Medical History and Right Hip Injury
HISTORY AND PHYSICAL EXAMINATION REPORT (H&P)
PATIENT NAME: Emma Parker
HOSPITAL NUMBER: 11259
ROOM NUMBER: 444
DATE OF ADMISSION: 25/9/2013
ADMITTING PHYSICIAN: Sherman Loyd, MD
ADMITTING DIAGNOSIS: Acute intertrochanteric fracture of right hip
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 emergency room 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 emergency room. In addition she had external rotation of the right leg. Initial x-ray demonstrated findings of intertrochanteric fracture, non-displaced of the right hip. Consultation was obtained from Doctor 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 history was an appendectomy in the past and repair of the 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.
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: Normal cephalic, normal hair distribution. PERRLA, EMOI, sclera anicteric. funduscopic exam essentially benign other then some mild cataract formation. Ear canals are clear tympanic
PATIENT NAME: Emma Parker
HOSPITAL NUMBER: 11259
ROOM NUMBER: 444
DATE OF ADMISSION: 25/9/2013
ADMITTING PHYSICIAN: Sherman Loyd, MD
ADMITTING DIAGNOSIS: Acute intertrochanteric fracture of right hip
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 emergency room 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 emergency room. In addition she had external rotation of the right leg. Initial x-ray demonstrated findings of intertrochanteric fracture, non-displaced of the right hip. Consultation was obtained from Doctor 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 history was an appendectomy in the past and repair of the 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.
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: Normal cephalic, normal hair distribution. PERRLA, EMOI, sclera anicteric. funduscopic exam essentially benign other then some mild cataract formation. Ear canals are clear tympanic