Elizabeth Katz

CUNY York PA – S

Chief complaint: left hip pain x 5 years

HPI

57 y.o M PMH osteoarthritis and gout presented to clinic c/o left hip pain. He states that he has had the pain for a number of years but it has become so severe over the past year that he is unable to walk more than 2-3 blocks. The pain is described dull and intermittent over the anterior groin with radiation to the thigh and left knee, is an 8/10 and is made worse with standing, stairs and walking. He takes ibuprofen with minimal symptom relief. The patient reports that he currently needs the support of a cane to walk and has difficulty with certain tasks of daily living such as taking stairs, using public transportation and putting on socks and shoes. He denies a hx of falls or trauma, CP, SOB, dizziness, back pain, dysuria or change in bowel habits.

PMH

Osteoarthritis

Gout

PSH

none

Medications

Methocarbamol 500mg QID

Ibuprofen 600mg q 6-8 h prn

Allergies

NKDA

FHX

Father: deceased at 72, MI

Mother: alive, HTN DMII

SHX

He is unmarried and lives in a shelter. He denies tobacco or illicit drug use and admits occasional alcohol use.

ROS

• Constitutional: denies fatigue, fever, chills or recent change in weight
• HEENT:
• Eyes: no recent changes in vision, photophobia, or glasses use
• Ears: hearing intact
• Nose: no epistaxis or obstruction
• Mouth and throat: no ulceration, hx of candidiasis, no recent dental visit
• Neck: no lumps, localized swelling or stiffness
• Respiratory: no SOB, cough, wheezing, hemoptysis, PE, pneumonia, TB or TB exposure
• Cardiac: no recent CP, palpitations, edema of hands or feet, syncope, known murmur
• Vascular: no hx of claudication, gangrene, DVT, aneurysm
• GI: denies abdominal N/V, change in bowel habits or BRBPR
• GU: denies urinary frequency and urgency, dysuria, hematuria, polyuria, or nocturia
• Hematological: no known blood or clotting disorders
• Rheumatic: known hx of gout, denies rheumatic arthritis, or lupus
• Dermatological: no new rashes or pruritus

PE

• VS: BP 137/72 left arm, sitting position; pulse 82 regular; O₂sat 99% room air; respirations 16/min; temp 98.4°F oral; weight 101.3 kg
• Patient is alert and oriented x 3, appears stated age and is resting comfortably
• HEENT: normocephalic atraumatic
• Neck: trachea midline, carotids 2+ b/l
• Heart: regular rate and rhythm, no heaves, gallops, murmurs
• Lungs: CTA bilaterally, no retractions
• Abdomen: soft, nontender to palpation, no CVA tenderness
• Extremities: no edema LE b/l, distal pulses intact
• Left hip – tenderness over anterolateral hip; ROM painful; extension 0, flexion 60, internal rotation 0, external rotation 10, abduction 10, adduction 5; muscle strength could not be ascertained due to pain; gait antalgic
• Right hip – no tenderness noted, extension 5, flexion 90, internal rotation 30, external rotation 50, abduction 40, adduction 30
• Skin: moist, good turgor, cap refill < 2 sec

Labs:

• CBC, BMP, PT/PTT: wnl
• Nasal culture: MSSA+

Imaging:

• DX pelvis: IMPRESSION – severe left hip osteoarthritis and mild right hip osteoarthritis, similar to the prior exam

Assessment: 57 yo M c/o left hip pain x 5 years with severe osteoarthritis schedule for left hip total arthroplasty without navigation.

1Plan

• Schedule for left hip total arthroplasty without navigation under general anesthesia
• Obtain consent
• CXR
• EKG
• CBC, BMP, PT/PTT, T&S