trose45116
Expert
I am getting a level 4 out of this. What are your thoughts?
history - EPF
exam - D
MDM- M
Chief Complaints:
1. Bilateral elbow pain.
HPI:
Appointment type:
Established patient - New problem Patient is a 63-year-old gentleman who comes in with chief complaint of bilateral elbow pain. With regards to the right elbow. He does have swelling about the elbow. He has no history of olecranon bursitis. He does have pain about the elbow. He denies numbness or paresthesias. This is been going on for a few weeks. He has not had an aspiration. He denies any other specific complaints. He denies any shoulder pain. He denies any wrist pain.
He also has medial sided elbow pain. He has full elbow range of motion. This is on the left elbow. He describes no specific pain in the shoulder or wrist. He denies any lateral sided pain. He denies numbness or paresthesias in the left upper extremity. He denies any other complaints.
ROS:
no change from 12-28-15.
Medical History: High blood pressure.
Surgical History: tonsillectomy, adenoids .
Family History:
cancer.
Social History:
tobacco- none
alcohol- infrequently
single.
Medications: Taking Irbesartan , Taking Nexium , Taking Lunesta , Taking Metaxalone , Taking Diclofenac , Taking Vitamin B-12 , Taking Vitamin D-3 , Taking Fluticasone Furoate , Taking AndroGel , Medication List reviewed and reconciled with the patient
Allergies: Sulfa.
Objective:
Vitals: Wt 200 lbs, BMI 27.89 Index, Ht 5 ft 11 in.
Physical Examination:
Alert and oriented x3 no acute distress. Examination of the right elbow reveals notes of skin abnormality. He does have fairly significant swelling on the elbow. He does have olecranon bursitis. No erythema. Full elbow range of motion. Full pronation, supination. Good grip strength. Normal motor sensation pulses and skin examination distally. Examination of left elbow shows no evidence of skin abnormality. Normal carrying angle. Pain with palpation medially over the condyle. No ulnar nerve tenderness to palpation. Negative Tinel. No lateral sided tenderness. Full wrist and shoulder range of motion. Good grip strength. Normal motor sensation pulses and skin examination distally.
Assessment:
Assessment:
1. Pain in unspecified elbow - M25.529 (Primary)
2. Medial epicondylitis of left elbow - M77.02
3. Medial epicondylitis of right elbow - M77.01
4. Pain in right knee - M25.561
Plan:
1. Pain in unspecified elbow
Imaging: Xray Elbow 3 View No evidence of ossific abnormality. Throughout the elbows. No evidence of fracture. No significant enthesophyte noted.
Notes: I had a long discussion with the patient. With regards to his right elbow. I did describe doing an aspiration coupled with a steroid injection. He was in agreement. He was taken to the procedure room. Under also guidance 5 cc of serous fluid was obtained. I then injected half cc Kenalog half cc Marcaine. Patient tolerated this well. With regards to his left elbow. I also described doing a steroid injection medially. He was in agreement. He was taken to the procedure room. Under ultrasound guidance, half cc Kenalog and half cc Marcaine was injected about the flexor pronator. Patient wanted this well. All questions were answered. I'll see him on a when necessary basis.
Procedure Codes: 73080 X-RAY EXAM OF ELBOW, COMPLETE, MINIMUN OF 3 VIEWS, 20606 DRAIN/INJ JOINT/BURSA W/US, J3301 Inj, Triamcinolong Acetonide 20mg, 20606 DRAIN/INJ JOINT/BURSA W/US, J3301 Inj, Triamcinolong Acetonide 20mg
Follow Up: prn
history - EPF
exam - D
MDM- M
Chief Complaints:
1. Bilateral elbow pain.
HPI:
Appointment type:
Established patient - New problem Patient is a 63-year-old gentleman who comes in with chief complaint of bilateral elbow pain. With regards to the right elbow. He does have swelling about the elbow. He has no history of olecranon bursitis. He does have pain about the elbow. He denies numbness or paresthesias. This is been going on for a few weeks. He has not had an aspiration. He denies any other specific complaints. He denies any shoulder pain. He denies any wrist pain.
He also has medial sided elbow pain. He has full elbow range of motion. This is on the left elbow. He describes no specific pain in the shoulder or wrist. He denies any lateral sided pain. He denies numbness or paresthesias in the left upper extremity. He denies any other complaints.
ROS:
no change from 12-28-15.
Medical History: High blood pressure.
Surgical History: tonsillectomy, adenoids .
Family History:
cancer.
Social History:
tobacco- none
alcohol- infrequently
single.
Medications: Taking Irbesartan , Taking Nexium , Taking Lunesta , Taking Metaxalone , Taking Diclofenac , Taking Vitamin B-12 , Taking Vitamin D-3 , Taking Fluticasone Furoate , Taking AndroGel , Medication List reviewed and reconciled with the patient
Allergies: Sulfa.
Objective:
Vitals: Wt 200 lbs, BMI 27.89 Index, Ht 5 ft 11 in.
Physical Examination:
Alert and oriented x3 no acute distress. Examination of the right elbow reveals notes of skin abnormality. He does have fairly significant swelling on the elbow. He does have olecranon bursitis. No erythema. Full elbow range of motion. Full pronation, supination. Good grip strength. Normal motor sensation pulses and skin examination distally. Examination of left elbow shows no evidence of skin abnormality. Normal carrying angle. Pain with palpation medially over the condyle. No ulnar nerve tenderness to palpation. Negative Tinel. No lateral sided tenderness. Full wrist and shoulder range of motion. Good grip strength. Normal motor sensation pulses and skin examination distally.
Assessment:
Assessment:
1. Pain in unspecified elbow - M25.529 (Primary)
2. Medial epicondylitis of left elbow - M77.02
3. Medial epicondylitis of right elbow - M77.01
4. Pain in right knee - M25.561
Plan:
1. Pain in unspecified elbow
Imaging: Xray Elbow 3 View No evidence of ossific abnormality. Throughout the elbows. No evidence of fracture. No significant enthesophyte noted.
Notes: I had a long discussion with the patient. With regards to his right elbow. I did describe doing an aspiration coupled with a steroid injection. He was in agreement. He was taken to the procedure room. Under also guidance 5 cc of serous fluid was obtained. I then injected half cc Kenalog half cc Marcaine. Patient tolerated this well. With regards to his left elbow. I also described doing a steroid injection medially. He was in agreement. He was taken to the procedure room. Under ultrasound guidance, half cc Kenalog and half cc Marcaine was injected about the flexor pronator. Patient wanted this well. All questions were answered. I'll see him on a when necessary basis.
Procedure Codes: 73080 X-RAY EXAM OF ELBOW, COMPLETE, MINIMUN OF 3 VIEWS, 20606 DRAIN/INJ JOINT/BURSA W/US, J3301 Inj, Triamcinolong Acetonide 20mg, 20606 DRAIN/INJ JOINT/BURSA W/US, J3301 Inj, Triamcinolong Acetonide 20mg
Follow Up: prn
