DATE OF SERVICE: MM/DD/YYYY
CHIEF COMPLAINT: Bilateral hip pain.
HISTORY OF PRESENT ILLNESS: The patient is a known patient of Dr. John Doe who is presenting for evaluation and ultrasound-guided injection in his right hip. He last had this injection in February and got about five weeks relief. He reports today that he has 10+/10 pain and that his pain is bilaterally. It goes along the anterior and posterior aspects of his pelvis and all the way down his legs.
He reports numbness in his legs down to his feet. He said he fell on Thursday because his legs gave out on him, and he thinks that he pulled his calf muscles at that time. He reports back pain as well and significant pain over the SI joint. He has difficulty telling us where his hip pain is. His says it is all equal and severe. He has been taking pain medications prescribed by his PCP and they are ineffective.
Today, he was seen by his PCP who ordered some lab work and started him on gabapentin 300 mg to titrate up the dose. He has a lumbar MRI and left hip MRI ordered by Dr. Jane Doe to evaluate this pain. He has had no recent x-rays of the lumbar spine, and his last hip x-rays were two years ago. He reports that everything makes his pain worse. He has been up all night. He reports weight loss of 20 pounds over the past year. He has got some constipation and hand shaking that is chronic.
Past medical history, medications, allergies, surgeries, family history and social history were reviewed, and there are no changes to report in the chart.
PHYSICAL EXAMINATION:
VITAL SIGNS: Height 6 feet 4 inches, weight 164 pounds, pain is 10+/10.
GENERAL: In general, he is in distress with pain, writhing on the table, unable to really sit up and participate in the conversation.
PSYCH: He is very distressed, out of sorts, unable to give correct answers to questions as far as chronology and what tests he has ordered and are pending. His significant other was helpful in this situation.
NEUROLOGIC: Sensation in the lower extremities appears to be intact, but he reports numbness. He was in too much pain to do any further neuro exam on him today.
SKIN: There is no bruising or rashes that are noted.
RESPIRATORY: No increased work of breathing.
EXTREMITIES: Extremities are well perfused.
LYMPH: No lower extremity lymphadenopathy. He was really too sore to do a deep inguinal exam to palpate for lymph nodes.
GU: No abdominal tenderness to palpation.
SPINE: Reveals tenderness to palpation over the SI joint.
MUSCULOSKELETAL: Exam is limited due to his inability to cooperate with the exam due to severe pain, but he has sensitivity just to light touch along the entire pelvis, anterior and posteriorly, down his legs bilaterally.
DIAGNOSTIC DATA: X-rays of the pelvis were reviewed and showed no signs of AVN, fracture, arthritis, dislocation or loose bodies. There are some signs of constipation and fecalith seen on examination.
ASSESSMENT AND PLAN: The patient is a known patient with a history of a right labral tear for which he has responded well to intra-articular injections in the past; however, now, he has severe new-onset pain that is concerning for autoimmune conditions or reflex sympathetic dystrophy.
We reviewed his labs, and as far as the ones that have returned from today, CBC and other markers of inflammation are relatively normal. We have ordered a pelvis MRI to reevaluate the right hip and see something has changed, to look for any signs of osteoarthritis that are not visible on x-ray or if he has signs of infection or RSD or AVN that is not showing up on x-ray. We recommend continuing with the pain medicine prescribed by Dr. Jane Doe, and we will follow up with him next week after his MRI.
