|
HISTORY:
(firstName) presents to the office today for a follow up visit concerning (his_her) {right | left} hip symptomatology.
{The patient denies any injuries subsequent to their previous visit. | The patient denies any injuries since their last visit. | The patient denies any injuries subsequent to their initial injury. | The patient notes that there was a new injury since their last visit to this office. {NEW INJURY LOCATION} {NEW INJURY SPECIFIC} | | The patient notes that there was an additional injury subsequent to their initial injury, but prior to today.} {The patient notes that there has been some modest improvement in their condition since the previous visit. | | The patient notes that there has been no improvement in their condition since the previous visit. | The patient notes that there has been no change in their condition since the previous visit. | The patient notes that there has been worsening in their condition since the previous visit. | There has been a complete resolution in the symptoms since the last visit.} {Chiropractic therapy has been continued since the last visit and has been found to be helpful. | Chiropractic therapy has been continued since the last visit but, unfortunately, has not been helpful. | Chiropractic therapy has been discontinued since the last visit. | Physical therapy continues to be undertaken, and has been helpful. | Physical therapy continues to be undertaken, but unfortunately has not been helpful. | Physical therapy has been discontinued since the last visit. | There is no therapy currently being performed. | The patient has been compliant with their therapy program. | The patient has been not been compliant with their therapy program. | The patient has continued therapy with some relief.} {Celebrex is being used, without difficulty, and with good results. | The patient will be changed to Mobic 7.5 mg 1 TAB PO QD. | Celebrex is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with fair results. | Vioxx is being used, without difficulty, with good results. | Ibuprofen has been utilized with good results. | | Anti-inflammatory medications have been discontinued because of gastro-intestinal complications. | Anti-inflammatory medications have not been utilized because of a past history of gastro-intestinal difficulties. | | Advil | Aspirin | Accupril | Accutane | Adalat CC | Allegra | Augmentin | Axid | Azmacort | BuSpar | Calan SR | Cardizem CD | Cardura | Claritin D | Clozaril | Cordarone | Coumadin | Daypro | Depakote | Dilacor XR | Dilantin | Flonase | Fosamax | Glucophage | Humulin 70-30 | Humulin NPH | Hytrin | Imdur ER | Imitrex | K-Dur | Lamisil Oral | Lanoxin | Lescol | Lipitor | Lodine | Lotensin | Mevacor | Norvasc | Ortho-Novum | Oruvail | Paxil | Pepcid | Pravachol | Premarin | Prempro | Prevacid | Prilosec | Prinivil | Procardia XL | Propulsid | Prozac | Relafen | Rezulin | Risperdal | Serevent | Serzone | Sporanox | Synthroid | Ticlid | Toprol XL | Trental | Trtiphasil | Ultram | Vasotec | Zantac | Zestril | Ziac | Zocor | Zoloft | Zovirax | Zyprexa | Zyrtec} {The patient has been working. | The patient has been working at full duty. | The patient has been working at full duty, but is having problems with the current work load and needs new restrictions imposed. | The patient is not currently employed, but anticipates starting a new job in the near future. | The patient has been working at light duty, but feel ready to begin unrestricted duty after today's evaluation. | The patient has been working, but at a restricted duty. | The patient has not been working at all.}
{No additional studies are available for today's visit. | The patient presents to the office today with an MRI of the lumbar spine. The results show evidence of frank disc herniation at the level of {HNP L-SPINE}. | The patient presents to the office today with the results of EMG-NCS of the RLE. The results show evidence of radiculopathy at the level of {HNP L-SPINE}. | The patient presents to the office today with the results of EMG-NCS of the LLE. The results show evidence of radiculopathy at the level of {HNP L-SPINE}. | An MRI is available for review during today's visit. | An MRI is available for review during today's visit of the left hip, which reveals evidence of avascular necrosis of the femoral head. | An MRI is available for review during today's visit of the right hip, which reveals evidence of avascular necrosis of the femoral head. | A bone scan is available for review during today's visit of the right hip, which reveals evidence of a pathologic fracture to the femoral head. | A bone scan is available for review during today's visit of the left hip, which reveals evidence of a pathologic fracture to the femoral head. | A bone scan is available for review during today's visit of the left hip, which reveals evidence of a pathologic fracture to the femoral neck. | A bone scan is available for review during today's visit of the right hip, which reveals evidence of a pathologic fracture to the femoral neck. | A bone scan is available for review during today's visit of the right hip, which reveals evidence of a pathologic fracture to the trochanteric region. | A bone scan is available for review during today's visit of the left hip, which reveals evidence of a pathologic fracture to the trochanteric region. | A bone scan is available for review during today's visit of the left hip, which reveals evidence of a pathologic fracture to the sub-trochanteric region. | A bone scan is available for review during today's visit of the right hip, which reveals evidence of a pathologic fracture to the sub-trochanteric region. | An MRI report is available for review during today's visit. | An EMG report is available for review during today's visit.}
PHYSICAL EXAMINATION:
{The right hip range of motion is noted to be diminished in all planes and is consistent with previous examinations. | The left hip range of motion is noted to be diminished in all planes and is consistent with previous examinations. | The left hip range of motion is noted to be normal in all planes of movement. | The right hip range of motion is noted to be normal in all planes of movement. | The left hip range of motion is observed as follows:
Left Hip Flexion- {HIP FLEXION} degrees.
