Level 3 Visit with Primary Diagnosis of Osteoarthritis
A 36-year-old patient presents with unilateral primary osteoarthritis of the left hip. She reports her groin pain as 7 on a scale of 1–10. When she tries to straighten her left leg, she experiences increased groin pain. She is currently taking over-the-counter medication to relieve the pain, but it does not alleviate her pain completely. She reported no weight loss or gain since her last visit. All other systems reviewed were negative.
On examination, the patient appears alert and oriented. Her vital signs are: height 5’5”, weight 242 lbs. and temperature 98 degrees. The patient is morbidly obese due to excess calories and has a body mass index of 41. Her head, eyes, ears, nose and throat exam are normal. There is no lymphadenopathy. Her lungs are clear. Her heart is at a regular rate and rhythm, with no murmurs or friction rubs; there is also good peripheral pulse. Her abdomen is soft, non-tender, no mass or hepatosplenomegaly. When seated and her left leg is lifted, she shows a moderate decrease in range of motion with mild segmented movement. An X-ray of a unilateral view of the hip is ordered. A new prescription for the pain is prescribed, and the patient is scheduled for a follow-up visit in four weeks.