Pt is a |PATIENT AGE|yo |PATIENT SEX|, a patient of Dr.|PRIMARY CARE PHYSICIAN|,

here in MSK clinic for evaluation for possible corticosteroid injection.

Description of pain: {FLD:ALLFT47/200}

X-ray: {FLD:ALLLFT/RT/BILAT} {FLD:X BOX}Shoulder {FLD:X BOX}Knee

Patient has tried the following therapies for this pain: {FLD:X BOX}NSAIDs {FLD:X BOX}topical

analgesics {FLD:X BOX}PT

No hardware or prior surgery to affected joint

Not on warfarin, pradaxa, xarelto, eliquis, plavix

A1c <9

Most recent platelet count not less than 50k

Past Medical History includes:

|PROBLEM LIST- TAMPA|

ALLERGIES

|ALLERGIES/ADR|

OUTPATIENT MEDS

|ACTIVE MEDICATIONS|

|REMOTE ACTIVE MEDICATIONS|

EXAM: Alert, NAD

VITAL SIGNS taken by nursing staff (most recent):

Temperature: |TEMPERATURE|

Pulse: |PULSE|

Respiration: |RESPIRATION|

BP: |BLOOD PRESSURE|

Pain: |PAIN|

Height: |PATIENT HEIGHT|

Weight: |PATIENT WEIGHT|

BMI: |BMI|

SHOULER:{FLD:BDV INJECTION RIGHT/LEFT}

Atrophy or asymmetry {FLD:X BOX}yes {FLD:X BOX}no

Post/lateral subacromial space {FLD:X BOX}pain {FLD:X BOX}no pain

Biceps or AC jt palpation {FLD:X BOX}pain {FLD:X BOX}no pain

Full abduction and elevation {FLD:X BOX}pain {FLD:X BOX}no pain

Supraspinatus ROM/isometric challenge {FLD:X BOX}pain {FLD:X BOX}no pain

Internal rotation {FLD:X BOX}pain {FLD:X BOX}no pain

External rotation (infraspinatus) {FLD:X BOX}pain {FLD:X BOX}no pain

Hawkin's {FLD:X BOX}positive {FLD:X BOX}negative

Neer's {FLD:X BOX}positive {FLD:X BOX}negative

Speed's (strength/biceps) {FLD:X BOX}positve {FLD:X BOX}negative

Yergesons (turning/biceps) {FLD:X BOX}positve {FLD:X BOX}negative

Hornblowers (teres minor) {FLD:X BOX}positve {FLD:X BOX}negative

Cross-arm test (AC joint impingement) {FLD:X BOX}positve {FLD:X BOX}negative

Strength in all 4 RC muscles {FLD:X BOX}weakness {FLD:X BOX}intact

--------------------------------------------------------------------------------

KNEE: {FLD:BDV INJECTION RIGHT/LEFT}

ROM of knee {FLD:X BOX}full {FLD:X BOX}partial

Effusion {FLD:X BOX}yes {FLD:X BOX}no

Warmth {FLD:X BOX}abnormal {FLD:X BOX}normal

Patellar grind {FLD:X BOX}pain {FLD:X BOX}no pain

Medial joint line {FLD:X BOX}pain {FLD:X BOX}no pain

Anserine bursa {FLD:X BOX}pain {FLD:X BOX}no pain

Lateral joint line {FLD:X BOX}pain {FLD:X BOX}no pain

McMurray's (meniscus) {FLD:X BOX}pain {FLD:X BOX}no pain

Lachman (ACL) {FLD:X BOX}pain {FLD:X BOX}no pain

IT Band {FLD:X BOX}pain {FLD:X BOX}no pain

No sig genu varus or valgus on standing; gait is antalgic

good hip ROM without pain bilat

periph NV ok

ASSESSMENT/PLAN: {FLD:X BOX}DJD/OA {FLD:X BOX}Bursitis

Procedure: Joint Injection

Informed consent obtained via Imed consent. Risks, benefits, alternatives

were discussed. These risks include bleeding, damaging internal structures,

introducing infection, nerve or cartilage damage, and post injection site flare.

Indication for procedure: Pain

Site marked and Immediately prior to the start of the procedure a time-out was

taken:

The patient's identity was verified by asking for his/her

{FLD:X BOX}Full Name

{FLD:X BOX}His/Her Full Social Security Number

{FLD:X BOX}Date of Birth.

Veteran may return in 6 months, if needed, for repeat injection.

{FLD:X BOX} Discussed with patient about core muscle strengthening and weight loss