1/11/25, 12:47 AM eRemittance - AETNA

eRemittance - AETNA

Payee :DELMARVA PAIN SPINE CENTER, LLC (3RQX ) Date: 01/09/2025

1 CENTURIAN DR STE 110 TIN: 815148669
NEWARK DE 197132154 TIN: 815148669
Reference ID: 825009000011196
Payor : AETNA (60054 ) , (60054) , (60054) Amount: $491.73
151 FARMINGTON AVENUE
HARTFORD CT 06156

Explanation of Payment
----------------------------------------------------------------------------------------------------------
Claims: 1

(1)
Patient Name HALL CHARLES A Patient ID W197042005 Claim Status 1
Subscriber Name - Payer Claim ID PAADKK9T60000 Claim Amount $460.17
Provider Name WINKLER MOLLY Provider Claim ID 43029 Paid Amount $0.00
Claim Statement 12/18/2024 - 12/18/2024 Received Date 01/03/2025 Pt Responsibility -
Dates
Claim Status Description : Processed as Primary
Serv Date Units Serv Code Billed Paid Allowed Adjustments
12/18/2024 - 0 HC:99214 $385.17 $0.00 - CO-193: $385.17
12/18/2024
REM: N1
12/18/2024 - 0 HC:80305:QW $25.00 $0.00 - CO-193: $25.00
12/18/2024
REM: N1
12/18/2024 - 0 HC:G2211 $50.00 $0.00 - CO-193: $50.00
12/18/2024
REM: N1

----------------------------------------------------------------------------------------------------------
Adjustment Group Codes
CO : Contractual Obligations

Adjustment Reason Codes

193 : Original payment decision is being maintained. Upon review, it was determined that this claim was processed
properly.

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https://dedpscapp.ecwcloud.com/mobiledoc/jsp/webemr/index.jsp#/mobiledoc/jsp/webemr/webpm/claimLookup.jsp 1/1
 AETNA HEALTH
151 FARMINGTON AVE

HARTFORD CT 061560001
X XX X XX
X W197042005
HALL, CHARLES, A 11 29 1956 X HALL, CHARLES, A

4205 CHRISTIANA MDWS X 4205 CHRISTIANA MDWS

BEAR DE BEAR DE

197012882 197012882

314818-025-00304

X 11 29 1956 X

Signature On File Signature On File

12 18 24 431

DN TIFFANY GARCIA 1699026815

X
0
M170 M961 M47816 M792
F4542 Z79891 G894
08D2135844

12 18 24 12 18 24 11 99214 BACD 385 17 1 1295331155

12 18 24 12 18 24 11 G2211 G 50 00 1 1295331155

12 18 24 12 18 24 11 80305 QW F 25 00 1 1295331155

815148669 X 43029 X 460 17 385 17

302 3550900
DELMARVA PAIN AND SPINE CE Delmarva Pain and Spine Center LLC
1 CENTURIAN DR STE 110 1 CENTURIAN DR. STE 110
MOLLY WINKLER, PA NEWARK DE 197132154 NEWARK DE 197132154
01 10 25 1750810305 1750810305
1/11/25, 12:48 AM eCW (Ascend, AliRaz )

HALL, CHARLES A DOB: 11/29/1956 (68 yo M) Acc No. 13766 DOS: 12/18/2024

HALL, CHARLES A
68 Y old Male, DOB: 11/29/1956
Account Number: 13766
4205 CHRISTIANA MDWS, BEAR, DE-19701-2882
Home: 302-545-9229
Guarantor: HALL, CHARLES A Insurance: Aetna Health Payer
ID: 60054
PCP: Irene Szeto Referring: Tiffany Garcia
Appointment Facility: Delmarva Pain And Spine Center Llc

