My 2010 *MEDICAL* History

Hey everyone.  I've decided to share my medical record notes below.  This is the more "technical" notation taken by doctors and physical therapists in 2010 while I was at UCLA.

JUNE 15, 2010:  SPORTS MEDICINE VISIT

SUBJECTIVE

24 y/o with L groin pain.

Small improvement since last visit.  Went running on beach, no pain.  Less pain getting in and out of car.

Adductors don't feel weak.

Pain is medial groin on L, doesn't radiate to medial thigh.  Is not burning or electric sensation.

Pain with L leg adduction.

(+) h/o pain and stiffness in adductor region in morning, now better

(-) pain with coughing/sneezing

OBJECTIVE

NAD

ttp just distal to R pubic symphysis on proximal adductor tendon.  (-) conjoint tendon tenderness. (-) hernia appreciated in superficial inguinal ring. (-) ttp at pubic symphysis or at rectus abdominus attachment.

(-) pain with sit-up

(+) pain with resisted adduction L medial thigh

Sensation normal over medial L thigh

5/5 strength hip adduction, abduction bilaterally in seated and supine position

ROM o-135 hip flexion, 10 of IR in full flexion and 50 ER in full flexion.  No pain with these movements.

(-) FADDIR

ASSESSMENT

24 y/o man with 6 months L groin pain.  Most c/w sports hernia.  Also in ddx = obturator neuropathy however no adductor weakness on exam so less likely.  Adductor attachment and pubic symphysis appear normal on recent MR arthrogram (though limited because can only see in coronal sections per radiologist).  Slight labral tear but patient's sxs do not support primary diagnosis of intraarticular pathology.  Overall he is gradually improving, though slowly.

Diagnosis

GROIN INJURY

MAY 15, 2010:  SPORTS MEDICINE VISIT

INITIAL ASSESSMENT

Reason for consultation:  left groin pain x's 5 months

SUBJECTIVE

24 y/o man here with L groin pain.

Started 12/09.  2/10 persisted --> Told not a hernia, dx'd with pulled groin.

PT since 2/10 but PT wondering if had MRI b/c injury persisting.

No swelling, no acute injury.  Dancer, noticed pain with practice over time.

+ click during stretching a couple weeks ago, happend 2x, painless, felt deep

pain when wakes up in morning, stretching

pain getting in and out of car, with lateral motion of hip

hurts worst with active adduction on theraband adduction

Goal = return to dance.  hip hop.

Otherwise was training gymnastics, contortion, chinese acrobatics

(-)  nighttime  awakening

(-) weight loss, except with hard training 2009, dropped 20-30#, was training a lot, then injured.

Eats 6 meals a day, no h/o eating d/o. No anorexia, bulemia.  Drinks milk.  Unsure if has fhx osteoporosis.

Meds: ibuprofen OTC.

Overall has had improvement with PT but cannot return to his sports.  Minimal daily activity.

OBJECTIVE

NAD

Palpation: nontender lateral hip, nontender at ASIS, AIIS, tender just distal to L pubic symphsis with resisted adduction L hip.  Worse with sit-up.

Seated IR L 25, R 30, no pain.  ER 60 bilaterally.

Supine minimal IR bilaterally

Strength 5/5 hip flexion, knee ext, pain with resisted adduction, no pain with abduction

Sensation intact light touch B LE

(-) FABER bilaterally

(-) FADDIR B

(-) SLR B

(-) inguinal LAD

ASSESSMENT

L groin pain, ddx includes adductor strain, rectus strain, less likely intraarticular give (-) FABER, (-) FADDIR however could be labral tear given lack of improvement with PT after 2-3 months and decreased IR.  Sports hernia also in ddx but dx of exclusion.

Diagnosis

GROIN PAIN

APRIL 28, 2010:  PHYSICAL/OCCUPATIONAL THERAPY - PROGRESS REPORT

SUBJECTIVE

1/10.  usually when wake up in morning.  can adduct v. yellow band without pain.  feels it pinch a little while walking around campus.

OBJECTIVE

L groin pain reproduced with Adduction

PT / OT FUNCTIONAL ASSESSMENT

poor posterior hip glides, poor SIJ stability.  pt instructed to start planks for increasing strength of pelvic stabilizers.

check leg length.  foam roll marching.  squats on balance board.  lunges.

MUSCLE STRAIN, GROIN

APRIL 20, 2010:  PRIMARY CARE VISIT

INITIAL ASSESSMENT

Reason for visit: f/u groin pain

SUBJECTIVE

no known drug allergies

OBJECTIVE

Vitals

BP - 108/61; Temp=98 F Oral; Pulse=72; Resp=16

ASSESSMENT

physical therapy x 6 SX same.  Pt doing no exercise at all since 12/09, gained 8 lb.

SX same:  Pain L groin, mild, lasts seconds, 10-15 x day.  SX still brought on with lat abduction L leg like hold door open with foot.

