Left hip, avascular necrosis.
Left knee sprain.

We spent time today reviewing this patient's ongoing left hip pain attributable to degenerative change. Conservative measures over the preceding months — activity modification, oral anti-inflammatories, and an intra-articular corticosteroid injection — have not provided durable relief, and his function and daily activities remain limited. Given the failure of non-operative care, we discussed proceeding with total hip arthroplasty. I reviewed the operation and the expected recovery, including rehabilitation, and covered the principal risks in general terms (bleeding, infection, injury to nearby structures, blood clots, stiffness, anesthetic risk, and the possibility of incomplete relief or future hardware issues). He understood the discussion, had his questions addressed, and elected to proceed and schedule at his convenience.

Left hip pain.

73-year-old male returning for follow-up of chronic left hip pain, previously seen on 11-Jan-2023. At the earlier visit he chose to continue conservative care and was to return if symptoms worsened. He carries a known diagnosis of left hip avascular necrosis and now wishes to review surgical options. He reports no other significant orthopedic concerns today.

Constitutional: Healthy, well nourished and appears stated age.

Respiratory: Breathing is normal, no respiratory distress.

Skin: Skin shows no rashes or lesions.

Psychiatric: Alert and oriented x 3. Normal mood and affect.

Musculoskeletal: LEFT HIP: No bruising, redness, or effusion. Discomfort at the extremes of internal rotation with reduced range of motion. No tenderness over the greater trochanter. Straight-leg raise negative. Sensation grossly intact distally with normal circulation. Gait mildly antalgic.

Cardiovascular: No evidence of edema and/or varicosities. Peripheral pulses intact.

Electronically signed by: Chris (J) Reed, M.D.; Mar 8 2023 2:19PM Central Standard Time

Provider Statement: I personally performed this service and the scribe documentation accurately reflects this service.