Sample Name: Hip Pain
Description: Persistent left hip pain. Left hip avascular necrosis. Discussed the possibility of hip arthrodesis versus hip replacement versus hip resurfacing
(Medical Transcription Sample Report)
CHIEF COMPLAINT: Left hip pain.
HISTORY OF PRESENT ILLNESS: The patient is a 32-year-old male seen by Dr. ABC several weeks ago for persistent left hip pain. He has a long eight to ten year history of pain into the left hip. He has been worked up by several specialists and evaluated. He was thought initially to have low back pain with radiculopathy. He does have a history of antibiotic steroid use as well as heavy drinking. He reports his symptoms started approximately eight years ago when he was doing some construction at which time he began to have left hip pain. He has had difficulties on and off ever since then. On the last visit, radiographs revealed severe degenerative changes of the left hip joint with apparent AVN of the left femoral head. He was given some pain medication and discussion took place regarding referring him to a specialist for evaluation of possible hip resurfacing versus conventional total hip replacement. He came for a second opinion in the area and we discussed his problems further. He continues to have primarily groin pain, which limits his daily activities. He has used a cane in the past for a short period and he continues to have difficulty with the left hip.
PAST MEDICAL HISTORY: Diabetes and high blood pressure.
PAST SURGICAL HISTORY: He had a history of surgery for an undescended testicle.
MEDICATIONS: Metformin, Prozac, lisinopril, Norco, and glimepiride.
SOCIAL HISTORY: The patient current smokes.
PHYSICAL EXAMINATION: Reveals significant limited internal rotation of the left hip. He essentially has 0 degrees of internal rotation compared to the contralateral hip, which has approximately 30 degrees. He has significant pain with hip range of motion. There is no significant leg length discrepancy. He has no numbness or tingling distal and 2+ pulses.
X-RAYS: Review of films taken previously reveals severe degenerative changes consistent with AVN.
ASSESSMENT: Left hip avascular necrosis.
Keywords: office notes, hip pain, radiculopathy, degenerative changes, avascular necrosis, hip resurfacing, arthrodesis, hip replacement, avn,