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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.