12/18/2024 Appointment Provider: MOLLY WINKLER, PA

Reason for Appointment

Current Medications 1. Low back pain radiating into bilateral lower extremities
Taking 2. Bilateral knee pain
Gabapentin 800 MG Tablet 1 tablet
Orally three times a day History of Present Illness
oxyCODONE HCl 5 MG Tablet 1 tablet
Orally three times a day Depression Screening:
Morphine Sulfate ER 15 MG Tablet PHQ-2 (2015 Edition) Little interest or pleasure in doing things? Not at
Extended Release 1 tablet Orally every 12 all, Feeling down, depressed, or hopeless? Not at all, Total Score 0.
hrs INITIAL HPI:
Methocarbamol 750 MG Tablet 1 tablet
Orally three times a day HPI: Mr. Hall is a pleasant 67-year old male with a PMHx of HTN, COPD,
Rosuvastatin Calcium 20 MG Tablet 1 who originally presented with complaints of chronic low back pain with RLE
tablet Orally Once a day pain.
amLODIPine Besylate 10 MG Tablet 1
tablet Orally Once a day
Diclofenac Sodium 50 MG Tablet Regarding onset, he states that in January of 2020, the pain developed on
Delayed Release 1 tablet Orally Twice a its own without any inciting events. No trauma, falls or MVAs. He started to
day developed pain in the low back with radiation into the RLE. He did seek
Combivent Respimat 20-100 conservative therapy and started PT at that time in January of 2020 with
MCG/ACT Aerosol Solution 1 puff as
needed Inhalation every 6 hrs transient improvement of pain. This prompted further evaluation with
diphenhydrAMINE HCl 25 MG chiropractic therapy with Dr. Tiffany Garcia which he is currently doing at this
Capsule 1 capsule at bedtime as needed time. He has workup as dictated below.
Orally Once a day
Glucosamine 750 MG Tablet as
directed Orally Twice a day Regarding pain, he notes primarily low back pain on the right side that
Aspirin 81 81 MG Tablet Delayed radiates along the posterolateral aspect of his RLE. He does have paresthesia
Release 1 tablet Orally every other day specifically numbness and tingling in the bilateral distal LE. The pain is
Lisinopril 40 MG Tablet 1 tablet Orally constant and is described as aching, throbbing, sharp, stabbing in character.
Once a day
Modafinil 200 MG Tablet 1 tablet in The current pain intensity is 2/10 at rest, increasing to 4-5/10 with activity.
the morning Orally Twice a day The pain increases with ambulation, upright posture, prolonged standing,
Breztri Aerosphere 160-9-4.8 walking, over-activity and is decreased with rest and medications but overall,
MCG/ACT Aerosol INHALE 2 PUFFS is not getting better. The patient reports that performing activities of daily
TWICE A DAY Inhalation
Not-Taking living is not a problem and walk independently into the office today.
Valium 5 MG Tablet 1 tablet as needed
Orally Once a day The patient denies significant weakness, ataxia, bowel or bladder
Advair Diskus 250-50 MCG/DOSE incontinence. PREVIOUS REHABILITATION THERAPIES:
Aerosol Powder Breath Activated 1 puff
Inhalation Twice a day Physical Therapy: completed recently 7 sessions in January of 2020 with
Atorvastatin Calcium 20 MG Tablet 1 transient improvement
tablet Orally Once a day Chiropractic Therapy: ongoing with Dr. Garcia and completed 2
Theraworx Relief - Liquid as directed sessions. PREVIOUS MEDICATION
Externally as needed
oxyCODONE HCl 5 MG Tablet 1 tablet NSAIDS: Tylenol 500 mg Q6H, Aspirin 81 QD PRN, Diclofenac 75 mg QD
as needed Orally three times a day NEUROPATHIC MEDICATIONS: None
traMADol HCl 50 MG Tablet TAKE 1 MUSCULOSKELETAL MEDICATIONS: None
TABLET BY MOUTH TWICE A DAY AS

Progress Note: MOLLY WINKLER, PA 12/18/2024

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
1/11/25, 12:48 AM eCW (Ascend, AliRaz )

