S:

TV is a 77 yo female presenting to the ED with her daughter with PMH significant for osteoporosis and chief complaint of left hip pain. The pain began 2 hours ago when she fell onto her left side at her daughter’s house. She was trying to sit down when her “knee gave out.” The 10/10 pain feels like she “broke her hip,” has been constant since the fall, and does not radiate. Denies fever, chills, weight loss, hitting her head, loss of consciousness, shortness of breath or chest pain preceding the fall.

PMH: Osteoporosis, HTN, Hypothyroidism, Ovarian Cyst, Thyroid Nodules

PSH: Ovarian Cyst Removal x 30y ago, Thyroidectomy

Allergies: NKDA; Codeine causes nausea and disorientation per patient’s daughter

Medications: Levothyroxine 25mcg PO qd, Losartan-HCTZ 100mg/12.5mg PO qd, Amlodipine 5mg PO qd, Calcium Supplement 500mg PO qd

FHx: Non-contributory

SHx: Current Smoker, Occasional EtOH use, Denies illicit drug use

O:

T 36.8C | BP 190/75mmHg | P 71 BPM, regular | RR 16 breaths/min, unlabored | SpO2 94% RA

H 65in | W 140 lb. | BMI 23.3

Gen: Slender female, neatly groomed, looks her stated age of 77 years. AxO x3. Appears uncomfortable and in pain.

CV: RRR. S1 and S2 are normal. There are no murmurs, S3, S4, splitting of heart sounds, friction rubs.

Pulm: Clear to auscultation and percussion bilaterally. Chest expansion symmetrical. No wheezing, rhonchi, rales, dullness.

Musculoskeletal: Left lower extremity appears shortened and externally rotated. Loss of iliac crest with inspection as compared to right lower extremity. No soft tissue swelling, erythema, ecchymosis, atrophy. Left hip tender to palpation with crepitus noted. Unable to perform active range of motion and pain with passive range of motion.

Peripheral Vascular System: The extremities are normal in color and temperature. Pulses are 2+ bilaterally in upper and lower extremities. Capillary refill <2s throughout. No bruits, cyanosis, stasis changes, or ulcerations.

Neurological: Sensation intact to left lower extremity including anteromedial aspect of thigh and medial side of leg and foot. No foot drop.

A:

77 yo female with severe left hip pain appearing with shortened, externally rotated leg and crepitus on exam. Likely hip fracture.

Differential Diagnosis:

1. Left Hip Fracture
2. Left Hip Dislocation
3. Left Hip Contusion
4. Left Hip Tendonitis
5. Left Hip Bursitis
6. Left Hip Malignancy (Bone Metastasis)

P:

Labs:

• CBC, BMP
• PT/INR, PTT, T/S
• UA

 

 

Imaging/Tests:

• ECG, CXR
• AP/Lat X-Ray Pelvis and Hip

Likely Left Hip Fracture:

• Start 1L Normal Saline IV
• Start Morphine Sulfate 4mg IV q2-6h prn
• If X-Ray is positive for hip fracture, request Orthopedic consult

Osteoporosis:

• Calcium Supplement 500mg PO qd

HTN:

• Losartan-HCTZ 100mg/12.5mg PO qd
• Amlodipine 5mg PO qd

Hypothyroidism:

• Levothyroxine 25mcg PO qd

Smoking:

• Smoking and tobacco use cessation counseling

 

/s/ Daniel DeMarco, PA-S

Physician Assistant Student

 

Initial DDx Based on CC:                                              Adjusted DDx After H&P:

Hip Fracture                                                                Left Hip Fracture

Hip Dislocation                                                            Left Hip Dislocation

Hip Tendonitis                                                             Left Hip Contusion

Hip Bursitis                                                                 Left Hip Tendonitis

Hip Malignancy (Bone Metastasis)                            Left Hip Bursitis

Hip Contusion                                                              Left Hip Malignancy (Bone Metastasis)

Hip Osteoarthritis

Hip Avascular Necrosis

Peritonitis

Septic Arthritis of the hip

Ovarian Cyst

Urinary Tract Infection

Pelvic Inflammatory Disease

Nephrolithiasis

Diverticulitis