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M25.452 Effusion, left hip

ICD-10 Chief Complaint:

HPI: 
There is pain in the hip which has progressed to the point that it limits activity and sleep.  It is affecting daily activities.  There has not been improvement with conservative care. 
Physical Exam: 
General Appearance: Well-nourished, well developed in no acute distress.  Orientation: Oriented to person, place and time. Mood / Affect: Calm.  Gait: antalgic Coordination: normal.  Hip Exam (Bilateral). Inspection / Palpation LE (R/L): marked tenderness over greater trochanter. Reproduces symptoms.  hip pain is increased with adduction and internal rotation.  Symmetric hip ROM.  Strength LE: 5/5 EHL, tibialis anterior, plantar flexion bilaterally.  Sensation: Subjective normal distal sensation bilaterally.  Vasculature: 2+ dorsalis pedis pulse bilaterally.  LE Skin: no rashes or lesions bilaterally.  Lymph LE: no noted lymphadenopathy 
Diagnostic Studies: 
A/P pelvis and A/P and lateral of the hip were personally evaluated by me and demonstrate mild joint space narrowing. There are no irregularities or calcific deposits around the greater trochanter
Assessment: 
M25.452 Effusion, left hip
Plan: 
Discussed natural history, operative and non-operative treatments; risks, benefits and expected rehab course of each. All questions were answered. 

Category:

ICD-10: 
M25.452
ICD: 
M25

Side:

ICD-10CM Year: 
2019

ICD-10 Location: