[patient] good morning miss reyes . [doctor] good morning . [patient] how are you doing ma'am ? [doctor] i'm doing well dr. , how are you ? [patient] i am fine , thank you . so you've been having some problems with your right hip ? [doctor] yeah . [patient] okay and where are you hurting ? can you show me ? [doctor] right in the groin area . [patient] okay and this has been going on since february 2020 ? [doctor] yeah . [patient] okay and is it worse with movement ? [doctor] and i almost fall back okay so kind of grabs you yet okay this all started when you were walking while walking around the infusion room okay so it started if i took a step back or you know sep like that now it happens anywhere . [patient] okay , so now it hurts whenever you move . [doctor] it hurts when i pivot . [patient] okay , so if you pivot , then it hurts , got it . [doctor] sometimes do it sometimes it will go and sometimes it will do it several times in a row several times in a row okay and sometimes i fall . [patient] okay and you rate the pain to range from 2-7 out of 10 ? yeah , that's correct . okay and are you experiencing fever or chills ? no . okay and any tingling or numbness ? no . [doctor] and have you had any problems with your bowel or bladder ? [patient] no . [doctor] okay and if you stay still , do you feel better ? yes , but i do n't want to stay still . [patient] i understand , no problem and for past medical history , do you have anything going on ? [doctor] pcos i had infertility gallbladder removed but that that okay and for family history it looks like there is high blood pressure diabetes . [patient] thyroid disease , heart disease , kidney disease , and gastric ulcers for your current medications , it does n't look like you're taking anything at this time and you are allergic to percocet , vicodin and reglan and it looks like you had intentional weight loss , [doctor] yes i've lost 110 pounds . [patient] that is awesome and how did you do that with weight watchers great and how many months have you been participating in weight watchers ? [doctor] i started in 2018 and i've been at my current weight for a little over a year . [patient] that is awesome . [doctor] yeah , thank you . [patient] yeah very good and congratulations and so for social history , it looks like you work at an infusion center . [doctor] yes . [patient] okay and you live with your roommate , no history of tobacco and alcohol intake less than five drinks per month . [doctor] that's correct . [patient] take a look at your hip . [doctor] okay . [patient] please use my general physical exam template . physical exam miss reyes is a pleasant 56-year-old woman who is 5 feet 6 inches in height , weighing 169 pounds , [doctor] blood pressure is 115/75 . pulse rate is 67 . ankles , no ankle edema is noted . no calf tenderness . okay miss reyes , can you go ahead and stand up for me please and take a couple of steps . [patient] great and can you walk on your tippy toes ? [doctor] good , okay and can you walk on your heels , kind of a heel walk and toe walk are intact . go ahead and turn around please . okay . examination of the cervical spine , any pain here now ? [patient] no . [doctor] okay . no tenderness . look at your right and your left and then over to the right . then go ahead and look up and look down and look straight ahead range of motion is full in the neck without pain . spurling's test is negative . exam of the low back . any pain here ? [patient] no . [doctor] okay . skin is intact . no midline tenderness to palpation . go ahead and lean back and lean to your right to your left . does that hurt at all ? no . [patient] okay , great and go ahead and bend forward and then come back up and that does n't bother you ? [doctor] no , i did or do have several bulging disks . [patient] okay , but you're not hurting right now ? [doctor] no , the weight loss has really decreased all the pain . okay . range of motion is decreased in exertion . lateral flexion without pain . any pain when i push ? [patient] no . okay . you can go ahead and sit down please . no pain ? [doctor] no . [patient] okay . sacroiliac signs are negative . examination of the hips , [doctor] trochanteric is nontender . go ahead and lift your knee up . does that bother you ? [patient] just a little bit . [doctor] okay . little bit and then back one probably bothers you ? right there like the area . [patient] okay . how about this way ? not too bad ? [doctor] no . okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . [patient] okay , go ahead and keep it up , do n't let me push it down . does that hurt ? right there . okay . resisted right hip flexion causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ? [doctor] yeah . okay . motor control is normal in the lower extremities . go ahead and lift your knee up . [patient] okay . [doctor] okay . lift it up , any pain ? [patient] no . [doctor] okay and this one ? [patient] yeah . [doctor] and squeeze your knees together push it out and kick your leg out straight now go ahead and bring it back and kick it out straight again and go ahead and lean back , keep it loose okay all set and go ahead and sit up now okay , thank you . [patient] you're welcome . so what i think we're dealing with is right hip degenerative joint disease . [doctor] okay . [patient] and we do have some options , so first is to start some low impact exercises . i can provide you with a handout with what exercises you can do . you should take nsaids as needed to help with the pain and discomfort as well as use of a cane to help offload the right side . a cane will help support your painful side to help reduce the pain . [doctor] i do n't love that idea , but i will give it a try . [patient] okay , that would be great and we can also try a cortisone injection into the right hip joint to see if that offers any relief . [doctor] i would like to definitely get that injection . [patient] okay . we can take care of that today while you are here and then schedule a follow-up appointment in 3 months to see how you are doing and then receive another injection if needed . [doctor] okay that sounds good . [patient] okay and here are the risks associated with getting the injection please just take a moment to review it and consent to the shot . [doctor] i'm good . [patient] great . we'll get that set up for you . alright , well i hope things feel better and we will see you back here in 3 months . [doctor] thank you . have a nice day . [patient] thank you so much , you as well . [doctor] deep tendon reflexes 1+ throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list . [patient] next radiographs , mr arthrogram of the right hip done june 3 , 2021 show high grade chondromalacia involving the anterosuperior right acetabulum , with subchondral marrow edema and cyst formation . , plan , options include low impact exercise program , use of an nsaid and use of the cane to offload the right . we discussed that she'd like to proceed with a cortisone injection in right hip joint . i explained the risks of injection , including needles , sterile , and covid . she understood and decided to proceed with the injection . [doctor] she will follow up with me in 3 months for another injection if needed . end of dictation .
CHIEF COMPLAINT

