Age: 84.0
Sex: F
Vaccine: COVID19
Symptoms: Arthralgia, Atrial fibrillation, Chronic kidney disease, Dysstasia, Fall
Clinical narrative: Date of Admission: 11/24/2023     Medical Diagnosis: Femur fracture     Date of Surgery/Procedure: 11/25/23 left hip ORIF   Precautions: Fall risk   PPE Worn:  Provider: Surgical Mask and Face Shield Patient masked? Yes   Covid-19 Testing:   Lab Results Component Value Date/Time   CORONAVIRUS COVID NOT DETECTED 12/30/2022 05:12 PM       Current History: Per Dr's HPI on 11/24/23 "Patient is an 87 year old female with a history of tobacco use, aflutter, CKD, HTN, MDD who presented to QOV with left hip pain after slipping and landing on the ground this am.  Family reports that she lives alone but they have a camera in her house and this am they noted she was on the ground which they thought she was looking for something.  Around 10 minutes later she was still on the ground so the family went to her house and found she was unable to get off the floor with left hip pain.  She reports she slipped upon standing and landed on her left hip and was unable to stand due to pain in her leg.  She denies any syncope, chest pain, palpitations, nausea, vomiting, dizziness, or other complaints.  She went to QOV where xray found a left intertrochanteric fracture.  While in the ER she had afib with RVR that spontaneously converted.  She was transferred to hospital, admitted to HBS with a consult to orthopedics."          Past Medical History:   Past Medical History Active Ambulatory Problems   Diagnosis Date Noted ? HX OF TOBACCO USE 08/20/2010 ? MICROCYTIC ANEMIA 08/23/2010 ? HX OF COLONOSCOPY 10/19/2010 ? ATRIAL FLUTTER, PAROXYSMAL 10/26/2010 ? BREAST CYST. 10/27/2010 ? PREDIABETES 11/22/2010 ? AFTERCARE, OSTEOPOROTIC FX VERTEBRAE. 12/01/2010 ? MAJOR DEPRESSIVE DISORDER, RECURRENT EPISODE, IN FULL REMISSION 06/30/2012 ? OSTEOPOROSIS 09/27/2015 ? ATHEROSCLEROSIS OF AORTA 10/12/2015 ? HTN (HYPERTENSION) 04/04/2017 ? FEMALE GENITAL ORGAN PROLAPSE 01/21/2020 ? CKD STAGE 3A (GFR 45-59) 08/29/2022 ? LEFT FEMUR INTERTROCHANTERIC FX 11/24/2023    No Additional Past Medical History      SUBJECTIVE: patient up in chair and wanting to go back to bed. Agreeable to physical therapy    Pain Assessment             Location: left hip              Intensity: (0-10 scale): 2   OBJECTIVE:   Vitals:  Stable    Balance:    11/26/2023 comments Static Sitting:              Good -    Dynamic Sitting:    Fair    Static Standing:    Fair plus with front wheel walker    Dynamic Standing:   Fair - with front wheel walker                         Range of Motion:             Within functional limits except left hip    Strength: within functional limits    Neurological Status:             Sensation:   Intact               Functional Assistance Level: Level of assist key: Maximal Assistance The patient is unable to assist in any effective way in performing a task.  The therapist performs 75% or more of the task for the patient.   Moderate Assistance: The patient is able to voluntarily assist in a task but requires a moderate amount of contact assistance for balance, sequence of movement, plus some verbal cues.  The therapist performs 25% to 75% of the task for the patient. Minimal Assistance: The patient requires a small amount of physical support and verbal cues to complete a task.  The therapist performs less than 25% of the task for the patient.   Stand-by-Assistance:The patient requires close (arm's length) guidance, verbal or physical, in performance of tasks.   Supervision: The patient requires constant attention of supervisory personnel for safety while executing tasks, but does not require physical assistance or contact. Independent: The patient is able to perform tasks safely without the present of supervisory personnel.     Bed Mobility:                 11/26/2023 comments Scoot/Bridge:                           Min assist     Rolling:                           Min assist     Supine to Sit:             Not tested     Sit to Supine:    Min assist       Transfer:                11/26/2023 comments Sit to Stand:    Min assist to moderate with front wheel walker     Stand to Sit:   Min assist     Bed to Chair:   Not tested     Chair to Bed:   Min assist       Gait:    11/26/2023 comments Weight bearing Status:           weight bearing as tolerated    Assistive Device:   Front wheel walker    Level of Assistance:   Min assist     Number of Persons:   1   Distance:   5 ft   Gait Deviations:   Antalgic on left stance    Stair Training:   Not tested       Functional Mobility PROMIS score found in flowsheet      Treatment: Evaluation, Therapeutic Exercises   Miscellaneous: Patient supine in bed , Bed alarm activated, Call light within reach, Bedside tray table within reach, All lines intact, Nursing notified   Plan for next session: progress functional mobility.  PT     Late entry for session at: Treatment Start Time: 0950 Treatment End Time: 1020       DISCHARGE DISCLAIMER: In the event that this patient is discharged from the hospital prior to the next physical therapy session, the patient will be considered discharged from Physical Therapy Services.  For patient status at the time of discharge please see the final Physical Therapy progress note.    Cosigned by:  (M.D.) at 11/27/2023 12:35 PM  Note Details  Author  (P.T.) File Time 11/27/2023 12:35 PM Author Type THERAPIST, PHYSICAL Status Signed Last Editor (P.T.) Specialty GENERAL, OTHER  Admit Date 11/24/2023  Admission (Discharged) on 11/24/2023  Admission (Discharged) on 11/24/2023   Revision History   Detailed Report  Note shared with patient Care Timeline  11/25   Admitted 0855    HIP ORIF 11/27   Discharged 1503