Case 02 H P examination
Case 02 H&P Examination
Patient: Emma Parker
PCP: Sherman Loyd, MD
Hospital: 11259
Room: 444
Date of admission: 09/25/2015
ADMITTING DIAGNOSIS
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.
Patient: Emma Parker
Hospital: 11259
Date of admission: 09/25/2015
HEENT
Normocephalic. Normal hair distribution. PERRLA EOMI. Sclerae anicteric. Fundoscopic
Patient: Emma Parker
PCP: Sherman Loyd, MD
Hospital: 11259
Room: 444
Date of admission: 09/25/2015
ADMITTING DIAGNOSIS
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.
Patient: Emma Parker
Hospital: 11259
Date of admission: 09/25/2015
HEENT
Normocephalic. Normal hair distribution. PERRLA EOMI. Sclerae anicteric. Fundoscopic