The patient is a 32-year-old male here for the first time.
Chief complaint: Left knee area is bothersome, painful moderate severity. The patient also notes swelling in the knee area, limited ambulation, and inability to perform physical activities such as sports or exercises. The patient first noticed symptoms approximately 4 months ago. Problem occurred spontaneously. Problem is sporadic. Patient has been prescribed hydrocodone and meloxicam. Patient has had temporary pain relief with the medications. The meloxicam has caused digestion problems so patient has avoided using it.
Past medical history: Patient denies any past medical problems.
Surgeries: Patient has undergone surgery on the appendix.
Hospitalizations: Patient denies any past hospitalizations that are noteworthy.
Medications: Hydrocodone
Allergies: Patient denies having allergies.
Family history: Mother: No serious medical problems; Father: No serious medical problems
Social history: Patient is married. Occupation: Patient is a chef.
Review of Systems:
Constitutional: Denies fevers. Denies chills. Denies rapid weight loss.
Eyes: Denies vision problems
Ears, Nose, Throat: Denies any infection. Denies loss of hearing. Denies ringing in the ears. Denies dizziness. Denies a sore throat. Denies sinus problems.
Cardiovascular: Denies chest pains. Denies an irregular heartbeat.
Respiratory: Denis wheezing. Denies coughing. Denies shortness of breath.
Gastrointestinal: Denies diarrhea. Denies constipation. Denies indigestion. Denies any blood in stool.
Genitourinary: Denies any urine retention problems. Denies frequent urination. Denies blood In the urine. Denies painful urination.
Integumentary: Denies any rashes. Denies having any insect bites.
Neurological: Denies numbness. Denies tremors. Denies loss of consciousness.
Hematologic/Lymphatic: Denies easy bruising. Denies blood clots.
Psychiatric: Denies depression. Denies sleep disorders. Denies loss of appetite.
Review of previous studies: Patient brings an MRI which is reviewed. Large knee effusion. No lateral meniscal tear. No ACL/PCL tear. No collateral fracture. Medial meniscus tear with grade I signal.
Vitals: Height: 6'0", Weight: 160
Physical examination: Patient is alert, appropriate, and comfortable. Patient holds a normal gaze. Pupils are round and reactive. Gait is normal. Skin is intact. No rashes, abrasions, contusions, or lacerations. No venous stasis. No varicosities. Reflexes are normal patellar. No clonus.
Knee: Range of motion is approximately from 5 to 100 degrees. Pain with motion. No localized pain. Negative mechanical findings. There is an effusion. Patella is tracking well. No tenderness. Patient feels pain especially when taking stairs or squatting.
Hip: Exam is unremarkable. Normal range of motion, flexion approximately 105 degrees, extension approximately 10 degrees, abduction approximately 25 degrees, adduction approximately 30 degrees, internal rotation approximately 30 degrees, external rotation approximately 30 degrees.
Neck: Neck is supple. No JVD.
Impression:
- Synovitisof the left knee
- Contractureof the left knee
- Possible medialmeniscaltear of right knee
Assessment and plan: A discussion is held with the patient regarding his condition and possible treatment options. Patient has GI upset. Patient is recommended to takeMotrin 400 two to three times a day, discussion is held regarding proper use and precautions. Patient is given a prescription for physical therapy. We will obtain an MRI to rule out potential medial meniscus tear. Patient is instructed to follow up with PMD with labs. Patient is referred to Dr. XYZ. Patient may need arthroscopy if patient does have medial meniscus tear and repeat effusion.
What are the CPT codes reported?