HALL, CHARLES A DOB: 11/29/1956 (68 yo M) Acc No. 13766 DOS: 12/18/2024

NEEDED FOR 7 DAYS Oral OPIOIDS: None

Cyclobenzaprine HCl 10 MG Tablet 1 ANTI-DEPRESSANTS: None. PREVIOUS NERVE BLOCKS,
tablet as needed Orally twice a day
Pregabalin 100 MG Capsule 1 capsule INJECTIONS, OR SURGERIES:
Orally Once at night No prior injections. IMAGING STUDIES:
Acetaminophen 500 MG Capsule two
tablets Orally at night MRI L-spine 02/21/2024 showed
PredniSONE (Pak) , Notes to
Pharmacist: LAST DOSE TAKEN: 1. At L2-3, progression of disc space narrowing perviously moderate now
06/17/2020 - 5 day pack advanced progression of degenerative plate changes with Schmorl's nodes,
Ibuprofen 600 MG Tablet 1 tablet with and mild progression of the grade 1 retrolisthesis. Progression of the
food or milk as needed Orally Three times associated broad-based disc bulge along with facet arthropathy and buckling
a day
Mupirocin 2 % Ointment 1 application of the ligamentum flavum with increased canal stenosis previously moderate
Externally Three times a day to severe and now severe with further crowding of the cauda equina nerve
Medication List reviewed and reconciled roots and further impingement of the bilateral traversing L3 nerve roots.
with the patient Mild progression of the moderate bilateral neuroforaminal stenosis.
2. At L3-4, progression of the disc space narrowing previously moderate and
Past Medical History now advanced and progression of degenerative plate changes with Schmorl's
HTN. nodes. Stable mild grade 1 retrolisthesis. Mild progression of the broad-
COPD.
Basal Cell Skin (removed).
based disc bulge. Along with buckling of the ligamentum flavum and facet
arthropathy there is further increase in degree of the severe canal stenosis,
Surgical History crowding of the cauda equina nerve roots, and impingement of the bilateral
lumbar spine decompression, traversing L4 nerve roots. Further progression of the severe bilateral
laminectomy L3-L5 (Dr. Maidoh) neuroforaminal stenosis and impingement of the bilateral exiting L3 nerve
12/8/2021
Lumbar spine surgery (Dr. Maidoh)
roots.
8/23/24 3. At L4-5, stable mild grade 1 anterolisthesis with associated stable broad-
based disc bulge again impinging the bilateral exiting L4 nerve roots.
Family History Combined with facet arthropathy there is stable severe right and moderate
Father: diagnosed with Unspecified to severe left-sided neuroforaminal stenosis. Along with buckling of the
essential hypertension
Mother: diagnosed with Unspecified heart
ligamentum flavum there is stable severe canal stenosis, crowding of the
disease cauda equina nerve roots, and impingement of the bilateral traversing L5
Paternal Grand Father: diagnosed with nerve roots.
Unspecified essential hypertension 4. At L5-S1, stable mild grade 1 retrolisthesis with associated stable disc
Non-Contributory
osteophyte complex again impinging the exiting left L5 nerve root.
Social History Combined with facet arthropathy there is stable moderate to severe left
Tobacco Use: sided neuroforaminal stenosis.
Tobacco Use/Smoking Are you a current 5. Redemonstration of mild levoscoliosis.
smoker, How often do you smoke
cigarettes? every day, How many
cigarettes a day do you smoke? 31 or
more. Tobacco use other than smoking EMG BLE 028/13/2024 showed
Are you an other tobacco user? No. 1. Abnormal study.
Opioid Risk Tool: 2. Probable mild sensorimotor polyneuropathy.
Family History of Substance Abuse
Alcohol No, Illegal Drugs No, Rx Drugs
3. Chronic bilateral L4-S1 radiculopathy some subacute features left S1
No. Personal History of Substance Abuse pattern.
Alcohol No, Illegal Drugs No, Rx Drugs 4. Old peroneal nerve injury as noted previously.
No. Age Between 16-45 Years Age 16-45 ?
No. History of Preadolescent Sexual
Abuse History of Sexual Abuse ?
XR bilateral knee 09/23/2022 showed left knee changes with complete
No. Psychological Disease ADD, OCD, medial compartment joint loss. Lesser right knee arthrosis.
Bipolar, Schizophrenia ? No, Depression ? Chondrocalcinosis bilaterally. Demineralization.
No. Total Score Score Combined 0.
Drugs/Alcohol:
Drugs Have you used drugs other than
MRI L-spine 11-04-2021 showed severe central canal stenosis at L4-L5.
those for medical reasons in the past 12 Moderate-severe central canal stenosis at L3-L4. Mild central canal stenosis
months? No. Alcohol Screen (Audit-C) at L2-L3 and L5-S1. Multilevel disc bulges and posterior element
Did you have a drink containing alcohol in hypertrophy. Mild lumbar levoscoliosis. Mild retrolisthesis at L2-L3, L3-L4,
the past year? No, Points
0, Interpretation Negative. Caffeine
and L5-S1. Severe right foraminal narrowing at L3-L4 related to a right
Intake: 1-2 cups per day. Do you smoke foraminal disc herniation. Moderate left foraminal narrowing at L5-S1.
Severe right foraminal narrowing and mild left foraminal narrowing at L4-

