DATE OF ADMISSION: MM/DD/YYYY
DATE OF DISCHARGE: MM/DD/YYYY
DISCHARGE DIAGNOSES:
1. Contusion, right hip and right knee, secondary to fall, negative for any fracture.
2. Gait instability.
3. Osteoporosis.
4. Dementia.
5. Depression.
6. History of recent femoral neck fracture, status post open reduction and internal fixation.
7. Poor oral intake.
8. Deconditioning.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old female who was transferred from an assisted living facility after she was found to be fallen on the floor with contusion to the right hip and right knee region. The patient had recently gone through a fall and fracture of femoral neck, right side, for which she had open reduction and internal fixation surgery, following which she was in rehab. The patient finished rehab and had just moved to an assisted living facility a week ago prior to this admission. The patient is very unsteady in her gait and comorbidities include dementia, depression, osteoporosis, osteoarthritis, generalized weakness, poor oral intake, dysphagia, and deconditioning.
HOSPITAL COURSE: The patient was transferred to rule out acute fracture. X-rays were done of the right hip and right knee, which clinically does not show any fracture. However, a bone scan was recommended. The patient had a CT scan of the right hip region, which showed no evidence of fracture or dislocation. The patient also had an orthopedic evaluation with Dr. John Doe, whose opinion was to start PT for ambulation, and bone scan may be an option if things do not improve and did not recommend for any new form of treatment.
The patient appears to be doing fine. She was put on therapy yesterday and is able to do some therapy. Hence, the patient will be discharged back to the nursing home. Discussed with the patient’s son and have recommended the patient is no more a candidate for assisted living facility and would be a safe move into the nursing unit in view of above-mentioned multiple comorbidities. The patient needs more ADL care.
Would also put the patient on physical therapy for gait training and for improving balance. Oral intake still seems to be an issue. Discussed extensively with the patient’s son regarding oral feeding, preference of food types, and artificial and alternate feeding mechanisms, including feeding tube placement. However, at the present time, the decision, as per family, is to continue oral intake, and the son is going to think about feeding tube placement. However, in view of dementia and progressive decline and as the patient is eating orally without any dysphagia, we have recommended against feeding tube. The patient may need some assistance on one-on-one meal monitoring and supplements and multivitamins.
