REASON FOR ADMISSION: Impaired mobility and activities of daily living independence secondary to status post right hip hemiarthroplasty due to femoral neck fracture.
HISTORY OF PRESENT ILLNESS: This is a (XX)-year-old Asian female who was admitted on MM/DD/YYYY for intensive inpatient rehabilitation evaluation after discharge from an outside hospital under Dr. John Doe and Dr. Jane Doe’s service on the same day.
She was initially admitted to the outside hospital after she tripped and fell in her shower. She was found to have a displaced right femoral neck fracture.
On MM/DD/YYYY, she underwent right hip hemiarthroplasty with a posterior approach by Dr. Jane Doe. The postoperative course was complicated by slow progress with limited mobility and exercise tolerance and endurance. She also developed postoperative anemia further limiting her endurance. She was recommended as a candidate for intensive inpatient rehabilitation evaluation and program.
PAST MEDICAL HISTORY: Significant for insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, and obesity.
PAST SURGICAL HISTORY: She has a history of hysterectomy.
FAMILY HISTORY: Essentially noncontributory.
PSYCHOSOCIAL AND FUNCTIONAL HISTORY: She is married and lives in a one-level house. She has been independent for mobility and self-care activities.
ALLERGIES: PENICILLIN.
REVIEW OF SYSTEMS: She has insulin-dependent diabetes mellitus, hypertension, hypercholesterolemia, and obesity as mentioned. Appetite fair. No BM since surgery. Has indwelling Foley catheter. Denies headache, nausea, vomiting, chest pain, shortness of breath or abdominal pain. Hip pain is moderate.
PHYSICAL EXAMINATION:
General: The patient is in fair spirits, has a stable affect, in no distress.
Vital Signs: Blood pressure 104/56, pulse 74, respirations 18, and temperature 98.4 degrees.
Heart: Regular rhythm without murmur.
Lungs: Clear to percussion and auscultation.
Abdomen: Soft and nontender. Bowel sounds are physiologic.
Pelvic: Examination is deferred.
Rectal: Examination is deferred.
Skin: No rashes or decubiti.
Neuromusculoskeletal: Mental Status Examination: The patient is awake, alert, and oriented x3. Memory and intellectual function intact. Affect and insight appropriate. Cranial nerves II through XII are intact. The active range of motion is full in both the upper and the left lower extremity with muscle strength at least fair to good. The right hip surgical incision is clean and dry and there are no staples. There is no sign of deep vein thrombosis in the legs. Peripheral circulation appears adequate in both lower and upper extremities. Sensory examination is unremarkable.
FUNCTIONAL STATUS: The patient has good mentation. She is well cooperative and motivated. Pain is moderate. Appetite fair. No BM since surgery. Has indwelling Foley catheter. She has stood at the side of bed requiring moderate assistance before coming to rehabilitation. Full mobility and activities of daily living evaluation is pending.
CODE STATUS: Full code.
CONDITION ON ADMISSION: Fair and stable.
IMPRESSION:
1. Impaired mobility and activities of daily living independence secondary to status post right hip hemiarthroplasty due to displaced femoral neck fracture from a fall. Weightbearing as tolerated.
2. Constipation.
3. Urinary retention.
4. Anemia.
5. Insulin-dependent diabetes mellitus.
6. Hypertension.
7. Hypercholesterolemia.
8. History of hysterectomy.
9. Obesity.
10. Allergic to penicillin.
REHABILITATION CARE PLAN
GOALS:
Short-term rehabilitation goals: To prevent injuries during the rehabilitation program, to obtain optimal pain control, to obtain optimal wound healing, to regain bladder and bowel regulation, to improve self-mobility and self-care independence and endurance.
Long-term rehabilitation goals: To regain mobility and self-care independence before returning home to family.
REHABILITATION POTENTIAL: Fair.
ESTIMATED LENGTH OF REHAB STAY: Ten to fourteen days.
PLAN: Intensive inpatient rehabilitation evaluation and program as indicated. The patient will first be placed on an initial evaluation period of about 3 to 5 days before determining the potential for further rehabilitation program.
The initial evaluation will consist of rehabilitation nursing, physical therapy, occupational therapy, therapeutic recreation, and social service. The initial evaluation will be emphasized on mobility and activities of daily living, independence, safety and endurance, bladder and bowel, and the psychosocial aspect of function. Optimal medical management and consultation with Dr. Jane Doe and Dr. John Doe when indicated.
With further program, she will be discharged home when she achieves her maximum mobility and self-care independence with reasonable safety and endurance level.
