Kaitbohrer
Contributor
SECOND OPINION FOR THIS E/M NEEDED PLEASE!
Diagnosis: PAIN ONLY
treatment: RX anti inflam
After reading the chart note below, would you consider this an undiagnosed new problem with uncertain prognosis? (MODERATE) with RX management (MODERATE)?
Is this just a terrible note - I feel very confused by the following?......
Assessment and Plan:
MRI results were reviewed and results were discussed with patient. I explained to the patient that he has some ill-defined findings in his hip. They appear to be symmetric. I explained to the patient I am unsure why his hip is giving him pain. I recommended conservative treatment. I'm going to place him on a prescription anti-inflammatory. He's going to continue his home exercises. He will see me back in six weeks if he's not improved. At that time, if he is still symptomatic I would recommend an intra-articular steroid injection.
History of Present Illness: 38 y.o. male who presents today for follow-up to review an MRI.
No past medical history on file.
No past surgical history on file.
No family history on file.
No Known Allergies
Objective: There were no vitals taken for this visit. There is no height or weight on file to calculate BMI.
Physical Examination:
General: well appearing and well nourished
Eyes: Pupils equally round and reactive
Mood/Affect: appropriate
Skin: Skin color, texture, turgor normal. No rashes or lesions
Pulmonary: Breathing is clear and unlabored
Cardiac/Vascular: peripheral pulses symmetrical and radial 2+
Imaging:
I independently reviewed his the patient's MRI performed at ______ Health System it demonstrates ill defined anterior superior labral tear in the left and right hip. Bone marrow edema in the acetabulum.
Diagnosis: PAIN ONLY
treatment: RX anti inflam
After reading the chart note below, would you consider this an undiagnosed new problem with uncertain prognosis? (MODERATE) with RX management (MODERATE)?
Is this just a terrible note - I feel very confused by the following?......
Assessment and Plan:
MRI results were reviewed and results were discussed with patient. I explained to the patient that he has some ill-defined findings in his hip. They appear to be symmetric. I explained to the patient I am unsure why his hip is giving him pain. I recommended conservative treatment. I'm going to place him on a prescription anti-inflammatory. He's going to continue his home exercises. He will see me back in six weeks if he's not improved. At that time, if he is still symptomatic I would recommend an intra-articular steroid injection.
History of Present Illness: 38 y.o. male who presents today for follow-up to review an MRI.
No past medical history on file.
No past surgical history on file.
No family history on file.
No Known Allergies
Objective: There were no vitals taken for this visit. There is no height or weight on file to calculate BMI.
Physical Examination:
General: well appearing and well nourished
Eyes: Pupils equally round and reactive
Mood/Affect: appropriate
Skin: Skin color, texture, turgor normal. No rashes or lesions
Pulmonary: Breathing is clear and unlabored
Cardiac/Vascular: peripheral pulses symmetrical and radial 2+
Imaging:
I independently reviewed his the patient's MRI performed at ______ Health System it demonstrates ill defined anterior superior labral tear in the left and right hip. Bone marrow edema in the acetabulum.