DOI: 12/12/2014. Patient is a 52-year-old female sales advisor who sustained a work-related injury when she almost fell off the toilet seat in the rest room. As per OMNI, she was diagnosed with right hip pain.
Based on the progress report dated 08/24/16, the patient presents for reevaluation regarding her right hip pain. She had her FCE done 7/6/16. She continues to complain of bilateral hip pain and is wanting the left hip checked out to rule out any other possible problems that may be causing such severe pain in the low back and pelvic region. She is having a difficult time sleeping and is requesting something to help with that. She has tried over the counter treatments such as Tylenol PM, melatonin, and benadryl. She was started on Silenor but she says she could not pick it …show more content…
The pain is better with medications and physical therapy. Past medications tired include Aspirin, ibuprofen, Cymbalta and Norco. Pas treatments tried include aquatherapy, sacroiliac joint belt, cognitive behavioral therapy, heat, ice and transcutaneous electrical nerve unit (TENS).
Review of systems is positive for night sweats, fatigue, decreased vision, ,nausea/vomiting, joint/muscle pain, joint swelling, muscle weakness/spasms, stiffness, migraines, numbness, dizziness, headaches, balanac e problems, depression, anxiety and insomnia.
On examination of the lumbar spine, there is tenderness over the lumbar paraspinals and bilateral sacroiliac joints. There is pain with lumbar flexion and extension. On examination of the hips, there is tenderness over trochanteric bursa, bilaterally.
Range of Motion of the right hip shows pain with internal rotation, and limitation of internal rotation (15-30 degrees). Left hip exam was deferred because she cannot put pressure on her right leg to move left hip. Lower extremity strength shows 5-/5 with bilateral hip flexors.
Gait is slightly antalgic, favoring the right
Based on the progress report dated 08/24/16, the patient presents for reevaluation regarding her right hip pain. She had her FCE done 7/6/16. She continues to complain of bilateral hip pain and is wanting the left hip checked out to rule out any other possible problems that may be causing such severe pain in the low back and pelvic region. She is having a difficult time sleeping and is requesting something to help with that. She has tried over the counter treatments such as Tylenol PM, melatonin, and benadryl. She was started on Silenor but she says she could not pick it …show more content…
The pain is better with medications and physical therapy. Past medications tired include Aspirin, ibuprofen, Cymbalta and Norco. Pas treatments tried include aquatherapy, sacroiliac joint belt, cognitive behavioral therapy, heat, ice and transcutaneous electrical nerve unit (TENS).
Review of systems is positive for night sweats, fatigue, decreased vision, ,nausea/vomiting, joint/muscle pain, joint swelling, muscle weakness/spasms, stiffness, migraines, numbness, dizziness, headaches, balanac e problems, depression, anxiety and insomnia.
On examination of the lumbar spine, there is tenderness over the lumbar paraspinals and bilateral sacroiliac joints. There is pain with lumbar flexion and extension. On examination of the hips, there is tenderness over trochanteric bursa, bilaterally.
Range of Motion of the right hip shows pain with internal rotation, and limitation of internal rotation (15-30 degrees). Left hip exam was deferred because she cannot put pressure on her right leg to move left hip. Lower extremity strength shows 5-/5 with bilateral hip flexors.
Gait is slightly antalgic, favoring the right