Avascular necrosis of the hip

The patient comes in today for a follow-up visit. She is a 33-year-old female patient with bilateral hip pain with associated vascular necrosis in the right hip. She states her orthopedic surgeon wants to do hip replacement; however, she is not willing to do surgery at this point. In addition, she has pain going down the both lower extremities all the way down to the ankles with numbness and tingling and swelling in the right lower extremity. She had recent vascular studies, which were reported to be normal. She has had pain since 2007. It has progressively gotten worse over time. She has swelling, cramping, and shooting pains, but pain is describes as sharp, stabbing, and aching. Pain is constant and is made worse with weather and decreased with alleviating her feet. She has had some physical therapy in the past and taken pain medications. She has been taking Percocet without relief and recently given Vicodin 7.5 mg with some mild relief. She has taken Naprosyn as well as anti-inflammatory. She did have MRI of the hips. On her initial office visit, she was recommended to have MRI of the lumbar spine, which she has not had done. She denies any changes in her past medical history, past surgical history, medication history, allergies, family history, social history, or review of systems, otherwise.

DIAGNOSES:
715.95 Bilateral hip osteoarthritis.
Avascular necrosis of the hip.
724.4 Lumbar radiculopathy.

RECOMMENDATIONS:
We will recommend the patient begin physical therapy and she is going to start tomorrow as ordered by her orthopedic doctor. I think she does have hip pain, but also she has symptoms of a radiculopathy with the pain radiating down her legs to the ankles. Vascular workup was reportedly normal. So, I think she may have nerve root issue and would like to get MRI of the lumbar spine without contrast and schedule for her an EMG study of the lower extremities. For pain, I have ordered her the Norco 10/325 mg one three times per day as needed for pain and she signed medication management agreement today. I will get urine drug toxicology. We will also recommend at some point, she has DEXA scan since she was on prednisone for a number of years to ensure that there has been no bone loss that may need to be treated. We will recommend she prophylactically take calcium with vitamin D. We will see the patient back in a two-week period of time.

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