Progress Note: MOLLY WINKLER, PA 12/18/2024

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
1/11/25, 12:48 AM eCW (Ascend, AliRaz )

HALL, CHARLES A DOB: 11/29/1956 (68 yo M) Acc No. 13766 DOS: 12/18/2024

marijuana?: Denies. Do you drink L5. Moderate left foraminal narrowing at L3-L4. Mild bilateral foraminal
alcohol?: Socially. narrowing at L2-L3.
Allergies
N.K.D.A. MRI L-spine showed severe canal stenosis at L4-L5. Fine multilevel
disc degeneration at L3-L4, L4-L5 and L5-S1 with foraminal narrowing.
Hospitalization/Major
Diagnostic Procedure XR L-spine 2019 demonstrate mild lumbar levoscoliosis and minimal
Denies Past Hospitalization retrolisthesis of L2 on L3 and L3 on L4; lumbar vertebral bodies otherwise
maintain normal stature and alignment. There is no fracture. No
Review of Systems destructive/aggressive osseous process is evident. There is and moderate to
GENERAL / CONSTITUTIONAL: severe disc space narrowing and endplate osteophytosis at L5-S1. There is
Change in appetite denies. moderate disc space narrowing and endplate spurring throughout the
Chills denies. Fatigue denies. remainder of the lumbar spine. Hypertrophic facet changes are most
Fever denies. Headache denies. Night pronounced at L4-5 and L5-S1. Sacroiliac joints are unremarkable. There are
sweats denies. Sleep moderate degenerative changes of both hips
disturbance denies. Weight
gain denies. Weight loss denies.
ALLERGY / IMMUNOLOGY:
XR right hip 2019-12-20 showed
Blistering of skin denies.
1. No evidence of fracture.
Congestion denies. Cough denies.
2. Mild degenerative change
Rash denies.
OPHTHALMOLOGIC:
Blurred vision denies. Diminished XR left foot 2017-09-26 showed hallux valgus deformity. Mild arthritis
visual acuity No recent changes in of the mid tarsal bones seen on the lateral view
vision. Eye Pain denies.
ENT: XR L-spine 2015-09-10 showed degenerative changes are as described
Decreased hearing denies. Dry above. No acute abnormality is seen. INTERVAL HISTORY: DATE OF LAST
mouth denies. Mouth breathing at VISIT (11/19/2024): He presents for follow-up. At todays visit, he is
night denies. Swollen glands denies. complaining of low back pain radiating into bilateral lower extremities and
ENDOCRINE: bilateral knee pain. He underwent lumbar spine surgery with Dr. Maidoh on
Diabetes denies. Difficulty 8/23/24 and he denies any signs of infection. He is doing PT at Pivot PT
sleeping denies. Frequent three times a week with improvement. His NRS pain score today is 6/10. He
urination denies. Weakness denies. describes the pain as burning and achy in nature. He reported having
RESPIRATORY: increased pain with increased activity, ambulation and standing, and
Cough denies. Pain with decreased pain with rest and medications. UDS collected and PDMP
inspiration denies. Shortness of reviewed. All of the patient's questions were answered.
breath denies. Wheezing denies.
CARDIOVASCULAR:
Therapy efficacy: Adverse: Pt denies neg side effects from meds.
Chest pain denies.
Activity: when taken in the past provides great relief and functional
Claudication denies. Dizziness denies.
improvement with walk further and range of motion improved.
Dyspnea on exertion denies. Fluid
Analgesia: Injections provide relief, but she would like as need
accumulation in the legs denies. Heart
medications. Aberrenacy: Pt denies loss of control of use of
problems denies. Palpitations denies.
medications or cravings in the past. Affect: Pt denies compounding
GASTROINTESTINAL: mood or affect changes from baseline.
Abdominal pain denies. Change in
bowel habits denies. Currently the patient is taking:
Constipation denies. Diarrhea denies. Oxycodone 5 mg TID PRN, request refill
Nausea denies. Vomiting denies. Morphine ER 15 mg BID, request refill
HEMATOLOGY: Gabapentin 800 mg TID
Currently undergoing anticoagulation Diclofenac 50 mg BID PRN
therapy No. Bleeding problems denies. Methocarbamol 750 mg TID PRN
Easy bruising denies. Prolonged Valium 5 mg QD
bleeding denies. Family member with Aspirin 81 mg once every other day
bleeding problems denies. Patient is compliant with current regimen as prescribed and shows no
GENITOURINARY:
signs of aberrant drug taking behavior.
Blood in urine denies. Difficulty
.
urinating denies. Frequent

