DATE OF CONSULTATION: MM/DD/YYYY
REFERRING PHYSICIAN: John Doe, MD
REASON FOR CONSULTATION: Right hip fracture.
HISTORY OF PRESENT ILLNESS: This is an (XX)-year-old female who reportedly fell at home last night injuring her right hip, sustaining possible right hip fracture. She reports that she had recently been hospitalized for chest pain and what apparently was worked up and demonstrated to be a dissecting aortic aneurysm. The patient reports that it was decided to treat her aneurysm nonoperatively. She has been using a walker over the past month to get around. She decided to try to get herself ready for bed without the help of her family. As she was walking with the walker, she felt her legs were somewhat weak and decided to sit on the edge of a stool. Apparently, the stool fell and she fell to the ground.
The patient developed acute onset of pain involving the right lateral hip and proximal thigh. She also reported some pain about her right ankle. She states her ankle pain has subsequently resolved. She continues to have pain about her right hip. She is currently in Buck’s traction. The patient denies other injuries.
PAST MEDICAL HISTORY:
1. Coronary artery disease.
2. Dissecting aortic aneurysm.
3. Hypertension.
4. Recent closed head injury with negative CT scan.
MEDICATIONS:
1. Zocor.
2. Lotrel.
3. Labetalol.
4. Protonix.
5. Clonidine.
ALLERGIES: No known drug allergies.
REVIEW OF SYSTEMS: Negative for current chest pain, lightheadedness, fever, chills, or cough.
SOCIAL HISTORY: The patient is a tobacco user, lives with son.
PHYSICAL EXAMINATION:
GENERAL: The patient is a healthy-appearing female, in no acute distress. She is awake and alert with appropriate affect.
HEENT: The patient has an area of slight residual ecchymosis involving her anterior right-sided forehead.
NECK: Supple and nontender.
EXTREMITIES: Upper extremities appear intact with good overall motion. There is no obvious swelling or deformity. Skin is intact bilaterally. Lower extremities are notable for external rotation and shortening of the right lower extremity. She has pain with attempted passive motion of the right hip. She has tenderness about the lateral right proximal thigh and hip. Mild swelling about the right hip. She has good motion of both ankles and feet without appreciable pain. There is no significant swelling about the right ankle. There is no tenderness over the medial-lateral malleoli on the right. Appeared to be satisfactorily perfused. She has healed scars, apparently related to saphenous vein harvesting. There is no calf tenderness appreciated. She appears to have good muscle tone and strength.
DIAGNOSTIC STUDIES: X-rays of the right hip were notable for displaced intertrochanteric fracture of the right proximal femur with probable subtrochanteric extension. The patient does have diffuse osteopenia.
IMPRESSION: The patient is a (XX)-year-old female with:
1. Displaced intertrochanteric/subtrochanteric fracture, right proximal femur.
2. Probable osteoporosis.
3. History of dissecting aortic aneurysm, reportedly being treated nonoperatively.
4. Coronary artery disease, status post coronary artery bypass surgery.
5. Hypertension.
6. Recent closed head injury with reported negative CT scan.
PLAN: We have reviewed her condition and treatment alternatives, both nonoperative and operative, as well as associated risks and benefits. We plan on discussing her case with Dr. Jane Doe, who has expertise in the management of this type of fracture. If the patient elects to proceed with surgical treatment, it can be performed once she is medically cleared. The patient is to remain in Buck’s traction at this time.
Thank you for referring this pleasant female to my care.
