Closed fracture of intertrochanteric section of neck of femur Other chronic nonalcoholic liver disease Alcohol abuse unspecified Accidental fall from other furniture Home accidents Personal history of tobacco use
 
Name:  ___                    Unit No:   ___
 
Admission Date:  ___              Discharge Date:   ___
 
Date of Birth:  ___             Sex:   M
 
Service: ORTHOPAEDICS
 
Allergies: 
Hayfever / adhesive tape / Latex / Effexor XR
 
Attending: ___.
 
Chief Complaint:
Right hip pain
 
Major Surgical or Invasive Procedure:
R hip TFN - ___ 

 
History of Present Illness:
HPI: ___ male with history of hepatic steatosis presents 
s/p fall with R hip pain and deformity. States he was watching 
television this morning when he dozed off, rolled off the cough 
landing on his right side on a concrete floor with immediate 
onset of severe R hip pain. Also reports mild L anterior chest 
wall pain. Called EMS and was transported to ___ ED where he 
was noted to have shortening and external rotation of the R leg 
with intact neurovascular exam. No other complaints at this 
time.

Imaging showed an intertrochanteric fracture of the R hip, for 
which we are consulted.

 
Past Medical History:
PMH/PSH: 
-Hepatic steatosis
-Perforated duodenal ulcer, s/p repair
-L shoulder labral repair
-Bilateral meniscal repair
-Ruptured appendix s/p appendectomy

 
Social History:
___
Family History:
N/C
 
Physical Exam:
Exam on Discharge
 
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 right intertrochanteric fracture and was admitted to 
the orthopedic surgery service. The patient was taken to the 
operating room on ___ for right hip TFN 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 rehab 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 
WBAT in the right 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. Citalopram ___ mg PO DAILY 
2. Gabapentin 600 mg PO TID 
3. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis 
4. OxycoDONE (Immediate Release)  ___ mg PO Q6H:PRN pain 
5. QUEtiapine Fumarate 50-100 mg PO QHS 
6. Multivitamins 1 TAB PO DAILY 

 
Discharge Medications:
1. Citalopram ___ mg PO DAILY 
2. Gabapentin 600 mg PO TID 
3. Multivitamins 1 TAB PO DAILY 
4. QUEtiapine Fumarate 50-100 mg PO QHS 
5. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 
6. Calcium Carbonate 1250 mg PO TID 
7. Docusate Sodium 100 mg PO BID 
8. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks 
Start: Today - ___, First Dose: Next Routine Administration 
Time 
9. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain 
Do not drink alcohol, drive, or operate heavy machinery while 
taking. 
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 
hours Disp #*50 Tablet Refills:*0
10. Senna 8.6 mg PO DAILY 
11. Vitamin D 800 UNIT PO DAILY 
12. Hydrocortisone ___. Cream 0.2% 1 Appl TP BID:PRN psoriasis 

 
Discharge Disposition:
Extended Care
 
Facility:
___
 
Discharge Diagnosis:
Right intertrochanteric femur fracture

 
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid 

 
Discharge Instructions:
Instructions After Orthopedic 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:
- Weight bearing as tolerated right lower extremity with upper 
extremity assist as needed

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

DANGER SIGNS:

Please call your PCP or surgeon's office and/or return to the 
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning 
changes in your incision
- Persistent or increasing numbness, tingling, or loss of 
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid, 
medications down
- Any other medical concerns
Physical Therapy:
___ - WBAT RLE with upper extrmeity assist as needed 
Treatments Frequency:
Dry sterile dressing changes daily, as needed PRN staining. 
 
Followup Instructions:
___

{'Right hip pain': ['Closed fracture of intertrochanteric section of neck of femur'], 'Mild L anterior chest wall pain': [], 'Hepatic steatosis': ['Other chronic nonalcoholic liver disease'], 'Fall': ['Accidental fall from other furniture'], 'History of drug use': ['Alcohol abuse'], 'Smoking history': ['Personal history of tobacco use']}