Left Hip Extension- {HIP EXTENSION } degrees.
Left Hip Adduction- {HIP ADDUCTION} degrees.
Left Hip Abduction- {HIP ABDUCTION} degrees.
Left Hip Intern | The right hip range of motion is observed as follows:
Right Hip Flexion- {HIP FLEXION} degrees.
Right Hip Extension- {HIP EXTENSION } degrees.
Right Hip Adduction- {HIP ADDUCTION} degrees.
Right Hip Abduction- {HIP ABDUCTION} degrees.
Right Hip}
{The motor function in both lower extremities is within normal limits. | The motor function in both lower extremities is noted to be diminished. | The motor function in the RLE is noted to be diminished. | The motor function in the LLE is noted to be diminished. | The motor function in the LLE is noted to be severely diminished. | The motor function in the RLE is noted to be severely diminished. | The motor function in the RLE is noted to be severely diminished with obvious muscle atrophy. | The motor function in the LLE is noted to be severely diminished with obvious muscle atrophy.} { | Reflexes in both lower extremities are noted to be equal and symmetrical. | Reflexes in both lower extremities are noted to be diminished. | Reflexes in both lower extremities are noted to be severely diminished. | Reflexes in both lower extremities are noted to be absent. | Reflexes in the LLE are noted to be absent. | Reflexes in the RLE are noted to be absent. | Reflexes in the RLE are noted to be diminished. | Reflexes in the LLE are noted to be diminished. | Reflexes in the LLE are noted to be hyper-reflexive. | Reflexes in the RLE are noted to be hyper-reflexive.} {On palpation of the right hip, tenderness is noted over the greater trochanteric bursa. | On palpation of the left hip, tenderness is noted over the greater trochanteric bursa. | On palpation of the right hip, tenderness is noted in the inguinal region with internal and external rotation. The patient also has pain with standing and ambulation. | On palpation of the left hip, tenderness is noted in the inguinal region with internal and external rotation. The patient also has pain with standing and ambulation. | On palpation of the left hip, tenderness is noted in the inguinal region with internal and external rotation. | On palpation of the right hip, tenderness is noted in the inguinal region with internal and external rotation. | On palpation of the paralumbar region, tenderness is noted at the level of L5-S1 bilaterally. | On palpation of the paralumbar region, tenderness is noted at the level of L5-S1 on the right side only. | On palpation of the paralumbar region, tenderness is noted at the level of L5-S1 on the left side only. | On palpation of the paralumbar region, tenderness is noted to be present throughout the thoracolumbar junction bilaterally. | On palpation of the paralumbar region, tenderness is noted to be present throughout the thoracolumbar junction on the right side. | On palpation of the paralumbar region, tenderness is noted to be present throughout the thoracolumbar junction on the left side. | On palpation of the paralumbar region, tenderness is noted to be present in the right sacroiliac joint. | On palpation of the paralumbar region, tenderness is noted to be present in the left sacroiliac joint. | On palpation of the paralumbar musculature, spasm is noted to be greater on the left. | On palpation of the paralumbar musculature, spasm is noted to be greater on the right. | On palpation of the paralumbar musculature, spasm is noted to be present bilaterally.} {Spasm is noted in the paralumbar musculature at the level of L5-S1 bilaterally. | Spasm is noted in the paralumbar musculature at the level of L5-S1 on the right side. | Spasm is noted in the paralumbar musculature at the level of L5-S1 on the left side. | Spasm is noted in the right thoracolumbar junction. | Spasm is noted in the left thoracolumbar junction. | Severe spasm is noted in the left thoracolumbar junction. | Severe spasm is noted in the right thoracolumbar junction.