Hand Weakness

Patient presents with complaints of hand weakness.  Onset of weakness was (onset timeframe, e.g., gradual over several months, sudden this morning).  Location of weakness is described as (location, e.g., entire right hand, fingers of left hand, thumb and index finger).  The weakness affects (activities of daily living, e.g., gripping objects, opening jars, buttoning clothes, writing).  Patient denies (negative symptoms, e.g., numbness, tingling, pain).  Associated symptoms include (associated symptoms, e.g., fatigue, muscle cramps, difficulty with fine motor skills).  Medical history is significant for (relevant medical history, e.g., diabetes, hypertension, carpal tunnel syndrome, prior stroke, cervical radiculopathy).  Family history includes (relevant family history, e.g., history of neuromuscular disorders).  Social history includes (relevant social history, e.g., smoking, alcohol use, occupation involving repetitive hand movements).  Physical examination reveals (objective findings, e.g., decreased grip strength 45 on the right, 55 on the left, atrophy of thenar muscles, positive Phalen's maneuver).  Differential diagnosis includes (differential diagnoses, e.g., carpal tunnel syndrome, ulnar neuropathy, radial neuropathy, cervical radiculopathy, stroke, peripheral neuropathy).  Assessment: Hand weakness, likely secondary to (presumptive diagnosis, e.g., carpal tunnel syndrome).  Plan includes (plan of care, e.g., nerve conduction study, electromyography, referral to neurology, occupational therapy, splinting, corticosteroid injection).  ICD-10 code (appropriate ICD-10 code) is considered.  CPT codes for evaluation and management (appropriate CPT E&M code) and any procedures performed (e.g., injection) will be billed.  Patient education provided regarding diagnosis, treatment options, and prognosis.  Return to clinic scheduled for (follow-up timeframe).