Scribd Logo
Upload

Welcome to Scribd!

  • 231 views

    Hip Hpi

    Uploaded by

    Rebecca Lau
    A 50-year-old female presented with left hip pain after a fall. X-rays showed a displaced femoral neck fracture of the left hip. She reported being unable to move her left lower extremity due to pain after the fall. The plan is for an open reduction internal fixation surgery of the left hip to be performed by Dr. Passick pending medical clearance.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd

    Hip Hpi

    Uploaded by

    Rebecca Lau
    231 views2 pages
    A 50-year-old female presented with left hip pain after a fall. X-rays showed a displaced femoral neck fracture of the left hip. She reported being unable to move her left lower extremity due to pain after the fall. The plan is for an open reduction internal fixation surgery of the left hip to be performed by Dr. Passick pending medical clearance.

    Original Title

    HIP HPI

    Copyright

    © © All Rights Reserved

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    A 50-year-old female presented with left hip pain after a fall. X-rays showed a displaced femoral neck fracture of the left hip. She reported being unable to move her left lower extremity due to pain after the fall. The plan is for an open reduction internal fixation surgery of the left hip to be performed by Dr. Passick pending medical clearance.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    231 views2 pages

    Hip Hpi

    Uploaded by

    Rebecca Lau
    A 50-year-old female presented with left hip pain after a fall. X-rays showed a displaced femoral neck fracture of the left hip. She reported being unable to move her left lower extremity due to pain after the fall. The plan is for an open reduction internal fixation surgery of the left hip to be performed by Dr. Passick pending medical clearance.

    Copyright:

    © All Rights Reserved
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 2

    CHIEF COMPLAINT: Left hip pain.

    HISTORY OF PRESENT ILLNESS: 50-year-old caucasian female presented to the clinic


    s/p fall. Pt reports she was lifting a heavy box and tripped on the rug and landed on her
    right side. Pt states she had right hip pain and was unable to move her right lower
    extremity due to pain. Pt states she was transported via EMS to Coney Island Hospital
    Emergency Room, where she was seen and evaluated in the emergency room by the
    emergency room physicians. Pt reports x-rays were taken and demonstrated a right
    displaced femoral neck fracture. Patient denies any numbness, tingling, fever, chills,
    sweats, weight changes, chest pain, shortness of breath, dyspnea or productive cough,
    headaches, loss of bladder and bowel function.
    PAST MEDICAL HISTORY: No past medical history
    PAST SURGICAL HISTORY: Negative.
    CURRENT MEDICATIONS:
    ALLERGIES: NKDA.
    SOCIAL HISTORY: not applicable
    FAMILY HISTORY: Non-contributory.
    ROS:
    Gen: Denies weakness, fatigue, fever, weight, chills, night sweats, heat intolerance.
    Skin: Denies changes, pruritis, rash, or changes in hair.
    Head: Positive for occ migraine headaches.
    ENT: Denies visual changes, eye pain, hearing loss, tinnitus, vertigo, ear pain, ear
    discharge, epistaxis, nasal discharge, sinusitis, teeth problems, abnormal taste, sore
    throat, or speech difficulty
    Neck: Denies neck swelling, pain, stiff neck, goiter, or masses, nodes.
    Cardiopulmonary: Denies cough, dyspnea, wheezing, hemoptysis, chest pain,
    palpitations, orthopnea, P.N.D., murmurs, edema, claudication, syncope, hypertension
    GI: Neg for n/v, hematemesis, melena, dysphagia, heartburn,
    flatulence, abdominal pain, jaundice, change in bowel habits, diarrhea,
    constipation, hematochezia, or rectal pain.
    MS: Denies backache, muscle pain, joint pain, stiffness.
    Neuro: Denies seizures, paralysis, muscle weakness, parasthesia, sensation changes.
    and tremors.
    PHYSICAL EXAMINATION:
    VITAL SIGNS:
    Height 5'2, weight 120 pounds, blood pressure 128/80, pulse 88,
    temperature 98.0 F, respirations 16.
    GENERAL:
    The patient is a well developed, well nourished, elderly, white
    female in no acute distress without complaints of shortness of
    breath, dyspnea or acute pain. Alert and oriented x3
    SKIN:
    Warm, dry and intact.
    HEENT:
    Clear mucous membranes. No inflammation, redness, irritation or
    lesions. Extraocular muscles intact. Pupils are equal, round and
    reactive to light and accommodation. Normocephalic, atraumatic.
    CHEST:
    Clear to auscultation bilaterally. No rhonchi or rales. Respiratory
    expansion equal bilaterally.
    CARDIAC:
    Regular rate and rhythm, S1 and S2 both audible. No murmurs,
    rubs or gallops. Peripheral pulses positive. Capillary refill less

    ABDOMEN:
    EXTREMITIES:

    than 3 seconds.
    Round, soft, nondistended and nontender to palpation. No
    palpable masses. No auscultatable bruits. Bowel sounds
    positive x4. No costovertebral angle tenderness to percussion.
    Limited passive and active ROM to right hip secondary to pain.
    Neurovascular status is intact x4. Pulses 2+. Strength 1/5.

    No

    NEUROLOGIC:

    cyanosis, clubbing or edema. Negative Homans sign bilaterally.


    She does have a positive log roll test on the right that we do not
    appreciate on the left
    Examination is grossly intact globally. Cranial nerves II through
    XII are grossly intact. No facial asymmetry. The patient is alert
    and oriented x4. Reflexes are normal and symmetrical bilaterally
    in both extremities.

    RADIOLOGIC DATA: X-rays demonstrate a left displaced femoral neck fracture.


    DIAGNOSIS:
    Left displaced femoral neck fracture.
    Differential diagnosis:
    Osteoarthritis
    Hip dislocation
    Hip tendonitis and bursitis
    Femoral Neck Stress fracture
    PLAN: The surgical procedure will be an open reduction internal fixation of the right hip,
    surgery as needed, to be done at Coney Island Hospital by Dr. Passick on Oct 20, 2015
    pending medical clearance.

    You might also like