Other closed transcervical fracture of neck of femur Fall from other slipping tripping or stumbling Unspecified essential hypertension Personal history of pneumonia (recurrent) Mitral valve disorders Sicca syndrome Other and unspecified hyperlipidemia Unspecified disorder of thyroid Gastrostomy status
 
Name:  ___               ___ No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
meropenem
 
Attending: ___.
 
Chief Complaint:
left hip pain
 
Major Surgical or Invasive Procedure:
Closed reduction and percutaneous pinning, left
femoral neck fracture

 
History of Present Illness:
This is a ___ yo woman in her USOH until the day of presentation 
when she sustained a mechanical fall onto her left lower 
extremity with immediate pain, inability to ambulate.  The 
patient denies LOC, premonitory symptoms and ROS is otherwise at 
baseline. 

 
Past Medical History:
Anemia  
Borderline cholesterol  
Recurrent C. Diff  
Flatulence  
Heart Murmur  
Hypertension  
Hypothyroidism  
Mitral Regurgitation  
Osteoporosis  
Pneumonia  
Sinusitis  
Sjo___  
 
Social History:
___
Family History:
Long history of hypertension in her family.  Father's family has 
a history of multiple cancers.  She has a grandfather with a 
history of stomach cancer and an uncle with a history of throat 
cancer.  No history of colon cancers. Father had stroke. No 
family h/o MI. Mother had a heart valve replaced.

 
Physical Exam:
On admission: 
Pelvis stable to AP and lateral compression.  
BLE skin clean and intact 
LLE
Shortened and externally rotated, painful with internal or 
external rotation of the hip.  
Thighs and leg compartments soft 
Saphenous, Sural, Deep peroneal, Superficial peroneal SILT 
___ FHS ___ TA Peroneals Fire 
1+ ___ and DP pulses 
Knee stable to varus and valgus stress.   
Negative anterior, posterior drawer signs.  

On discharge: 
NAD, A+Ox3
INcision: dressing changed ___ - c/d/i
Neurovascularly intact, strenght intact, SILT s/s/dp/sp/t 
distributions
WWP, 2+ DP pulse

 
Pertinent Results:
Hip XR ___: IMPRESSION:  Impacted left subcapital femoral neck 
fracture.
 
Brief Hospital Course:
On ___ the pt was admitted to the ortho trauma service and 
found to have a valgus impacted left femoral neck hip fracture, 
for which she underwent closed reduction and percutaneous 
pinning, left
femoral neck fracture by Dr. ___

On ___ the patient was noted to be recovering well from 
surgery. She became hypotensive with physical therapy, which 
normalized after stopping exercise. 

On ___ the patient continued to do well. She was seen by 
physical therapy and cleared for discharge to a rehab facility. 
SOcial work saw pt for her difficulty coping with decreased 
mobility. Her labs showed sodium level of 130, unchanged from 
___ and similar to 132 on admission. She was given instructions 
to f/u with Dr. ___ in clinic in 2 weeks, and will be on 
lovenox subq 40 mg daily in the interim. 

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY 
2. Lisinopril 5 mg PO DAILY 
3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 
4. mirtazapine 30 mg Oral QHS 

 
Discharge Medications:
1. Levothyroxine Sodium 75 mcg PO DAILY 
2. Lisinopril 5 mg PO DAILY 
3. MethylPHENIDATE (Ritalin) 2.5 mg PO BID 
4. mirtazapine 30 mg Oral QHS 
5. Acetaminophen 1000 mg PO TID 
6. Aluminum-Magnesium Hydrox.-Simethicone ___ ml PO QID:PRN 
Dyspepsia 
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 
8. Biotene Dry Mouth Rinse (saliva substitution combo no.8) 1 
application Mucous Membrane q2hr 
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 
10. Calcium Carbonate 1250 mg PO TID 
11. Docusate Sodium 100 mg PO BID 
12. Enoxaparin Sodium 40 mg SC DAILY DVT prophylaxis Duration: 
14 Days Start: ___, First Dose: Next Routine Administration 
Time 
RX *enoxaparin 40 mg/0.4 mL 40 mg subq daily Disp #*14 Syringe 
Refills:*0
13. Milk of Magnesia 30 ml PO BID:PRN Dyspepsia 
14. Multivitamins 1 CAP PO DAILY 
15. OxycoDONE (Immediate Release)  2.5 mg PO Q6H:PRN pain 
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp 
#*60 Tablet Refills:*0
16. Pantoprazole 40 mg PO Q24H 
17. Senna 2 TAB PO HS 
18. Vitamin D 800 UNIT PO DAILY 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
left femoral neck fracture

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or 
wheelchair.

 
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 can get the wound wet/take a shower starting 3 days after 
your surgery.  You may wash gently with soap and water, and pat 
the incision dry after showering.  

- 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.

 

ACTIVITY AND WEIGHT BEARING:

touch-down weight-bearing LLE
Physical Therapy:
Touch-down weight bearing LLE
Treatments Frequency:
WOUND CARE:

- You can get the wound wet/take a shower starting 3 days after 
your surgery.  You may wash gently with soap and water, and pat 
the incision dry after showering.  

- 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.

 
Followup Instructions:
___

{'left hip pain': ['Other closed transcervical fracture of neck of femur'], 'inability to ambulate': ['Other closed transcervical fracture of neck of femur'], 'mechanical fall': ['Fall from other slipping, tripping, or stumbling'], 'immediate pain': ['Other closed transcervical fracture of neck of femur'], 'hypotension': ['Unspecified essential hypertension'], 'difficulty coping with decreased mobility': ['Personal history of pneumonia (recurrent)'], 'heart murmur': ['Mitral valve disorders'], 'flatulence': ['Sicca syndrome'], 'borderline cholesterol': ['Other and unspecified hyperlipidemia'], 'hypothyroidism': ['Unspecified disorder of thyroid']}