Discharge Summary

Only available on StudyMode
  • Download(s) : 312
  • Published : March 16, 2013
Open Document
Text Preview
DISCHARGE SUMMARY
Patient name: Emma Parker
Hospial No: 11259
Admitted: 09/25/13
Discharged: 10/01/13
Consultations: Carol Dodd, M.D, Orthopedics
Saul Thompson, M.D., Cardiology
Procedure: Open reduction, internal fixation of right hip.
Complication: Elevated cardiac enzymes postop.
Admitting Diagnosis: Acute intertrochanteric fracture of right hip. ENTERING STATEMENT: This 69-year-old black female patient was brought to the ER after she sustain an injury to her right hip. She states she was walking when her right leg “gave out.’’ She fell onto the right hip. She complained of mild pain in the right hip and there was mild pain in the right hip and there was mild edema 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. Patient was subsequently admitted for further evaluation and treatment, including surgical intervention.

HOSPITAL COURSE: Following admission the patient was taken to the OR was performed with a DePuy fixation device. Patient tolerated the procedure well under endotracheal anesthesia and was in stable condition postoperatively. She was continued on lactated Ringer’s postoperatively, and Accu-Chek was used to monitor blood sugar q.i.d. Ancef 1 g IVPB was administered x 6 doses. Diet was advanced to a 1200-calorie ADA postoperatively, and Micronase 5 mg p.o.q.d. was started on September 27.

During her postoperative course she developed elevated cardiac enzymes with a CPK of 1590, LDH of 341, and SGOT of 136. Her actual physical status remained stable. She denied chest pain and dyspnea, was nondiaphoretic, and when reviewing her EKGs the admitting EKG demonstrated nonspecific ST-T wave changes. Postoperative findings were consistent with a possible inferior myocardial infraction with anterior ischemic...
tracking img