Physical therapy suggest pt needed MRI.

Will get sports med evaluation.  Again discussed with pt.

Pt should not "baby" self but resume usual ADLs as I told him last appt.

Diagnosis

GROIN PAIN

APRIL 10, 2010:  PHYSICAL/OCCUPATIONAL THERAPY - PROGRESS REPORT

SUBJECTIVE

0/10. Pain was worse over the last few weeks moving and cleaning apartment.  Didn't do exercises for a week.

OBJECTIVE

Needs to return to break dance:  L leg is power leg with head spin.

hip resting anterior and in external rotation

PT / OT FUNCTIONAL ASSESSMENT

poor hip arthrokinematics and adductor strain.  Adductor tightness when established correct hip position.  Pain with active adduction today.

plan: continue clocks and strengthening.

MUSCLE STRAIN, GROIN 

MARCH 15, 2010:  PHYSICAL/OCCUPATIONAL THERAPY - PROGRESS REPORT

SUBJECTIVE
woke up in AM yesterday without pain.  Today it did hurt in hip 2/10 when stretching in the AM.  Not having pain when getting out of the car.

PT / OT FUNCTIONAL ASSESSMENT

Symptoms improvement noted with improved activity tolerance.  Improved ability to recruit core muscles while moving the leg, even when unsupported.  Able to progress to more challenging stabilization exercises in a functional context related to patient's dance form to assist in return to such activities with good core recruitment and less strain on groin.

MUSCLE STRAIN, GROIN

MARCH 10, 2010:  PHYSICAL/OCCUPATIONAL THERAPY - PROGRESS REPORT

SUBJECTIVE
1/10 twinges of pain with running.  Hurts with stood up straight.

pt injured left groin - seeing PT - going twice weekly

PT / OT FUNCTIONAL ASSESSMENT

Poor pelvic stabilization and weakness in psoas and pain in Adductors delating healing process.

Plan:  pelvic stabilization and hip flexor strengthening progress hip adductors isometrically and then conc/ecc when tol

MUSCLE STRAIN, GROIN  

FEBRUARY 20,  2010 PHYSICAL/OCCUPATIONAL THERAPY - PROGRESS REPORT

ICD Coed(s):  MUSCLE STRAIN, GROIN

SUBJECTIVE EXAMINATION

CURRENT / PREVIOUS HISTORY

L groin pain with Abduction L leg x 6 wk.  Dance (tumbling, hip-hop, hand balancing) & gymnastics

Onset: Dec.  Nov started using martial arts stretching machine and was doing this a few times a week for a couple of months for 20 min (to help splits)

Mechanism:  once after practice noticed pain, still danced after a week

1/10 now

PLOF: T, THR gymnastics, 2-4x/week dance class

If he tried to dance it would be a 10/10

BEHAVIOR OF SYMPTOMS

Aggravates (activity, posture, severity, duration):

dancing (windmills with legs in full abduction)

Eases (activity, posture, duration):

not using it (ibuprofen)

Morning pain: hurts more in the AM when stand up

Day pain:  decreases after moving around

Night pain:  pain rolling around in bed

GENERAL HEALTH

Medications:  ibuprofen

Special Questions:  no other hip/knee injuries, denies other medical conditions

OBJECTIVE EXAMINATION

stands in slight hip external rotation

CLINICAL ASSESSMENT

Pt is a 24 yo male with groin pull from doing hip hop dance (head spins) and martial arts stretching (with a crank machine).  Pt presents with pulled groin, poor hip mobility into internal rotation and poor hip capsule motor posterior.  Pt would benefit from hip flexor stretches.  DTM for tissue healing, and glute strengthening and hip stretches to improve internal rotation.

Rehab Potential  Excellent

 
FEBRUARY 10, 2010 MEN'S HEALTH EVALUATION

Patient dances and does gymnastics.  Pain L groin onset late December.
Intensity: mild
Character: pinching
Duration: second
Frequency: approximately 15 x day and with gymnastics
No radiation SX.
No previous SX.
No new ADL's or exercise program
SX brought on with ADL's lat abduction L leg like getting on bike or hold door open with foot
SX improved with ice & ibuprofen.

Alert, no distress.
Back FAROM no SX
No pain palpation bilaterally over trochanteric bursa or hip
R hip FPROM no SX, L FRPOM pain on external rotation (miniman int rotation)
Knee bilateral FPORM no pain.  Pain with abduction knees against resistance but not adduction.
Gait normal.
No SX with squat.
Genital: both testes normal without tenderness, masses, hydroceles, varicoceles, erythema or swelling.
No inguinal hernia noted.  No inguinal lymphadenopathy, mass or tender to palpation.

Defer X ray at this time as not change management
Continue PRN ice and ibuprofen

Diagnosis:  MUSCLE STRAIN, GROIN
Referred to : Physical Therapy