Initial -CCC
Note Date: 11/08/16
Signed by (ORTHOPEDIC SURGEON), MD, PHD on 11/11/16 at 3:32 pm Affiliation:
HOSPITAL
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Active Medication list as of 11/08/16:
Medications - Prescription
FLUROSEMIDE – 20 mg daily
TYLENOL – OTC as needed
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This is a first office visit to my clinic by Mr. Magoo, a very pleasant 57-year-old male patient, who sustained in 1993,
as the result of a ski accident, a pelvic fracture with vertical shear that has healed in about an inch vertical
shortening. Nevertheless, Mr. Magoo has had a remarkably active life. He exercises and has been managing very well over
the last few years until recently when he has developed some groin type pain, very reminiscent of arthritic symptoms.
Films obtained today confirmed that finding with some bone-on-bone contact and significant posttraumatic hip
osteoarthritis.

He actually has a remarkably good gait. He has overall good strength. He has pain along the groin. He has a little bit of
anterior medial pain that may be muscular in nature and even though he has a leg length discrepancy, he walks a very
normal gait on exam. His extremitya ppears to be sensory intact and well perfused. He reports the typical symptoms of
pain on initiation of motion, winter pain and pain at end of the day.

Mr. Magoo's past medical history and intake sheet was reviewed. He has a past medical history that is not relevant to his
musculoskeletal presentation and manages his pain with occasional Tylenol.

We had a long and frank conversation with Mr. Magoo. I have explained to him t hat given the nature of his hip he is at
this point, based on the radiographic standpoint, certainly a candidate for hip arthroplasty. Though, he is 57 years old
and I have explained to him that his hip if done at this age could potentially require revision before he is ready to
become more sedentary at a later age. I explained to him that ultimately it is his choice, and it is not unreasonable to
do a hip replacement at this point, but if he is comfortable and this condition is not severely affecting his lifestyle,
he would benefit from waiting.

We recommend that Mr. Magoo have full length film taken to measure the leg length discrepancy and meet with an Orthotist
to discuss a lift. Follow up with physical therapy for strength training is also recommended.

Overall, we had a nice conversation, and we will keep in touch with Mr. Magoo in the future. We spent half the time of
this new 30-minute visit discussing and counseling regarding his findings, assessing his gait and counseling regarding
the need for hip replacement.
