Initials, Age, Sex, Race,
Save your time - order a paper!
Get your paper written from scratch within the tight deadline. Our service is a reliable solution to all your troubles. Place an order on any task and we will take care of it. You won’t have to worry about the quality and deadlinesOrder Paper Now
Chief Complaint: left hip pain
Mrs L, a 66 year old Caucasian female present to the clinic with complaints of left hip pain which she first noticed 3 weeks ago. She reports experiencing pain more frequently now, it is almost constant with walking or standing for a long period of time. It is a throbbing pain with does not radiate. The pain is aggravated by walking, bending, standing, squatting and relief is noted with rest. She has taken Ibuprofen 800 mg intermittently for the pain, and states at worst the pain rated as 8/10, at best 0/10 when at rest.
Ibuprofen 200-800 PRN hip pain
Allergies: None stated
No chronic illness. Chicken pox as a child. No hx previous fractures.
All vaccines up to date
PSHX: Hysterectomy 20 years ago, Cholecystectomy 20 years ago
Last mammogram 5 years ago, colonoscopy WNL, no history of DEXA
Single, Retired x 4 years, previous office management, non-smoker, occasionally has a glass of wine with dinner, no illicit drugs, walks 1 mile a day.
Parents are deceased, siblings in good health.
General: denies headache, vision changes, night sweats, fever
CV: No chest pain, palpitations
Respiratory: No SOB, no cough
Musculoskeletal: Reports pain with standing, walking, squatting, no back pain,
Neuro: No numbness, tingling, or weakness noted in extremities
BP: 123/84; HR 80; RR 20; T: 98.5; Hgt: 5’2″; Wgt: 120 lbs; BMI: 20 (weight loss of 7 lbs from last year)
General: No acute distress
HEENT: Head normocephalic without evidence of masses or trauma.
PERRLA, EOMs intact, non-injected. Ear canal without redness irritation, TMs clear, pearly, bony landmarks visible, no discharge, no pain noted. Neck negative for masses, no thyromegaly. No JVD distention.
Skin: intact. No bruising noted.
CV: S1/S2, RRR, no murmurs, no rubs
Lungs: CTA bilaterally.
Abdomen: Soft, non-tender, non-distended, BS present x 4, no organomegaly, no bruits
Musculoskeletal: No pain to palpation of left or right hip ; Right leg: full active and passive ROM Left leg: Decreased active and passive ROM with stiffness and report of discomfort. Antalgic gait noted with rise from seated position, to standing, and initiation of ambulation
Neuro: Sensation intact bilateral upper and lower extremities, bilateral UE/LE strength 5/5
Psych: PHQ 9 score 5
Diagnostic or Lab results: None Available
Primary Diagnosis: Osteoarthritis (M16.12):
Secondary Diagnosis: Health maintenance, Gait Disturbance (ICD-10 R26.89):
Hip fracture (stress fracture) (ICD-10 M84.352):
25-hydoxyvitamin D, calcium level
X-ray of the left hip
· Ibuprofen 200 mg tablet (treatment of OA)
Sig: Take 2 tablets three times daily, Disp: 120 Refill: 3
· Tramadol 25 mg tablet
Sig: take one tablet every 6 hours as needed for severe pain. Disp: 20 Refill: 0
Discussed OA diagnosis and will screen for osteoporosis with DEXA
Recommend water aerobic/hydrotherapy
Exercises should stress range of motion and stretching such as yoga or tai chi
Hot and cold therapy as tolerated. Heat applied prior to exercise to reduce aches, cold following exercise to reduce swelling and relieve pain. Use heat no longer than 15 minutes at a time and cold therapy for no longer than 20 minutes at a time to prevent thermal injury
Discussed fall prevention. Recommend removing throw rugs from the home due to gait.
Physical therapy referral to assist with gait
PHQ 9 score 5: discussed to call office if experiences increased signs of depression
Referrals: GI for colonoscopy, physical therapy
Follow up: return to office in 2 weeks to evaluate pain level and review diagnostics results.