Dispatch
Medic 4 was dispatched to the above-listed address for a fall.
Chief Complaint
Pt is an 81 YOF with a chief complaint of a fall. Pt was located supine on the floor at a residence in the bedroom. Pt was alert upon arrival.
History
History was obtained from Family. Pt has a history of hypertension and osteoporosis. Pt denies recent surgery or other pertinent history. It was reported that Pt stood from a chair, felt lightheaded, and fell to the floor. Pt denies a loss of consciousness and reports a head strike was not felt.
Allergies: no known drug allergies. Medications: a list was given to the ED. Last oral intake was breakfast.
Events leading up: Family heard the fall and found Pt on the bedroom floor, unable to stand.
Onset was sudden. It is provoked by movement. Quality is sharp. Radiation: to the hip. Severity 8/10. Time constant since onset.
Assessment
Airway is intact. No airway compromise noted. Respirations are initially 18. Respirations are regular, adequate, and unlabored. Initial BP was 132/74. Pt's initial pulse is 88. The pulse is strong and regular. The Pt's skin is pink, warm, and dry. Pt appeared emergent. ER evaluation is indicated for a fall.
Physical Exam
Head: atraumatic. No hematoma. Pupils are equal and reactive. Pt is AOx4.
Neck: no midline tenderness.
Chest: Pt denies chest pain and shortness of breath. Lung sounds are clear.
Pelvis and the right hip are tender to palpation. The right leg is shortened and rotated. Pt is negative for DCAP-BTLS except the right hip tenderness described above.
Diagnostic Tests
SPO2 97% on room air. Blood glucose 104 mg/dL.
Primary Impression
Hip fracture.
Medications and Procedures
Pt was moved to the cot with a scoop stretcher and padded in a position of comfort. No medications were administered.
Transport
Pt was transported nonemergent to Sycamore Hospital. Pt remained stable during transport. A report was given on arrival. Pt was released to the RN staff in the emergency department in a stable condition.