trose45116
Expert
Chief Complaints:
1. Distal radius fracture, left wrist. Reduced 8-16-15 (elsewhere).
HPI:
Appointment type:
Established patient - Established problem Patient returns for her left wrist. She has been in a cast. She's been doing well. Her pain is improved. She denies any other issue..
ROS:
no change from 9-4-15.
Medical History: diabetes, high BP, headaches, depression.
Family History:
arthritis, cancer, diabetes, heart problems, HTN, stroke,.
Social History:
tobacco- no
alcohol- no
single.
Medications: Taking Lasix , Taking potassium , Taking Metformin HCl , Taking Losartan Potassium-HCTZ , Taking glyburide , Taking Aspirin , Taking Tylenol PM Extra Strength , Discontinued Ultram 50 MG Tablet 1 tablet as needed every 6 hrs, Discontinued Ultram 50 MG Tablet 1 tablet as needed every 6 hrs, Medication List reviewed and reconciled with the patient
Allergies: Penicillin.
Objective:
Vitals: Wt 324 lbs, BMI 57.39 Index, Ht 5 ft 3 in.
Physical Examination:
Examination of the left hand and wrist reveals no evidence of skin abnormality. She does have decreased range of motion secondary to tightness. She is decreased pronation, supination secondary to tightness. She has full digital range of motion. EPL, FPL, interossei firing. Radial pulse 2+.
Assessment:
Assessment:
1. Distal radial fracture - 813.42 (Primary)
2. Wrist pain - 719.43
Plan:
1. Distal radial fracture
Notes: I'll long discussion with the patient. She is shifted her fracture somewhat. I do feel that she can continue to be treated conservatively. I explained this to her. She is essentially 6 weeks out from injury. We need to get her moving. We will send her to formal therapy. I'm going to place her into removal. All questions were answered. I will see her back in 1 month's time.
2. Wrist pain
Imaging: Xray Wrist Complete Radiographs show the fracture has settled a bit. She was also had some increase in dorsal tilt. Her ulnar variance remains neutral.
Procedure Codes: 73110 X-RAY EXAM OF WRIST, L3908 QUICKFIT WRIST II, LT
Follow Up: 4 Weeks
1. Distal radius fracture, left wrist. Reduced 8-16-15 (elsewhere).
HPI:
Appointment type:
Established patient - Established problem Patient returns for her left wrist. She has been in a cast. She's been doing well. Her pain is improved. She denies any other issue..
ROS:
no change from 9-4-15.
Medical History: diabetes, high BP, headaches, depression.
Family History:
arthritis, cancer, diabetes, heart problems, HTN, stroke,.
Social History:
tobacco- no
alcohol- no
single.
Medications: Taking Lasix , Taking potassium , Taking Metformin HCl , Taking Losartan Potassium-HCTZ , Taking glyburide , Taking Aspirin , Taking Tylenol PM Extra Strength , Discontinued Ultram 50 MG Tablet 1 tablet as needed every 6 hrs, Discontinued Ultram 50 MG Tablet 1 tablet as needed every 6 hrs, Medication List reviewed and reconciled with the patient
Allergies: Penicillin.
Objective:
Vitals: Wt 324 lbs, BMI 57.39 Index, Ht 5 ft 3 in.
Physical Examination:
Examination of the left hand and wrist reveals no evidence of skin abnormality. She does have decreased range of motion secondary to tightness. She is decreased pronation, supination secondary to tightness. She has full digital range of motion. EPL, FPL, interossei firing. Radial pulse 2+.
Assessment:
Assessment:
1. Distal radial fracture - 813.42 (Primary)
2. Wrist pain - 719.43
Plan:
1. Distal radial fracture
Notes: I'll long discussion with the patient. She is shifted her fracture somewhat. I do feel that she can continue to be treated conservatively. I explained this to her. She is essentially 6 weeks out from injury. We need to get her moving. We will send her to formal therapy. I'm going to place her into removal. All questions were answered. I will see her back in 1 month's time.
2. Wrist pain
Imaging: Xray Wrist Complete Radiographs show the fracture has settled a bit. She was also had some increase in dorsal tilt. Her ulnar variance remains neutral.
Procedure Codes: 73110 X-RAY EXAM OF WRIST, L3908 QUICKFIT WRIST II, LT
Follow Up: 4 Weeks