Progress Note: MOLLY WINKLER, PA 12/18/2024

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
1/11/25, 12:48 AM eCW (Ascend, AliRaz )

HALL, CHARLES A DOB: 11/29/1956 (68 yo M) Acc No. 13766 DOS: 12/18/2024

urination denies. Kidney Vital Signs

problems denies. Temp: 98.2 F, HR: 82 /min, BP: 118/72 mm Hg, Wt: 240 lbs, BMI: 35.44
MUSCULOSKELETAL:
Index, Ht: 69 in, RR: 14 /min, Oxygen sat %: 96 %, Pain scale: 6 1-10, Ht-
Arthritis denies. Back
cm: 175.26 cm, Wt-kg: 108.86 kg.
problems admits, RADIATE
INTO RLE. Joint stiffness denies. Examination
Leg cramps are felt in both legs. General Examination:
Muscle aches denies. Pain in GENERAL APPEARANCE: Patient is well developed, well nourished,
shoulder(s) denies. Painful alert and oriented x 3, in no acute distress. HEART: No chest pain or
joints denies. Sciatica denies. Swollen SOB. LUNGS: No resp distress or
joints denies. Weakness denies. SOB. MUSCULOSKELETAL: Comprehensive Musculoskeletal exam:
PERIPHERAL VASCULAR:
Decreased sensation in
Gait: normal, non antalgic, independent
extremities denies. Pain/cramping in
legs after exertion denies. Painful Paravertebral muscular Tenderness: absent at bilaterally lumbar region
extremities denies.
SKIN: BILATERAL knees:
Nail changes denies. Rash denies. + TTP medial and lateral joint lines
Skin lesion(s) denies. - erythema, swelling, crepitus
NEUROLOGIC: Full ROM with pain. NEUROLOGIC: Grossly WNL.
Balance difficulty denies. Difficulty
speaking denies. Gait Assessments
abnormality denies. 1. Primary osteoarthritis of both knees - M17.0 (Primary)
Irritability admits. Loss of 2. Post laminectomy syndrome - M96.1
strength denies. Loss of use of 3. Lumbar spondylosis - M47.816
extremity denies. Low back 4. Neuropathic pain - M79.2
pain admits. Pain admits. 5. Pain disorder with related psychological factors - F45.42
Paralysis denies. 6. Chronic prescription opiate use - Z79.891
Tingling/Numbness bilateral lower 7. Chronic pain syndrome - G89.4
extremities. Mr. Hall is a pleasant 67-year old male with a PMHx of HTN, COPD, who
PSYCHIATRIC:
Anxiety denies. Depressed
originally presented with complaints of chronic low back pain with RLE
mood denies. Psychiatric
pain. MRI L-spine showed at L2-3, progression of disc space narrowing
condition denies. Suicidal
perviously moderate now advanced progression of degenerative plate
thoughts denies.
changes with Schmorl's nodes, and mild progression of the grade 1
retrolisthesis. Progression of the associated broad-based disc bulge along
with facet arthropathy and buckling of the ligamentum flavum with
increased canal stenosis previously moderate to severe and now severe with
further crowding of the cauda equina nerve roots and further impingement
of the bilateral traversing L3 nerve roots. Mild progression of the moderate
bilateral neuroforaminal stenosis. At L3-4, progression of the disc space
narrowing previously moderate and now advanced and progression of
degenerative plate changes with Schmorl's nodes. Stable mild grade 1
retrolisthesis. Mild progression of the broad-based disc bulge. Along with
buckling of the ligamentum flavum and facet arthropathy there is further
increase in degree of the severe canal stenosis, crowding of the cauda equina
nerve roots, and impingement of the bilateral traversing L4 nerve roots.
Further progression of the severe bilateral neuroforaminal stenosis and
impingement of the bilateral exiting L3 nerve roots. At L4-5, stable mild
grade 1 anterolisthesis with associated stable broad-based disc bulge again
impinging the bilateral exiting L4 nerve roots. Combined with facet
arthropathy there is stable severe right and moderate to severe left-sided
neuroforaminal stenosis. Along with buckling of the ligamentum flavum
there is stable severe canal stenosis, crowding of the cauda equina nerve
roots, and impingement of the bilateral traversing L5 nerve roots. At L5-S1,
stable mild grade 1 retrolisthesis with associated stable disc osteophyte
complex again impinging the exiting left L5 nerve root. Combined with facet

