DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Follow up left groin pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old baseball player seen in followup consultation for evaluation of left groin pain secondary to athletic pubalgia. Overall, he states he continues to remain symptomatic. He denies any recent injury or trauma. Symptoms are aggravated with activity and improved with rest. The patient denies any numbness, tingling or weakness.
PAST MEDICAL HISTORY, MEDICATIONS, AND ALLERGIES: Reviewed and updated.
SOCIAL HISTORY: As noted above.
FAMILY HISTORY: Noncontributory.
REVIEW OF SYSTEMS: Full review of systems performed and found to be negative other than as noted above.
PHYSICAL EXAMINATION:
GENERAL: Well-appearing, in no apparent distress male who is alert and oriented x3. No evidence of respiratory distress.
MUSCULOSKELETAL: Left hip demonstrates tenderness at the insertion of the conjoint tendon into the pubic tubercle. Hip is otherwise nontender. Full strength and range of motion is present. Negative FADIR test. Negative straight leg test. There is no palpable lymphadenopathy. Bilateral lower extremity skin as well as neurovascular status is intact with no evidence of skin changes, sensory changes or lower extremity edema.
IMAGING: Musculoskeletal ultrasound performed at time of office visit demonstrates no evidence of ilioinguinal tendon tear. There is cortical irregularity noted at the insertion into the pubic tubercle.
ASSESSMENT AND PLAN: Left-sided athletic pubalgia. Given persistence of symptoms despite conservative management, the patient underwent a left ilioinguinal ligament tendon insertion site injection at the pubic tubercle in office today.
Procedure was performed utilizing sterile technique after risks and benefits were reviewed. Ultrasound guidance and Doppler imaging was utilized throughout. Risks reviewed included but were not limited to potential risk of infection, injury to local joint as well as neurovascular structures, potential risk of worsening pain as well as worsening of function. Under direct ultrasound visualization, 2 mL of Depo-Medrol and 6 mL of bupivacaine was injected utilizing a lateral approach after area was anesthetized with 3 mL of 1% lidocaine. Care was taken to avoid all associated neurovascular structures. The patient tolerated the procedure well, and there were no complications.
Plan is to avoid all heavy impact activity over the next two weeks. The patient may initiate light cross training in two weeks followed by graduated progression to full running activities over the following two weeks. The patient will use ice and Tylenol as needed for post procedure soreness.
The patient will follow up via phone with the office in three weeks to update on progress or sooner on an as-needed basis. All of the patient’s questions were addressed at the time of office visit.
