Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint: Briefly describe the patient’s main reason for this visit. This could include:
Hip pain (location, severity, duration)
Stiffness in the hip joint
Difficulty with activities of daily living (ADLs) due to hip pain (walking, stairs)
Worsening of previous symptoms
History of Present Illness:
Age at onset of hip pain
Progression of symptoms (gradual or sudden)
Factors that worsen pain (activity, weather)
Factors that relieve pain (rest, medications)
Any recent changes in symptoms or function
Past Medical History:
Previous injuries to the hip
Comorbid conditions (obesity, rheumatoid arthritis)
Prior surgeries (hip surgery, joint replacement)
Medications (prescription and over-the-counter) – pain medications, NSAIDs
Family History:
History of hip osteoarthritis in first-degree relatives
Social History:
Occupation (activities that may stress the hip joint)
Physical activity level
Physical Examination:
Gait assessment – limping, gait abnormalities)
Range of motion of the hip joint (flexion, extension, abduction, internal/external rotation)
Joint tenderness and point tenderness (localized pain on palpation)
Muscle strength and tone in the hip and leg
Neurologic exam (rule out nerve impingement)
Laboratory Tests:
Complete blood count (CBC) – to rule out inflammatory conditions
Inflammatory markers (ESR, CRP) – may be elevated in some cases of osteoarthritis
Imaging Studies:
X-ray (standard for diagnosis, shows joint space narrowing and osteophytes)
MRI (may be used to assess cartilage damage, soft tissue injury)
Diagnosis:
Hip osteoarthritis (specify severity based on X-ray findings)
Treatment Plan:
Non-surgical management:
Weight management (if overweight or obese)
Activity modification (avoiding activities that aggravate pain)
Physical therapy (exercises to improve strength, flexibility, and range of motion)
Assistive devices (cane, walker) as needed
Pain management medications (acetaminophen, topical NSAIDs)
Intra-articular injections (corticosteroids, hyaluronic acid) – limited use
Surgical management (considered for severe, disabling pain):
Hip replacement surgery (total hip arthroplasty)
Prognosis:
Osteoarthritis is a chronic condition, but symptoms can be managed
Discuss the importance of long-term management strategies
Patient Education:
Explain osteoarthritis and the cause of pain
Importance of weight management and exercise for joint health
Proper use of assistive devices
Safe pain management practices
Warning signs for worsening symptoms (increased pain, difficulty walking)
Next Follow-up:
Schedule for the next appointment to monitor response to treatment and address any ongoing symptoms