Same Level Fall
Hip Injury, no CT head/C-spine
The patient presents after a same level fall without LOC or reported head injury. The history of the fall indicates it was mechanical and not due to syncope/pre-syncope and there were no preceding symptoms. The patient is not on any blood thinners. On examination, the patient’s [R/L] lower extremity is outwardly rotated, shortened, and ROM is limited with TTP and apparent deformity at the hip. Distal pulses are easily palpable and neurologic exam is intact. I will obtain XRs and basic labs in anticipation of admission. IV analgesics. Currently, there is no indication for imaging of the head or C-spine as the patient reports no injury to these areas, there are no focal neurologic findings, and the patient is not on blood thinners. If necessary, additional testing, medication, and fluids will be ordered.
Re-exam, fracture
Found to have femur fracture on X-ray. Vitals stable. Pain is controlled. Distal neurovasculature remains intact. Spoke with orthopedics who will take to the OR at some point in the near future. Admitting.
Hip Injury, CT head/C-spine
The patient presents after a same level fall without LOC or reported head injury. The history of the fall indicates it was mechanical and not due to syncope/pre-syncope and there were no preceding symptoms. The patient is not on any blood thinners. On examination, the patient’s [R/L] lower extremity is outwardly rotated, shortened, and ROM is limited with TTP and apparent deformity at the hip. Distal pulses are easily palpable and neurologic exam is intact. I will obtain XRs and basic labs in anticipation of admission. IV analgesics. It does seem likely there is a possibility of head or cspine injury so CTs will also be ordered. If necessary, additional testing, medication, and fluids will be ordered.
Re-exam, fracture
Found to have femur fracture. CT’s unremarkable for acute injury. Vitals stable. Pain is controlled. Distal neurovasculature remains intact. Spoke with orthopedics who will take to the OR at some point in the near future. Admitting.
- Last updated January 21, 2023