REASON FOR ADMISSION: Rehabilitation status post left femur fracture.
HISTORY OF PRESENT ILLNESS: The patient is an (XX)-year-old Hispanic female who was in her usual state of fair health until MM/DD/YYYY when she sustained a fall in her home. The patient had significant pain in her left hip and was brought to the hospital where x-rays showed a subcapsular fracture of the left femur. The patient was brought to the operating theater where she underwent a left total hip arthroplasty. The patient tolerated the surgery well and postoperatively was started on physical therapy. She showed herself to be a good rehabilitation candidate and was then transferred to the rehabilitation hospital for continuation of her care.
PAST MEDICAL HISTORY: Significant for those mentioned in the HPI plus Alzheimer’s disease, peptic ulcer disease, hypertension, osteoarthritis, hyperlipidemia, and cardiovascular disease.
ALLERGIES: NO KNOWN DRUG ALLERGIES.
SOCIAL HISTORY: The patient lives with her husband in a one-story apartment. She was previously supervised with activities of daily living and mobility skills.
PHYSICAL EXAMINATION:
GENERAL: The patient is a well-developed, elderly female in no apparent distress.
VITAL SIGNS: Temperature 100.2 degrees, pulse 110 beats per minute, respirations are 20 breaths per minute, and blood pressure is 132/78 mmHg.
HEENT: Examination of the head and neck is normocephalic. She has full ocular range of motion. Pupils are equal and reactive to light.
NECK: Supple to palpation.
LUNGS: Clear to auscultation with diminished breath sounds.
HEART: Heart sounds S1 and S2 are present with grade 3/6 systolic ejection murmur, best heard in the left sternal border.
ABDOMEN: The patient has normoactive bowel sounds with a soft, obese, and nontender abdomen. No organomegaly is palpated.
EXTREMITIES: Examination of the patient’s extremities shows good peripheral pulses. The incision site is healing well without any sign of infection or skin breakdown. Staples and sutures are in place. Homans sign is absent. Tone is within normal limits in both lower extremities. Sensation is grossly intact in both lower extremities.
NEUROLOGIC: Cognitively, the patient had some impairment with short-term memory and processing.
FUNCTIONAL EVALUATION: The patient required moderate assistance with activities of daily living and maximal assistance with her self-care skills.
IMPRESSION:
1. Status post left femur fracture.
2. Left total hip arthroplasty.
3. Obesity.
4. Alzheimer’s disease.
5. Peptic ulcer disease.
6. Hypertension.
7. Fever of unknown origin.
8. Osteoarthritis.
9. Cardiovascular disease.
10. Possible cellulitis.
REHABILITATION GOALS: The goal is for the patient to be at a modified independent level with activities of daily living and mobility skills.
ESTIMATED LENGTH OF REHAB STAY: Seven to ten days before returning to home.
REHABILITATION PLAN: The patient is to undergo a course of physical and occupational therapy, dietary, and rehabilitation nursing with a goal of the patient being at a modified independent level with activities of daily living and mobility skills. Physical therapy will work with the patient on general mobilization skills, upper and lower body strengthening, pre-gait and gait training activities, and balance and coordination skills. Occupational therapy will work with the patient on feeding, grooming, upper and lower body dressing skills, toilet-to-tub/shower transfers with and without the use of adaptive equipment. Dietary will work with the patient on appropriate diet. Rehabilitation nursing will work with the patient on bowel and bladder management program and appropriate taking of medications. Medical will monitor the patient’s fever status and dementia and will adjust therapies and medications as needed. For possible cellulitis, we will start the patient on Levaquin. We will also perform family training while the patient is in the hospital prior to her discharge.
