Patient is a 63-year-old female who presented with complaints of low back pain across the lower back, neck pain, right hip pain, knee pain and fibromyalgia. She was started on physical therapy, which has helped with her pain complaints. Today, we will extend her physical therapy for four more weeks. She was also given a prescription for a lumbar brace, which she states is helping also with the back pain. Mobic is not making any relief in her pain and she claims it upset her stomach. We will change the Mobic to a different medication. Despite the physical therapy and the conservative management, she complains that the right hip pain is still bothering her to the point that it interferes with her enjoyment of life and activities of daily living. I discussed with her the performance of injection of steroids in her right hip in order to attempt to decrease the pain and this way improves the effectiveness of the therapy. I discussed with her at length the risk, benefit, alternatives and technical aspect of this procedure. She understands and agreed to proceed.
3. Lumbar facet joint arthropathy.
4. Myofascial pain/fibromyalgia.
5. Right hip bursitis.
6. Knee enthesopathy.
1. We will continue the physical therapy for four more weeks at three times a day.
2. Tramadol 50 mg one tablet p.o. q.8h. as needed. A prescription for 60 tablets was given.
3. Right hip injection of steroids and local anesthetic will be performed under fluoroscopic guidance and mild sedation at the surgical center. We discussed the performance of this procedure including the risk, benefit, alternative and technical aspects. Questions were answered and the patient is agreeable.
4. She will follow up in this office in one week after the procedure.
5. Continue the use of the lumbar support.