DATE OF CONSULTATION: MM/DD/YYYY
REQUESTING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Right hip possible labral tear with very subtle femoroacetabular impingement with small CAM lesion.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who was seen today in consultation for evaluation of her right hip. She has had problems, which developed after childbirth. She has had pain in her right hip and groin area. Symptoms bother her with activities, occasionally bother her at rest, especially with sleeping. The patient can get pain in her hip and thigh as well as pain in her back. She also notes some occasional clicking. The patient has tried therapy as well as chiropractic treatments without significant relief. The patient is being seen in consultation today for possible hip scope.
PAST MEDICAL HISTORY: Significant for wisdom teeth extraction and bunionectomies.
ALLERGIES: Sulfa and doxycycline.
CURRENT MEDICATIONS: None.
SOCIAL HISTORY: Divorced, one child. The patient does not smoke. She drinks occasionally.
FAMILY HISTORY: Significant for heart disease, hypertension, and cancer.
REVIEW OF SYSTEMS: Significant for headaches.
PHYSICAL EXAMINATION: This is a pleasant female who is 5 feet 6 inches, 132 pounds. Evaluation of lower extremities reveals she has equal leg lengths. She has right hip flexion up to 125, external rotation to almost 70, internal rotation to around 30 with pain in her back with impingement maneuver. The patient also has a little pain in her groin. FABER test causes pain in her back as well at about 8 inches. Good motion of her right knee and ankle. Left hip has similar range of motion, also causes some low back pain with an impingement maneuver.
DIAGNOSTIC DATA: X-rays show very minimal CAM deformity of both hips. She does not appear to have significant crossover signs. MRI arthrogram of her right hip was reviewed from outside, but it would not load into our system. There is a suggestion of very minimal labral pathology with very minimal bony femoral neck offset issues.
IMPRESSION: As above.
PLAN: Treatment options were discussed. The patient’s symptoms and physical examination are not quite conclusive and correlated with her radiographic studies. Her back symptoms, which seem to predominate, suggested maybe her pain is being referred. We are recommending a fluoroscopy-guided injection of local anesthetic into her right hip and evaluation would be on the same day to see how the injection affects her symptoms. If her pain is completely limited by the injection, we certainly would suggest it is intra-articular in nature. We will discuss options for treatment based on her response to the injection.
