
ICD:
S63
Pattern:
- Other
Encounter:
- Initial
ICD-10CM Year:
2019