History and Physical Examination

Topics: Medical history, Physical examination, Osteoporosis Pages: 3 (498 words) Published: January 28, 2011


Patient Name: Emma Parker

Hospital No.: 11259

Room No.: 444

Date of Admission: 09/25/2010

Admitting Physician: Sherman Loyd, M.D.

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 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 ER after she sustained an injury of her right hip. She states she was walking when her right leg just “gave out”, and she fell on to 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 findings of intertrochanteric fracture nondisplaced 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 deceases. She denies previous rheumatic fever or polio; the only surgical history was an appendectomy 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: Noncontributory.

REVIEW OF SYSTEMS: Otherwise unremarkable.

Patient: Emma Parker
Hospital No.: 11259
Date of Admission: 09/25/2010
Page 2

PHYSICAL EXAMINATION: General this is an alert black female patient appropriate for stated chronologic age who is in no acute distress....
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