Unspecified intracapsular fracture of left femur initial encounter for closed fracture Fall on same level from slipping tripping and stumbling without subsequent striking against object initial encounter Activity walking an animal Sidewalk as the place of occurrence of the external cause Gastro-esophageal reflux disease without esophagitis Pure hypercholesterolemia unspecified Nonrheumatic mitral (valve) prolapse Migraine unspecified not intractable without status migrainosus Personal history of nicotine dependence Personal history of urinary calculi Anxiety disorder unspecified Age-related osteoporosis without current pathological fracture Long term (current) use of anticoagulants
 
Name:  ___                 Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   F
 
Service: ORTHOPAEDICS
 
Allergies: 
omeprazole / Iodine and Iodide Containing Products / 
hallucinogens
 
Attending: ___.
 
Chief Complaint:
Left hip pain 
 
Major Surgical or Invasive Procedure:
Status post left CRPP ___, ___

 
History of Present Illness:
REASON FOR CONSULT: Femur fracture

HPI: ___ female presents with the above fracture s/p mechanical
fall. This morning, pt was walking ___, when dog
pulled on leash. Pt fell on L hip. Immediate pain. ___ ___ with movement. Denies Head strike, LOC or blood thinners.
Denies numbness or weakness in the extremities. 
 
Past Medical History:
- GERD  
 - Hypercholesterolemia  
 - Kidney stones  
 - Mitral valve prolapse  
 - Uterine fibroids  
 - Osteoporosis  
 - Migraine headaches 
 
Social History:
___
Family History:
+ HTN - father  
+ Dementia - father  
 
 
Physical Exam:
General: Well-appearing female in no acute distress.

Left Lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Full, painless ROM knee, and ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
 
Brief Hospital Course:
The patient presented to the emergency department and was 
evaluated by the orthopedic surgery team. The patient was found 
to have a left valgus impacted femoral neck fracture and was 
admitted to the orthopedic surgery service. The patient was 
taken to the operating room on ___ for left closed reduction 
and percutaneous pinning of hip, which the patient tolerated 
well. For full details of the procedure please see the 
separately dictated operative report. The patient was taken from 
the OR to the PACU in stable condition and after satisfactory 
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 ___ antibiotics and 
anticoagulation per routine. The patient's home medications were 
continued throughout this hospitalization. The patient worked 
with ___ who determined that discharge to home with services was 
appropriate. The ___ hospital course was otherwise 
unremarkable.

At the time of discharge the patient's pain was well controlled 
with oral medications, incisions were clean/dry/intact, and the 
patient was voiding/moving bowels spontaneously. The patient is  
weightbearing as tolerated in the left lower extremity, and will 
be discharged on Lovenox for DVT prophylaxis. The patient will 
follow up with Dr. ___ routine. A thorough discussion 
was had with the patient regarding the diagnosis and expected 
post-discharge course including reasons to call the office or 
return to the hospital, and all questions were answered. The 
patient was also given written instructions concerning 
precautionary instructions and the appropriate follow-up care. 
The patient expressed readiness for discharge.

 
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactaid (lactase) 3,000 unit oral DAILY:PRN 
2. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 
mg-unit oral DAILY 

 
Discharge Medications:
1.  Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever  
2.  Bisacodyl 10 mg PO/PR DAILY:PRN Constipation  
3.  Docusate Sodium 100 mg PO BID  
4.  Enoxaparin Sodium 40 mg SC QHS 
RX *enoxaparin 40 mg/0.4 mL 40 mg Subcutaneously Nightly Disp 
#*30 Syringe Refills:*0 
5.  OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - 
Moderate 
RX *oxycodone 5 mg 1 tablet(s) by mouth q4 PRN Disp #*25 Tablet 
Refills:*0 
6.  Senna 8.6 mg PO BID  
7.  Calcium Citrate + D (calcium citrate-vitamin D3) 315-200 
mg-unit oral DAILY  
8.  Lactaid (lactase) 3,000 unit oral DAILY:PRN  
9.  Multivitamins 1 TAB PO DAILY  
10.  Vitamin D 400 UNIT PO DAILY  

 
Discharge Disposition:
Home With Service
 
Facility:
___
 
Discharge Diagnosis:
Left valgus impacted femoral neck fracture

 
Discharge Condition:
AVSS
NAD, A&Ox3
LLE: Incision well approximated. Dressing clean and dry. Fires 
FHL, ___, TA, GCS. SILT ___ n distributions. 1+ DP 
pulse, wwp distally.

 
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:

- You were in the hospital for orthopedic surgery. It is normal 
to feel tired or "washed out" after surgery, and this feeling 
should improve over the first few days to week. 
- Resume your regular activities as tolerated, but please follow 
your weight bearing precautions strictly at all times.

ACTIVITY AND WEIGHT BEARING:
- Weightbearing as tolerated left lower extremity

MEDICATIONS:
  1)  Take Tylenol ___ every 6 hours around the clock. This is 
an over the counter medication.
  2)  Add oxycodone as needed for increased pain. Aim to wean 
off this medication in 1 week or sooner.  This is an example on 
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days, 
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.  
Then continue with Tylenol for pain.
  3)  Do not stop the Tylenol until you are off of the narcotic 
medication.
  4)  Per state regulations, we are limited in the amount of 
narcotics we can prescribe. If you require more, you must 
contact the office to set up an appointment because we cannot 
refill this type of pain medication over the phone. 
  5)  Narcotic pain relievers can cause constipation, so you 
should drink eight 8oz glasses of water daily and continue 
following the bowel regimen as stated on your medication 
prescription list. These meds (senna, colace, miralax) are over 
the counter and may be obtained at any pharmacy.
  6)  Do not drink alcohol, drive a motor vehicle, or operate 
machinery while taking narcotic pain relievers.
  7)  Please take all medications as prescribed by your 
physicians at discharge.
  8)  Continue all home medications unless specifically 
instructed to stop by your surgeon.
      
ANTICOAGULATION:
- Please take  Lovenox daily for 4 weeks
 
Followup Instructions:
___

{'Left hip pain': ['Unspecified intracapsular fracture of left femur'], 'Femur fracture': ['Unspecified intracapsular fracture of left femur'], 'GERD': ['Gastro-esophageal reflux disease without esophagitis'], 'Hypercholesterolemia': ['Pure hypercholesterolemia'], 'Kidney stones': ['Personal history of urinary calculi'], 'Mitral valve prolapse': ['Nonrheumatic mitral (valve) prolapse'], 'Migraine headaches': ['Migraine', 'unspecified', 'not intractable', 'without status migrainosus'], 'Osteoporosis': ['Age-related osteoporosis without current pathological fracture']}