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LOCATION: Outpatient, Clinic
PATIENT: Julia Jones
PHYSICIAN: Frank Gaul, M.D.
CHIEF COMPLAINT: Hip pain.
SUBJECTIVE: This is a 42-year-old Caucasian female who presentsto the clinic today to establish with me as her primary careprovider. At this particular visit she is complaining of right hippain and would also like to be weaned off her Zoloft because she isthinking that this is contributing to her increase in weight. Shealso complains of a nagging dry cough and would like to find outwhat might possibly be causing that. Her right hip pain has beengoing on for about three months now, which is constant and isaggravated by standing up from sitting. She does not feel the painas much when walking and she says that this pain sometimes radiatesto the buttocks and all the way down to her heel area. Sheoccasionally feels a tingling sensation at the lateral aspect ofthe thigh, particularly at night. She has been treating this withover-the-counter pain medication but has not found it to behelpful. In terms of her cough, she noticed that she usually getsthis whenever she has heartburn. She also thought that it might berelated to her smoking as well.
PAST MEDICAL HISTORY is remarkable for: 1. Gastroesphagealreflux disease and has been taking medication for this but shecannot recall the name of that medication right now. 2. She alsowas found to have only one kidney and this was thought to becongenital. 3. Obesity.
PAST SURGICAL HISTORY is remarkable for a hysterectomy due to abicornuate uterus.
PSYCHIATRIC HISTORY: She suffered from a major depressivedisorder and anxiety.
SCREENINGS: She gets a Pap smear and mammogram every year. Lasttime was last year, which were normal.
CURRENT MEDICATIONS: 1. Aspirin 81 mg daily. 2. Tums as needed.3. Zoloft 100 mg daily.
ALLERGIES: She otherwise has no known drug allergies.
FAMILY MEDICAL HISTORY: Her father died at the age of 70 from amyocardial infarction. Mother is presently having high bloodpressure and is taking medication for her heart. She also has highblood cholesterol. She is presently 67 years old. There is onebrother who has ankylosing spondylosis. She has a total of threesisters. One sister has a benign breast tumor.
PERSONAL AND SOCIAL HISTORY: She is married. She has been doingcurrent job for about 11 years now. She smokes and currently onepack will last her about two weeks. She denies alcohol use. I haveestablished a quitting date of smoking with her. She has a total oftwo children. One is 18 years old and one is 6 years old. She had amiscarriage and one stillbirth. She does not particularly exercisebut has been watching her diet, drinking Slim-Fast once a day, andfollowing Weight Watchers.
REVIEW OF SYSTEMS: Constitutional, head and neck, chest andlungs, cardiovascular, gastrointestinal, genitourinary, andextremities are as mentioned above. All others are negative.
OBJECTIVE FINDINGS: Vital signs: Blood pressure is 110/70. Pulserate of 88. Weight is 196 pounds. General survey: She is amiddle-aged lady who is pleasant and in no acute distress. Head andneck: Normocephalic and atraumatic. Pink conjunctivae. Pupils areequal, round, and reactive to light and accommodation. Extraocularmovements are intact. Neck is supple. No jugular venous distention.No carotid bruit. No thyromegaly. No cervical lymphadenopathy.Chest and lungs: Symmetrical expansion. Clear breath sounds. Norales or wheezes. Cardiovascular: Normal rate and regular rhythm.No murmur and no gallop. Abdomen is obese, soft; normoactive bowelsounds; nontender. No organomegaly. Extremities: She has no edema,cyanosis, or clubbing. Palpable distal pulses. Straight-leg raisetesting on both lower extremities is essentially negative. She haspain on internal rotation of the right hip joint. No pain onexternal rotation. On the left side internal and external rotationof the hip joints are negative.
ASSESSMENT/PLAN: 1. Hip pain, exact etiology is uncertain butthis could be most likely secondary to degenerative joint diseaseof the hip versus mild trochanteric bursitis. Superficial femoralnerve syndrome is also a consideration but not very likely.Discussed management with patient and we will just continue toobserve for now. I advised her to give us a call when she developsprogression of symptoms and referral to Orthopedics might beappropriate if that happens. 2. Cough, dry, probably related toheartburn symptoms. Advised her to elevate her bed at night andcontinue to take a proton pump inhibitor for heartburn and also toquit smoking at our established quitting day, nicotine dependence.3. Major depressive disorder, presently stable. She wants to beweaned off Zoloft and we are therefore decreasing her dose to 50 mgin the next two weeks and 25 mg after that. Then we will justdiscontinue it after one month. She agrees to this plan. She doesnot need to come to the clinic unless there is a new concern. Hernext possible visit would be one year from now.