Progress Note: MOLLY WINKLER, PA 12/18/2024

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
1/11/25, 12:48 AM eCW (Ascend, AliRaz )

HALL, CHARLES A DOB: 11/29/1956 (68 yo M) Acc No. 13766 DOS: 12/18/2024

arthropathy there is stable moderate to severe left sided neuroforaminal

stenosis. Redemonstration of mild levoscoliosis. Patient's clinical symptoms
and workup are consistent with lumbar radicular pain, lumbar spondylosis,
spinal stenosis, DDD and OA of both knees.
At todays visit, he is complaining of low back pain radiating into bilateral
lower extremities and bilateral knee pain. Given the nature of the patient's
pain symptoms, discussed proceeding with BILATERAL intra-articular knee
joint injections and he is in agreement. Risks and benefits were discussed in
detail with the patient at todays visit. The details of the procedure and
benefits/risks were discussed in detail with the patient at today's visit
including risks of infections, risks of bleeding, risks of being allergic to
medication used, nerve injuries, pneumothorax, PDPH, possible nerve
injury and paralysis as well as vascular complications. I also re-iterate to the
patient that these risks are very minimal in nature. He will continue taking
Gabapentin, Oxycodone as needed, and Morphine ER. Refill sent. Risks and
side effects of the medication were discussed with the patient. The patient
was advised not to mix opioids and sedative meds with benzodiazepine or
alcohol as well as muscle relaxer type medications due to risk of excessive
sedation and respiratory depression. The patient was instructed to use
caution including not driving when initiating or after increasing the dose
until you can ensure that your cognition and reaction time are not affected.
All dose increases will take place when driving is not needed such as on
weekends to further avoid incidents due to sedation. Educated the patient
on the use of Naloxone (a drug that can reverse the effects of opioid
overdose) in the setting of overdose on narcotics and we will consider
prescribing it. UDS collected and PDMP reviewed. All of the patient's
questions were answered.
Treatment
1. Post laminectomy syndrome
Continue Gabapentin Tablet, 800 MG, 1 tablet, Orally, three times a day, 90
days, 270 Tablet, Refills 0
Refill oxyCODONE HCl Tablet, 5 MG, 1 tablet, Orally, three times a day, 30
days, 90, Refills 0
Refill Morphine Sulfate ER Tablet Extended Release, 15 MG, 1 tablet, Orally,
every 12 hrs, 30 days, 60 Tablet, Refills 0

2. Others
Clinical Notes: -PHYSICAL THERAPY/ACTIVITY: We discussed engaging
in low impact exercises and remaining as active as possible. Continue HEP.

