Assessment
Mr. Smith is a 46 y/o male with a history of HIV, hepatitis C cirrhosis, and substance abuse, presenting with bilateral hip pain.
History of Present Illness
Mr. Smith, a 46-year-old man infected with HIV and hepatitis C virus (HCV), visits you every 3 months for HIV care presenting with bilateral groin pain. He was diagnosed with HIV infection 5 years ago on routine screening, and 2 years ago, when his CD4+ cell count dropped to 350/µL, he initiated emtricitabine-tenofovir and boosted darunavir.
Since then, Mr. Smith's CD4+ cell count has been between 400/µL and 500/µL, and his HIV RNA level has been below 48 copies/mL, both of which constitute an excellent response to therapy. He also has a history of HCV infection, which he believes he acquired through heroin injection. He has never received treatment for his HCV infection.
A liver biopsy 2 years ago was consistent with cirrhosis, and clinically, he has been well compensated.
Mr. Smith states that he has had an aching pain in his groin area on both sides for the past 3 months. It occasionally radiates to his buttocks. Initially, he thought he had strained a muscle at the gym, but the pain has gotten progressively worse. It is exacerbated by physical exertion and he has tried ibuprofen, which has had minimal effect. The pain has begun to have a substantial impact on his daily life, limiting his ability to run and bicycle, which are his favorite activities. His examination is remarkable for pain that limits the range of motion at his hips.
Past Medical History
- HIV
- Hepatitis C, cirrhosis
- Asthma, mild persistent. Last severe flare 5 months ago, requiring steroids which were tapered over 3 weeks.
Past Surgical History
- None
Current Medications
- Salmeterol and fluticasone inhalers daily
- Albuterol inhaler as needed
Allergies
- None
Family History
His mother and father are alive and in good health. His father has a history of alcohol abuse, but has not had a drink in more than 30 years.
Social History
Mr. Smith is divorced and lives alone. He has been on disability for the past 20 years and has not worked. However, he volunteers at the local AIDS outreach organization as a peer mentor twice a week, and is a lay leader in his local church.
Psychiatric History
Mr. Smith has no formal psychiatric diagnosis but sees a therapist weekly for situational and life adjustment issues. When asked about his mood, he replies that he feels “mostly content.” Screens for depression (PHQ-9) and anxiety (GAD-7) performed today and at his last few visits with his primary care doctor do not suggest a mood disorder.
Substance Abuse History
Mr. Smith used heroin sporadically during his 20s and 30s, until 8 years ago, when he entered a recovery program. He was originally in a methadone maintenance program, but successfully weaned off methadone, and has been substance free since that time. He continues to be an active participant in the recovery program, even mentoring new participants. He also smoked 1 pack of cigarettes per day for several years, but quit a year into his heroin recovery. He denies a history of alcohol use.
Review of Systems
As above.
Physical Exam
Vital Signs
Temperature 98.1, Blood Pressure 100/80 Heart Rate 80, oxygen saturation 99% on room air
General appearance
Thin man, chronically-ill appearing, in no distress
Head, ears, eyes, nose, throat and mouth exam
Normocephalic, sclera anicteric, conjunctivae pale, oral mucosa moist, oropharynx clear.
Lungs
Clear to ausculation bilaterally
Heart
Tachycardic, regular rhythm, no murmurs
Abdomen
Firm, palpable liver below costal margin, no masses, no tenderness to palpation
Extremities
No cyanosis, clubbing or edema
Skin
No rashes
Musculoskeletal
Strength 5/5 upper and lower extremities. Range of motion limited by pain when flexing legs at hips bilaterally. Range of motion at other lower extremity joints normal. Shortened step length increased time with both feet on the ground, with some trouble getting onto the examination table. Patrick’s test [for sacroiliac joint pathology] negative.
Neurological
Alert and oriented, cranial nerves intact.
