AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |
Back to Blog
Julia jones iowa clinic9/4/2023 ![]() Hip pain, exact etiology is uncertain but this could be most likely secondary to degenerative joint disease of the hip versus mild trochanteric bursitis. On the left side internal and external rotation of the hip joints are negative. ![]() She has pain on internal rotation of the right hip joint. Straight-leg raise testing on both lower extremities is essentially negative. Extremities: She has no edema, cyanosis, or clubbing. Abdomen is obese, soft normoactive bowel sounds nontender. Cardiovascular: Normal rate and regular rhythm. Pupils are equal, round, and reactive to light and accommodation. Head and neck: Normocephalic and atraumatic. General survey: She is a middle-aged lady who is pleasant and in no acute distress. OBJECTIVE FINDINGS: Vital signs: Blood pressure is 110/70. REVIEW OF SYSTEMS: Constitutional, head and neck, chest and lungs, cardiovascular, gastrointestinal, genitourinary, and extremities are as mentioned above. She does not particularly exercise but has been watching her diet, drinking Slim-Fast once a day, and following Weight Watchers. She had a miscarriage and one stillbirth. One is 18 years old and one is 6 years old. I have established a quitting date of smoking with her. She smokes and currently one pack will last her about two weeks. She has been doing current job for about 11 years now. PERSONAL AND SOCIAL HISTORY: She is married. There is one brother who has ankylosing spondylosis. Mother is presently having high blood pressure and is taking medication for her heart. FAMILY MEDICAL HISTORY: Her father died at the age of 70 from a myocardial infarction. ALLERGIES: She otherwise has no known drug allergies. Last time was last year, which were normal. SCREENINGS: She gets a Pap smear and mammogram every year. PSYCHIATRIC HISTORY: She suffered from a major depressive disorder and anxiety. PAST SURGICAL HISTORY is remarkable for a hysterectomy due to a bicornuate uterus. She also was found to have only one kidney and this was thought to be congenital. Gastroesphageal reflux disease and has been taking medication for this but she cannot recall the name of that medication right now. PAST MEDICAL HISTORY is remarkable for: 1. She also thought that it might be related to her smoking as well. In terms of her cough, she noticed that she usually gets this whenever she has heartburn. She has been treating this with over-the-counter pain medication but has not found it to be helpful. She occasionally feels a tingling sensation at the lateral aspect of the thigh, particularly at night. She does not feel the pain as much when walking and she says that this pain sometimes radiates to the buttocks and all the way down to her heel area. Her right hip pain has been going on for about three months now, which is constant and is aggravated by standing up from sitting. She also complains of a nagging dry cough and would like to find out what might possibly be causing that. At this particular visit she is complaining of right hip pain and would also like to be weaned off her Zoloft because she is thinking that this is contributing to her increase in weight. SUBJECTIVE: This is a 42-year-old Caucasian female who presents to the clinic today to establish with me as her primary care provider. LOCATION: Outpatient, Clinic PATIENT: Julia Jones PHYSICIAN: Frank Gaul, M.D. ![]()
0 Comments
Read More
Leave a Reply. |