Name: Grayson, Jillian
Physician: Roberta Jackson, MD
DATE OF ADMISSION: 04/25/2011
DATE OF BIRTH: 06/05/1936
Date of Consultation: 04/25/2011
Consulting Physician: Jacob Rawlings, MD
Mrs. Grayson is a 75-year-old woman who sliped and fell at her home on a tile floor while in her socks. She landed on her right hip and sustained a displaced comminuted intertrochanteric hip fracture with fragmentation of the lesser trochanter area. She is otherwise alert and have no loss of consciousness. She is currently comfortable on bed rest while in the Emergency Room. Pertinent medical problems include noninsulin dependent diabetes mellitus, hypercholesterolemia and an history of unidentified lower extremity surgery. The rest of her social and family history is noted on the admission report.
On physical examination, the patient is aware, oreinted and comfortable on bed rest with stable vital signs. The upper extremities have full range of motion without tenderness and neurovascular status is intact, as well as the left lower extremity. There was no tenderness on AP or lateral pelvic compression. Thoracic and lumbar spine nontender to palpation, and she has full range of motion to her cervical spine. The right lower extremity rests in a a foreshortened and externaly rotated position with no swelling and no ecchymosis. Neurovascular status is intact.
The patient is being admitted and taken to surgery this evening for open reduction and internal fixation of her right intertrochanteric hip fracture. The need for the surgery and surgical plan were discussed with the family and patient while utilizing x-ray. The risks, potential complications and treatment alternatives were discussed. The plan is to proceed with surgery tonight. The patient and her family understood the above information and consent was obtained with patient’s understanding and all questions answered....