Wiki Diagnosis discussed

[ny2scgirl]

I have a provider suddenly saying he discussed the diagnosis above but doesn't list what he discussed. Normally I would remove them but then he put the time spent with the patient. Do I leave the Dx with no treatment plan or leave them?

99214
M25.811
S90.221A
S90.222A
I25.810
D69.3
I73.9

Reason for Appointment 1. Neck and rt shoulder pain

History of Present Illness New symptom(s): multitude c/o but primary is R shoulder pains.

Vital Signs Nurse: , Temp: 98.0 F, HR: 78 beats per min, RR: 16 breaths per min, O2 sat %: 94, BP: 140/60 mm Hg, Wt: 214.6 lbs, Ht: 68.5 in, BMI: 32.15 Index, Wt-kg: 97.34 kg, Ht-cm: 173.99 cm.

Examination General Examination: GENERAL APPEARANCE: alert, well hydrated, in no distress . HEAD: normocephalic, atraumatic. NECK/THYROID: neck supple, no cervical lymphadenopathy. SKIN: both second toes have subungual ecchymoses. MUSCULOSKELETAL: R shoulder nl inspection, palpation, and 3/3 impingment signs pos R shoulder. PERIPHERAL PULSES: 2+ radials w brisk capillary refill time. PSYCH: alert, oriented, judgement and insight good.

Assessments 1. Impingement of right shoulder - M25.811 (Primary) 2. Subungual hematoma of toe of right foot, initial encounter - S90.221A 3. Subungual hematoma of toe of left foot, initial encounter - S90.222A 4. Coronary atherosclerosis of unspecified type of bypass graft - I25.810 5. Chronic ITP (idiopathic thrombocytopenia) - D69.3 6. Peripheral arterial disease - I73.9

Discussed all the listed dxes. The R shoulder xrays show mild arthritis and exam suggests strongly this is impingment syndrome, recommended formal PT, continue present pain mgmt. 30 min care time this day.

Treatment 1. Impingement of right shoulder IMAGING: Shoulder 2 Views or More RT W 7/21/2023 04:23:47 PM >inform xrays show just some mild arthritis in the shoulder Referral To Physical Therapy Physical Therapist Reason:R should impingment Referral To: Orthopedic Surgery Reason:R shoulder pain 2. Others Notes: Shoulder Pain: Care Instructions material was published.