History and Physical Examination Dissertation

HILLCREST MEDICAL CENTER

HISTORY AND PHYSICAL EXAMINATION

Patient Identity: Emma Parker

Hospital Number: 11259

Space No .: 444

Date of Admission: 09/25/2010

Admitting Doctor: Sherman Loyd, M. M.

Admitting Medical diagnosis: Acute intertrochanteric fracture of right hip.

The history under was from the patient and physical assessment was performed with her stated mental understanding and consent. She was alert oriented x3 with sensible thought content material she realized questions very well and was at no severe distress.

CHIEF PROBLEM: Right hip injury.

GREAT PRESENT ILLNESS: I was called to see this 69-year-old dark-colored female individual, well known to me, who was delivered to the IM OR HER after the lady sustained an accident of her right hip. She states she was walking when ever her correct leg only " offered out”, and she chop down on to the right hip. The girl complained of mild discomfort in the right hip, and mild edema was known in the SER. In addition the girl had external rotation in the right leg. Initial x-ray demonstrated results of intertrochanteric fracture nondisplaced of the proper hip. Assessment was obtained from Dr . Dodd who concurred with the medical diagnosis and treatment recommendations were made. She was subsequently admitted to the hospital for further analysis and treatment, including medical repair with the hip.

PAST HEALTH BACKGROUND: Usual the child years deceases. The lady denies past rheumatic fever or polio; the only operative history was an appendectomy in the past and repair of the fractured remaining hip in approximately 93.

CULTURAL HISTORY: Your woman lives acquainted with her husband, who is alternatively feeble. Forbids the use of cigarettes or alcoholic beverages.

GENEALOGY: Noncontributory.

OVERVIEW OF SYSTEMS: Or else unremarkable.

HISTORY AND PHYSICAL EXAMINATION

Patient: Emma Parker

Medical center No .: 11259

Date of Admission: 09/25/2010

Page two

PHYSICAL EVALUATION: General this can be an alert dark female affected person appropriate for stated chronologic era who is in no serious distress....

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