} {Sensory examination of the lower extremities is normal. | Sensory examination in the lower extremities is diminished. | Sensory examination in the lower extremities is severely diminished. | Sensory examination in the lower extremities is absent. | Sensory examination in the lower extremities is hyper-responsive to light touch. | Sensation to pin prick and light touch in the right lower extremity is diminished. | Sensation to pin prick and light touch in the left lower extremity is diminished. | Sensation to pin prick and light touch in the left lower extremity is severely diminished. | Sensation to pin prick and light touch in the right lower extremity is severely diminished.} { | The vascular status in both lower extremities is normal. | The vascular status in the RLE is diminished. | The vascular status in the LLE is diminished. | The vascular status in the LLE is severely compromised and the patient will require a vascular consult. | The vascular status in the RLE is severely compromised and the patient will require a vascular consult. | The vascular status in BLE is severely compromised and the patient will require a vascular consult.}
DIAGNOSIS:
{Right Trochanteric bursitis. | Left Trochanteric bursitis. | Left Hip Degenerative Joint Disease. | Right Hip Degenerative Joint Disease. | Right Hip Avascular Necrosis. | Left Hip Avascular Necrosis. | Left Hip Fracture. | Right Hip Fracture. | Right Hip Femoral Neck Fracture. | Left Hip Femoral Neck Fracture. | Left Hip Femoral Head Fracture. | Right Hip Femoral Head Fracture. | Right Hip Intertrochanteric Fracture. | Left Hip Intertrochanteric Fracture. | Left Hip Sub-trochanteric Fracture. | Right Hip Sub-trochanteric Fracture. | Right Hip Contusion. | Left Hip Contusion. | Left Hip Status Post ORIF. | Right Hip Status Post ORIF.}
PLAN:
{The patient has been advised to continue with therapy and anti-inflammatory medications as directed. | The patient has been instructed on a general conditioning program consisting of Thera-band exercises and strengthening of the adductors and abductors. | The patient has been instructed to discontinue use of anti-inflammatory medication due to GI disturbances. | The patient will be scheduled for an MRI of the lumbar spine to rule out disc pathology. In the mean time, the patient will continue with therapy and anti-inflammatory medications as directed. | The patient will be scheduled for in-patient ORIF of the right hip fracture and be followed in the office according to standard post operative protocol. | The patient will be scheduled for in-patient ORIF of the left hip fracture and be followed in the office according to standard post operative protocol. | The patient will be scheduled for in-patient THR on the right side and be followed in the office according to standard post operative protocol. | The patient will be scheduled for in-patient THR on the left side and be followed in the office according to standard post operative protocol. | The patient will be scheduled for in-patient Hemiarthroplasty on the left side and be followed in the office according to standard post operative protocol. | The patient will be scheduled for in-patient Hemiarthroplasty on the right side and be followed in the office according to standard post operative protocol.} {I would recommend that there be no limitation in the work activities at this point in time. | I would recommend that this patient be maintained at a light duty work status. | I would recommend that this patient be maintained at a moderate duty work status. | I would recommend that this patient be maintained at a sedentary work status consisting of administrative type task only. | I would recommend that this patient be maintained at a sedentary work status. | Since this patient still has symtomatology, I would recommend that they continue working, but only within their pain tolerance. | The patient is going to attempt a resumption of their current occupation with the understanding the an adjustment in work status may be required if the task prove to be difficult or painful.} {I have asked this patient to return to the office in 1 week. | I have asked this patient to return to the office in 2 weeks. | I have asked this patient to return to the office in 3 weeks. | I have asked this patient to return to the office in 4 weeks. | I have asked this patient to return to the office in 4 weeks, at which time the patient will likely be placed a MMI. | I have asked this patient to return to the office in 6 weeks. | I have asked this patient to return to the office in 8 weeks.}
|
