Problem
Read the patient visit report below and answer the following questions.
• What is the patient's chief complaint?
• What information in the scenario is "subjective"?
• What information in the scenario is "objective"?
• Does Dr. Jenkins have a definitive assessment of Ms. Gerry's problem?
• What is the plan for this patient?
Patient Visit Report
• History of Present Illness: Ms. Gerry is an 85 y.o. female who fell out of a wheelchair today. She comes in complaining of severe pain in her left hip. X-ray reveals an intertrochanteric fracture of the left hip.
• Past Medical History: Alzheimer's Disease, GERD, COPD, coronary artery disease.
• Medications: Zantac 75mg in the AM; Synthroid 88 mcg in the AM; Norvasc 2.5 mg in the AM; Nebulizer QID; Coumadin 2.5 mg Monday, Wednesday, Friday, and Saturday
• Physical Exam: Shortening of the left leg; good bilateral pedal pulses.
• Plan: Medical clearance. Vitamin K to decrease protime. Bucks traction. Open reduction and internal fixation of the left hip if cleared for surgery.
• X-ray After Surgery: Diffuse osteopenia present. The patient is post placement of a dynamic hip screw within the proximal left femur. There is near anatomical alignment of the intertrochanteric femoral neck fracture.