Right hip pain.

HISTORY OF PRESENT ILLNESS

Elizabeth Reyes is a 56-year-old female who presents for the evaluation of pain in her right hip and groin region. Her symptoms started on 02/2020 and has progressively worsened. She is employed as an RN and notes that her symptoms began while she was working and walking around the infusion room at Johnson. Initially the pain would only happen when she took a step back, but the pain has progressed and now occurs with any type of movement involving her right hip and groin. She describes that her hip will sometimes “catch” when she moves, causing her to fall on occasion. The pain improves when she is still and stops moving. She rates her pain as 2-7/10.

Starting in 2018, the patient intentionally lost 110 pounds through Weight Watchers. She has maintained the weight loss and her weight has been stabile for the past 1 year. She has a history of several bulging discs, but the pain has significantly reduced due to her weight loss. Today, she reports no back pain.

She denies fever, chills, new onset of bowel or bladder dysfunction, tingling or numbness.

Opioid Assessment

Opioid Use: No.

Pain Assessment

Pain is frequent.
Quality of Pain: Right hip catches.
Intensity of Pain Using VAS 0-10 Scale (0 = No pain, 10 = Worst imaginable pain)
• Current Pain Intensity: 2/10.
• Average Pain Intensity Over the Past Week: 4/10.
• Pain at Best: 2/10.
• Pain at Worst: 7/10.
Relieving Factors: Lying down, sitting.
Aggravating Factors: Walking, pivoting, turning, any movement engaging right hip.

PAST HISTORY

Medical
PCOS.

Surgical
Cholecystectomy.

SOCIAL HISTORY

Works at the infusion center at Johnson. Lives with a roommate. Denies tobacco use. Limits alcohol intake to less than 5 drinks per month.

FAMILY HISTORY

Hypertension.
Diabetes.
Thyroid disease.
Kidney disease.
Gastric ulcers.

CURRENT MEDICATIONS

NSAID PRN by mouth.

ALLERGIES

Percocet.
Vicodin.
Reglan.

VITALS

Blood pressure: 115/75
Pulse: 67.
Height: 5’6.
Weight: 169 lb.

PHYSICAL EXAM

Constitutional
Pleasant.

Integumentary
Skin is in tact.

Musculoskeletal
Extremities: No bilateral ankle edema or calf tenderness.
Examination of gait: Heel-walk and toe-walk are intact.
Cervical spine exam: No tenderness is elicited. Range of motion is full in all planes without pain. Spurling's test is negative.
Lumbar spine exam: Range of motion is decreased in extension and lateral flexion without pain. No tenderness is elicited in the midline.
Sacroiliac joint exam: Bilateral sacroiliac joints are nontender to palpation.
Bilateral hip exam: Range of motion is decreased in the right hip with pain in the groin on internal and external rotation. Resisted right hip flexion causes pain in the right groin region. Bilateral trochanteric regions are nontender to palpation.

Neurological
Motor bulk and tone are normal in both lower extremities. Motor strength testing reveals no focal motor weakness in the lower extremities. Deep tendon reflexes are 1+ throughout. No focal sensory deficit is noted.

RESULTS

MR arthrogram of the right hip completed on 06/03/2021 reveals evidence of high-grade chondromalacia involving the anterosuperior right acetabulum with subchondral marrow edema and cyst formation.

ASSESSMENT

• Right hip degenerative joint disease.

PLAN

I discussed the clinical and radiological findings with the patient. Treatment options discussed are low impact exercises, use of analgesics as needed, and use of a cane to offload the right hip. She would like to proceed with a cortisone injection into her right hip joint. We will administer the injection today. I reviewed the procedure in detail, including the risks of the injection related to the use of steroid in the COVID setting. She understands the risks and would like to proceed with the injection.

INSTRUCTIONS

Schedule a follow up appointment in 3 months to assess her pain. If needed, a second injection may be administered.
