HPI:
There is pain in the elbow 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 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 .
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):no lateral epicondyle tenderness. No ulnar distribution numbness with elbow flexion for >30 seconds. No 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.
Assessment:
Presence of right artificial elbow joint
Plan:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered.
Category:
- Encounters
ICD-10:
Z96.621
ICD:
Z96
ICD-10CM Year:
2019