Acute intertrochanteric fracture of right hip. The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert & oriented x 3 with reasonable thought content. She understood questions well and was in no acute distress. CHIEF COMPLAINT Right hip injury. HISTORY OF PRESENT ILLNESS I was called to see this 69-year-old black female patient, well known to me, who was brought to the ER after she sustained an injury of her right hip. She states she was walking when her right leg “gave out” and she fell onto the right hip.
She complained of mild pain in the right hip and mild edema was noted in the ER. In addition, she had external rotation of the right leg. Initial x- ray demonstrated finding of intertrochanteric fracture non-displaced of the right hip. Consultation was obtained from Dr. Dodd who concurred with the diagnosis and treatment recommendations were made. She was subsequently admitted to the hospital for further evaluation and treatment including surgical repair of the hip. PAST MEDICAL HISTORY Usual childhood diseases. She denies previous rheumatic fever or polio.
The only surgical procedure was an apendectomy in the past and repair of a fractured left hip in approximately 1993. SOCIAL HISTORY She lives at home with her husband who is rather feeble. Denies the use of tobacco or alcohol. FAMILY HISTORY Non-contributory. REVIEW OF SYSTEMS: Otherwise unremarkable. PHYSICAL EXAMINATION GENERAL: This is an alert black female patient appropriate for stated chronologic age who is no acute distress. SKIN: Demonstrates multiple senile keratotic lesions. (continued) Patient: Emma Parker Hospital: 11259 Date of admission: 09/25/2015 HEENT Normocephalic. Normal hair distribution.
PERRLA EOMI. Sclerae anicteric. Fundoscopic exam essentially benign other than some mild cataract formation. Ear canals are clear. TM’s normal. Buccal mucosa is moist. Oropharynx uninflamed. Teeth are present but in disrepair. NECK: Soft and supple, with no palpable nodes or masses noted. LUNGS: Clear in all fields without wheezes, rails, or rhonchi. CHEST: Symmetrically moving chest cage upon respiratory excursions. Heart rate regular with no murmur, click, gallop, or rub. PMI in left 5th intercostal space midclavicular line. ABDOMEN: Soft without tenderness, masses, or organomegaly.
GENITAL/RECTAL/BREASTS: Deferred at this time. Not felt to be indicated. EXTREMITIES: External rotation of right leg is noted. Peripheral pulses found to be symmetrically intact. Mild tenderness is noted over the outer aspect of the right hip joint. No frank deformity is noted. NEUROLOGIC: grossly intact with no focal deficits appreciated. IMPRESSION Intertrochanteric fracture of the right hip. PLAN Admit the patient in Buck’s traction, IV fluids, type and cross x 2 for anticipated surgery in the AM. Call Dr. Carol Dodd for orthopedic consultation. Sherman Loyd, MD SL:bcv D: 09/25/2015 T: 09/25/2015.