cwilson3333
Expert
Would like audit done on this visit:
CC: Right Shoulder Pain
HPI: The patient is right hand dominant and is s/p C4-5 fusion in 1998. She occasionally
gets numbness related to that. She has no history of injury with the shoulder. There is no past history of problems with it. She denies numbness or tingling. There is no neck pain right now. She says reaching behind her is bad. Reaching overhead is bad. It hurts to sleep at night.
MEDS: None
ALLERGIES: Morphine and Zithromax
SH: Negative. She is director of personnel. She ejoys swimming and sewing.
PSH: Tonsillectomy, appendectomy, cholecystectomy, breast CA, neck fusion, rotator cuff surgery and hysterectomy.
PMH: Breast CA and HTN
FH: Colon CA
ROS: Musculoskeletal: Right Shoulder Pain
Cardiovascular: HTN
GU: Gallstones
General: Breast CA
VITALS: h: 5'8", w:193 lbs, Temp 97.1, Pulse 64, PB 131/67
PHYSICAL EXAM:
General Appearance: WDWN female in no acute distress
Musculoskeletal: On exam, she has pain with abduction. She has pain with liftoff, SST and
Speed Testing.
ORDERS: Films of shoulder show glenohumeral and AC Arthritis; Fusion C4-5
ASSESSMENT: Rotator Cuff and Biceps Dysfunction
PLAN: MRI w/arthrogram. Lab Creatine and Bun. We will see her back when that is complete.
Dr XYZ
Would like to have someone breakdown this visit, i.e. HPI elements, ROS elements,
MDM and Level of Service.
CC: Right Shoulder Pain
HPI: The patient is right hand dominant and is s/p C4-5 fusion in 1998. She occasionally
gets numbness related to that. She has no history of injury with the shoulder. There is no past history of problems with it. She denies numbness or tingling. There is no neck pain right now. She says reaching behind her is bad. Reaching overhead is bad. It hurts to sleep at night.
MEDS: None
ALLERGIES: Morphine and Zithromax
SH: Negative. She is director of personnel. She ejoys swimming and sewing.
PSH: Tonsillectomy, appendectomy, cholecystectomy, breast CA, neck fusion, rotator cuff surgery and hysterectomy.
PMH: Breast CA and HTN
FH: Colon CA
ROS: Musculoskeletal: Right Shoulder Pain
Cardiovascular: HTN
GU: Gallstones
General: Breast CA
VITALS: h: 5'8", w:193 lbs, Temp 97.1, Pulse 64, PB 131/67
PHYSICAL EXAM:
General Appearance: WDWN female in no acute distress
Musculoskeletal: On exam, she has pain with abduction. She has pain with liftoff, SST and
Speed Testing.
ORDERS: Films of shoulder show glenohumeral and AC Arthritis; Fusion C4-5
ASSESSMENT: Rotator Cuff and Biceps Dysfunction
PLAN: MRI w/arthrogram. Lab Creatine and Bun. We will see her back when that is complete.
Dr XYZ
Would like to have someone breakdown this visit, i.e. HPI elements, ROS elements,
MDM and Level of Service.
