 Sample Type / Medical Specialty: Office Notes
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. Evans 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.

ALLERGIES: No know drug allergies.

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.

PLAN: I had a long discussion with the patient regarding his problem and he voiced understanding. We discussed the
    possibility of hip arthrodesis versus hip replacement versus hip resurfacing and the high likelihood that any one of
    these procedures may require further operations throughout his life secondary to his young age and high activity
    level. We discussed a referral to a hip specialist, who performs resurfacing procedures specifically Dr. Wu in
    Houston. Referral will be arranged for him. All questions were answered to his satisfaction. He was also given a
    prescription of Norco 10/325, #60 and Flexeril until he is able to arrange an appointment with a hip specialist.