-ADJUVANT MEDICAL THERAPY: He is recommended to continue taking

current medications including Gabapentin 800 mg TID, Oxycodone 5 mg
TID PRN, and Morphine ER 15 mg BID. Refill sent. Risks and side effects of
the medication were discussed with the patient. The patient was advised not
to mix opioids and sedative meds with benzodiazepine or alcohol as well as
muscle relaxer type medications due to risk of excessive sedation and
respiratory depression. The patient was instructed to use caution including
not driving when initiating or after increasing the dose until you can ensure
that your cognition and reaction time are not affected. All dose increases will
take place when driving is not needed such as on weekends to further avoid
incidents due to sedation. Educated the patient on the use of Naloxone (a
drug that can reverse the effects of opioid overdose) in the setting of
overdose on narcotics and we will consider prescribing it. UDS collected and
PDMP reviewed.

Progress Note: MOLLY WINKLER, PA 12/18/2024

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
1/11/25, 12:48 AM eCW (Ascend, AliRaz )

HALL, CHARLES A DOB: 11/29/1956 (68 yo M) Acc No. 13766 DOS: 12/18/2024

-IMAGING STUDIES: No new imaging.

-INTERVENTIONAL THERAPY: Will proceed with BILATERAL intra-

articular knee joint injections under fluoroscopic guidance without sedation.
Risks and benefits were discussed in detail with the patient at todays visit.
The details of the procedure and benefits/risks were discussed in detail with
the patient at today's visit including risks of infections, risks of bleeding,
risks of being allergic to medication used, nerve injuries, pneumothorax,
PDPH, possible nerve injury and paralysis as well as vascular complications.
I also re-iterate to the patient that these risks are very minimal in nature.

-SURGERY: Follow up with Dr. Maidoh next week.

-FOLLOW UP: for injection

Preventive Medicine
Counseling: BP Management: FIRST HYPERTENSIVE BP READING
FOLLOW-UP PLAN: Follow-up 4-6 days, LIFESTYLE
RECOMMENDATION: Lifestyle education, REFERRAL TO ALTERNATIVE
/ PRIMARY CARE PROVIDER: Referral to general practitioner. DEXA
Performed DEXA performed 03/01/2024. Care goal follow-up plan: BMI
management provided Yes, Above Normal BMI Follow-up Dietary needs
education.
Screenings: FALL RISK SCREENING Fall Risk Assessment: No falls in the
past year. TOBACCO USE SCREENING: The patient smoked:
cigarettes, Chewing tobacco: has not been used, Smoking tobacco was last
used: today, Smokeless tobacco was last used: never, smokeless tobacco has
never been used.
Visit Codes
99214 Office Visit, Est Pt., Level 4.
Procedure Codes
G2211 Complex e/m visit add on
80305 DRUG TEST PRSMV DIR OPT OBS, Modifiers: QW

Appointment Provider: MOLLY WINKLER, PA

Electronically signed by Dr. SHACHI PATEL , MD on 12/21/2024

at 10:16 AM EST
Sign off status: Completed

Progress Note: MOLLY WINKLER, PA 12/18/2024

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)
1/11/25, 12:48 AM eCW (Ascend, AliRaz )

HALL, CHARLES A DOB: 11/29/1956 (68 yo M) Acc No. 13766 DOS: 12/18/2024

Delmarva Pain And Spine Center Llc

1 CENTURIAN DR
STE 110
NEWARK, DE 19713-2154
Tel: 302-355-0900
Fax: 302-355-0901

Progress Note: MOLLY WINKLER, PA 12/18/2024

Note generated by eClinicalWorks EMR/PM Software (www.eClinicalWorks.com)