Read the following case study and answer the questions below. Physician Office Note This 15-year-old female patient was playing softball and attempted to catch a ball and fell on her right shoulder 2 days ago. She then presented to the emergency room and an x-ray was obtained; at that time the x-ray showed no fractures. She was referred to me for follow-up. Patient History: There is no significant medical history for this patient. Physical Examination: HEENT: Normal Heart: Within normal limits Extremities: The right shoulder is painful to touch, and there is limited mobility at this time. There are no other findings noted. Skin: There are no breaks in the skin at the sight of the right injury. There are no other findings. Assessment: Diagnosis: Right shoulder sprain and pain Plan: This patient should continue to ice the shoulder and rest the shoulder for the next 5 to 6 days. She was instructed not to play softball at this time. Answer the following questions after reading the case study. 1. Why did the patient come to see the physician? 2. What are the diagnoses(is) that need to be code? 3. What is the correct diagnostic code(s) for this case? 4. Explain the process that you followed to arrive at the code you selected?
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