Other closed fracture of lower end of femur Cardiac complications not elsewhere classified Hypotension unspecified Chronic airway obstruction not elsewhere classified Atrial fibrillation Fall from other slipping tripping or stumbling Accidents occurring in unspecified place Chronic kidney disease unspecified Hip joint replacement Hypertensive chronic kidney disease unspecified with chronic kidney disease stage I through stage IV or unspecified Personal history of tobacco use Surgical operation with implant of artificial internal device causing abnormal patient reaction or later complication,without mention of misadventure at time of operation Accidents occurring in residential institution
 
Name:  ___                Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
No Known Allergies / Adverse Drug Reactions
 
Attending: ___.
 
Chief Complaint:
R leg pain
 
Major Surgical or Invasive Procedure:
ORIF R femur ___

 
History of Present Illness:
___ c mild COPD, CKD (b/l Cre 1.2), and s/p R THA (___), 
transferred from ___ following slip and fall, with reported 
right distal femur fracture. The patient reports slipping on ice 
at ~7:30p on evening prior to presentation; she felt right knee 
buckle under her, and she fell on RLE. Immediate pain and 
inability to weight-bear. Denies prodromal symptoms; no HS/LOC 
or other injuries. Initially brought by ambulance to ___ 
___, where imaging demonstrated reported distal femur 
fracture; transferred to ___ ED for further management.

At time of interview, patient endorses right knee pain; no other 
injuries. Mild paresthesias over tips of right toes. At 
baseline, patient is active and ambulates without assistive 
device; she estimates that she could walk up ~8 stairs at a 
time.  
 
Past Medical History:
COPD, no home O2
CKD (b/l Cre 1.2) 
HTN
s/p R THA ___, ___ for acetab fx
s/p laparoscopic gynecologic cyst excision (___)
Denies any cardiac history; no echo in Atrius

 
Social History:
___
Family History:
nc
 
Physical Exam:
Vitals: 96.8 100 157/61 20 97% 4L  
Appears well

CAM:
Fluctuating Mental Status: no
Inattention: no
Disorganized Thoughts: no
Altered consciousness: no

Mini-Cog:
A&Ox3
3 Object Recall: ___
Clock-Draw: pass

Respirations non-labored
RRR
Abdomen soft, non-tender

RLE:
+swelling, TTP over knee
No focal TTP over hip, ankle, foot
No skin lacerations; very small, superficial abrasion over 
anterior knee
No pain with log roll at hip
Pain with any movement at knee
Palpable DP pulse, symmetric bilaterally
Dopplerable ___ pulse, symmetric bilaterally
Sensation intact sural, saphenous, tibial, DP, SP distributions, 
though with mild paresthesias over all 5 toes
Fires ___, TA, ___

LLE:
No skin breaks / deformities / areas of TTP over hip / knee / 
ankle / foot

Discharge PE:
AVSS
G:NAD
RLE:Incision c/d/i
NVID
 
Pertinent Results:
___ 06:25AM BLOOD WBC-6.3 RBC-2.92* Hgb-8.2* Hct-26.2* 
MCV-90 MCH-28.3 MCHC-31.5 RDW-15.1 Plt ___

Rib series...
 
Brief Hospital Course:
The patient presented to the emergency department and was 
evaluated by the orthopedic surgery team. The patient was found 
to have R femur fracture and was admitted to the orthopedic 
surgery service.  The patient was taken to the operating room on 
___ for ORIF R femur, which the patient tolerated well (for 
full details please see the separately dictated operative 
report). The patient was taken from the OR to the PACU in stable 
condition and after recovery from anesthesia was transferred to 
the floor.  The patient was initially given IV fluids and IV 
pain medications, and progressed to a regular diet and oral 
medications by POD#1. The patient was given perioperative 
antibiotics and anticoagulation per routine.  The patients home 
medications were continued throughout this hospitalization.  The 
patient worked with ___ who determined that discharge to rehab 
was appropriate. The ___ hospital course was otherwise 
unremarkable.

At the time of discharge the patient was afebrile with stable 
vital signs that were within normal limits, pain was well 
controlled with oral medications, incisions were 
clean/dry/intact, and the patient was voiding/moving bowels 
spontaneously. The patient is TDWB in the RL extremity, and will 
be discharged on lovenox for DVT prophylaxis.  The patient will 
follow up in two weeks per routine. A thorough discussion was 
had with the patient regarding the diagnosis and expected 
post-discharge course, and all questions were answered prior to 
discharge.

 
Medications on Admission:
Losartan 25'
Ca/Vit D
Ambien prn

 
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H 
2. Docusate Sodium 100 mg PO BID:PRN constipation 
3. Enoxaparin Sodium 30 mg SC QHS 
Start: Today - ___, First Dose: Next Routine Administration 
Time 
4. OxycoDONE (Immediate Release)  2.5-5 mg PO Q4H:PRN Pain 
Decrease dosage as soon as possible. 
5. Senna 8.6 mg PO BID:PRN constipation 
6. Vitamin D 400 UNIT PO DAILY 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
R femur fracture

 
Discharge Condition:
Improved. AO3. TDWB RLE.

 
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians 
at discharge.
- Continue all home medications unless specifically instructed 
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should 
drink eight 8oz glasses of water daily and take a stool softener 
(colace) to prevent this side effect.

ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks

WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken 
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless 
otherwise instructed
- Do NOT get splint wet

ACTIVITY AND WEIGHT BEARING:
- TDWB RLE in unlocked ___
Physical Therapy:
TDWB RLE in unlocked ___

Treatments Frequency:
DSD to wound PRN.
 
Followup Instructions:
___

{'R leg pain': ['Other closed fracture of lower end of femur'], 'Mild paresthesias over tips of right toes': ['Chronic kidney disease', 'unspecified'], 'Right knee pain': ['Other closed fracture of lower end of femur'], 'Swelling': ['Other closed fracture of lower end of femur'], 'TTP over knee': ['Other closed fracture of lower end of femur']}