Hip Note

Occupation:
Sport:
Involved Side:
Injury:
HPI: 25y/o female with gradually worsening right hip pain over several years. 3-7/10 groin pain. Worse with prolonged sitting and climbing stairs. Increased pain after running. Previous treatment: NSAIDs, no injections, no brace, no PT, no surgeries.
PMH:none
PSH:none
Medications:
Allergies:
SH: no tob, no ETOH
ROS: no fever, no chills, no drastic changes in weight, no bleeding problems, no metal allergies
PHYSICAL EXAM
HT: Wt:
Gait: normal
Skin / Lymph: normal, no scars
Tenderness: none
Flexion (R/L): 120 / 120
Extension (R/L): 30 / 30
Abduction (R/L): 45 / 45
Adduction (R/L): 25 / 25
Internal Rotation (R/L): 35 / 35
External Rotation (R/L): 45 / 45
No quad tightness
Seated SLR (R/L): - / -
Supine SLR (R/L): - / -
subjective normal distal sensation
5/5 EHL, TA, PF
2+ dorsalis pedis
Xray: The osseous structures are otherwise without fracture, dislocation or evidence of arthritis.
MRI: none
ASSESSMENT:
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions answered.
Physical Therapy
NSAIDS
Information sheet given
Follow-up 6-8 weeks