The history below was obtained from the patient and physical examination was performed with her stated verbal understanding and consent. She was alert oriented x3 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 just “gave out”, and she fell on to 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 findings of intertrochanteric fracture nondisplaced 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 deceases. She denies previous rheumatic fever or polio; the only surgical history was an appendectomy 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: Noncontributory. REVIEW OF SYSTEMS: Otherwise unremarkable. HISTORY AND PHYSICAL EXAMINATION Patient: Emma Parker Hospital No. : 11259 Date of Admission: 09/25/2010 Page 2 PHYSICAL EXAMINATION: General this is an alert black female patient appropriate for stated chronologic age who is in no acute distress. SKIN: Demonstrates multiple senile keratotic lesions. HEENT: Normocephalic. Normal hair distribution. PERRLA. EOMI SCLERA: Anicteric.
FUNDUSCOPIC EXAM: Essentially benign other than some mild cataract formation. Ear canals are clear. TM’s normal. Buccal-mucosa is moist. Orif-firings not inflamed. Teeth are present but in disrepair. NECK: Soft and supple with no palpable nods or masses noted. LUNGS: Clear in all fields without wheezes, rales, or rhonchi. CHEST: Symmetrically moving chest cage upon respiratory excursions. HEART RATE: Regular with no murmur, click, gallop, or rub. PMI in left fifth intercostals’ 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 in tact with no focal deficits appreciated. IMPRESSION: Intertrochanteric fracture of the right hip. PLAN: Admit the patient in Buck’s traction. IV fluids, type and crossed x2 for anticipated surgery in the AM. Call Dr. Carole Dodd for orthopedic consultation.