PATIENT: WHITE, SASHA ACCOUNT/EHR #: WHITSA001 DATE: 02/27/23 Attending Physician:…

PATIENT: WHITE, SASHA ACCOUNT/EHR #: WHITSA001 DATE: 02/27/23 Attending Physician: Sandford Lockard, MD S: This new Patient is a 25-year-old female who was involved in a two-car MVA while driving on the job. She is complaining about some neck pain. She has tingling into her left hand and her feet. She states that her arm hurts when she tries to pull it overhead. She apparently was told by a friend that she would likely need to see a spine doctor, but she came to see me first. PMH is remarkable for kidney trouble. Past bronchoscopy, laparoscopy, and kidney stone surgery, otherwise noncontributory as per the medical history form completed by the patient and reviewed at this visit. O: Height 5 feet 5 inches Weight 179 lb. R 16. Patient presented in a sling. She was told to use it by the same friend. She states if she does not use it, her arm does not feel any different, so I had her remove it. On exam, the left shoulder demonstrates full passive motion. She has normal strength testing. She has no deformity. She has some tenderness over the trapezial area. The reflexes are brisk and symmetric. X-rays of her chest two views and C spine AP/LAT are relatively benign, as are complete X-rays of the shoulder. A: Contusion of upper arm and shoulder, left P: 1. MRI to rule/out torn ligament 2. Rx: Naprosyn 3. Referral to PT 4. Referral to orthopedic specialist Answer 1: Diagnosis code Answer 2: Diagnosis code Answer 3: Diagnosis code Answer 4: Diagnosis code Answer 5: CPT code Answer 6: CPT code Answer 7: CPT code Answer 8: CPT code