cwilson3333
Expert
Would like someone to audit the E/M for this visit
SYBJECTIVE
CC: MRI Results
HPI: Orthopedics: Patient comes in for follow-up of right shoulder. This has been going on for a long time. He has trouble with daily activities and at night. It hurts to reach up and out, and to reach behind him. He has ACJ tenderness. It is all biceps
and deltoid.
Medications: Lyrica, Lotrel, Metformin
OBJECTIVE:
Examination: Imaging:MRI performed shows damage to rotator cuff and impingement syndrome.
ASSESSMENT: Incomplete tear of rotator cuff
PLAN: We discussed the treatment options. He has requested a procedure which would be a scope, decompression, address rotator cuff and biceps. I described the procedure, risks and complications including, but not limited to the fact that he might
be made worse. Risk of catastrophic outcome, including loss of limb or life. Risk of infections, clots, arthritis, stiffness, nerve damage, RSD, tendon damage, recurrence of problem, need for further surgeries, vascular injury including bleeding,
etc. The patient understands and the surgery will be scheduled at their convenience.
SYBJECTIVE
CC: MRI Results
HPI: Orthopedics: Patient comes in for follow-up of right shoulder. This has been going on for a long time. He has trouble with daily activities and at night. It hurts to reach up and out, and to reach behind him. He has ACJ tenderness. It is all biceps
and deltoid.
Medications: Lyrica, Lotrel, Metformin
OBJECTIVE:
Examination: Imaging:MRI performed shows damage to rotator cuff and impingement syndrome.
ASSESSMENT: Incomplete tear of rotator cuff
PLAN: We discussed the treatment options. He has requested a procedure which would be a scope, decompression, address rotator cuff and biceps. I described the procedure, risks and complications including, but not limited to the fact that he might
be made worse. Risk of catastrophic outcome, including loss of limb or life. Risk of infections, clots, arthritis, stiffness, nerve damage, RSD, tendon damage, recurrence of problem, need for further surgeries, vascular injury including bleeding,
etc. The patient understands and the surgery will be scheduled at their convenience.
