[doctor] good morning ms. reyes !
[patient] good morning .
[doctor] how are you doing ma'am ?
[patient] i'm doing well doctor , how are you ?
[doctor] i am fine thank you . so you've been having some problems with your right hip ?
[patient] yeah .
[doctor] okay , and where are you hurting ? can you show me ?
[patient] right in the groin area .
[doctor] okay , and this has been going on since february 2020 ?
[patient] yeah .
[doctor] okay . and is it worse with movement ?
[patient] well when it catches and i almost fall , yeah .
[doctor] okay . so it kinda grabs you ?
[patient] yeah .
[doctor] okay , and this all started when you were walking ?
[patient] well , walking around the infusion room .
[doctor] okay .
[patient] so it started if i took a step back or , you know , stuff like that . now it happens anywhere .
[doctor] okay , so now it hurts whenever you move ?
[patient] it hurts when i pivot .
[doctor] okay . so if you pivot then it hurts , got it . um ...
[patient] anything can sometimes do it . sometimes it wo n't though , and sometimes it'll do it several times in a row .
[doctor] several times in a row , okay .
[patient] and sometimes i fall .
[doctor] okay . and you rate the pain to range from two through seven out of 10 ?
[patient] yeah , that's correct .
[doctor] okay . and are you experiencing fever or chills ?
[patient] no .
[doctor] okay . and any tingling or numbness ?
[patient] 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 ?
[patient] yes , but i do n't want to stay still .
[doctor] i understand , no problem . and for past medical history , do you have anything going on ?
[patient] i've had a lot of surgeries . i've had pcl , i had infertility , a gall bladder removed , but that's it .
[doctor] okay . and for family history , it looks like there's high blood pressure , diabetes , 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're allergic to percocet , vicodin and regulin . and it looks like you've had intentional weight loss ?
[patient] yes , i've lost 110 pounds .
[doctor] that is awesome . and how did you do that ?
[patient] with weight watchers .
[doctor] that's great .
[patient] mm-hmm .
[doctor] and how many months have you been participating in weight watchers ?
[patient] i started in 2018 , and i've been at my current weight for a little over a year .
[doctor] that is awesome .
[patient] yeah , thank you .
[doctor] yeah , very good , and congratulations . and so , for social history , it looks like you work at an infusion center ?
[patient] yes , over at .
[doctor] okay . and you live with your roommate , no history of tobacco and you limit alcohol intake to less than five drinks per month .
[patient] that's correct .
[doctor] all right . well let's go ahead and take a look at your hip .
[patient] okay .
[doctor] please use my general physical exam template . physical exam . ms. reyes is a pleasant 56-year-old woman who is five feet , six inches in height , weighing 169 pounds . blood pressure is 115 over 75 . pulse rate is 67 . ankles , no ankle edema is noted , no calf tenderness . okay , ms. reyes , can you go ahead and stand up for me please and take a couple of steps ? great .
[patient] okay .
[doctor] and can you walk on your tippy toes ? good , okay . and can you walk on your heels ? kind of a heel walk and toe walk are intact . um , go ahead and turn around please .
[patient] okay .
[doctor] 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 , then 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 palpitation . go ahead and lean back . and lean to your right , to your left . does that hurt at all ?
[patient] no .
[doctor] okay , great . and go ahead and bend forward and then come back up . and that does n't bother you ?
[patient] no . i did or do have several bulging discs .
[doctor] okay . but you're not hurting right now ?
[patient] no , the weight loss has really decreased all the pain .
[doctor] okay . range of motion is decreased in exertion . lateral flection without pain . any pain when i push ?
[patient] no .
[doctor] okay . you can go ahead and , um , sit down please . no pain ?
[patient] no .
[doctor] okay . sacroiliac signs are negative . examination of the hips . trochanteric is non tender . go ahead and lift your knee up , does that bother you ?
[patient] um , just a little bit .
[doctor] okay , little bit . and then back one , probably bothers you ?
[patient] right there , like there , yeah .
[doctor] okay . how about this way ? not too bad ?
[patient] no .
[doctor] okay . range of motion is decreased in right hip with pain in the groin and internal and external rotation . okay , go ahead and keep it up , do n't let me push it down . does that hurt ?
[patient] right there .
[doctor] okay . resisted right hip flection causes pain in the right groin region . no tenderness is noted . do you feel me touching you all the way down ?
[patient] yeah .
[doctor] 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 . you can go ahead and sit up now .
[patient] okay , thank you .
[doctor] you're welcome . so what i think we're dealing with is right hip degenerative joint disease .
[patient] okay .
[doctor] and we do have some options . so first is to start some low impact exercises . i can provide you with a hand out 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 .
[patient] hmm , i do n't love that idea but i'll give it a try .
[doctor] 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 .
[patient] i would like to definitely get the injection .
[doctor] okay . we can take care of that today while you're here and then schedule a follow up appointment in three months to see how you're doing , and then receive another injection if needed .
[patient] okay , that sounds good .
[doctor] okay . and here are the risks associated with getting the inje- injection . um , please just take a moment to review it and consent to the shot .
[patient] i'm good .
[doctor] great . we'll get that set up for ya . all right , well i hope things , um , feel better , and we will see you back here in three months .
[patient] see you . have a nice day .
[doctor] thank you so much , you as well . deep tendon reflex is one plus throughout . no focal motor weakness is noted . no focal sensory deficit noted . can you please include the surgical list ? next radiographs , mr arthrogram of the right hip done june 3rd 2021 show high grade condromalacia involving the interosuperior right acetabulum with subchondral marrow edema and cyst formation . next paragraph plan . options include low impact exercise program , use of an nsaid and use of a cane to offload the right . we discussed that she'd like to proceed with the 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 . she will follow up with me in three months for another injection if needed . end of dictation .

Medical orders:
description: nsaids
order_type: medication
reason: right hip degenerative joint disease