ED Note

72-year-old female Patient arrived via ambulance after a fall at home. Assessed in the Emergency Department. Chief Complaint: Right hip pain and inability to bear weight after a fall. History of Presenting Complaint: • Patient fell approximately 2 hours prior to presentation while walking in her home. • She reports immediately experiencing severe right hip pain and was unable to stand or bear weight. • Pain is described as sharp, constant, and rated 8/10 at rest. • No loss of consciousness, head injury, or altered mental status reported. • No preceding dizziness, chest pain, or palpitations. • Aggravated by any movement of the right leg. • Relieved slightly by lying still. • No fever, chills, or night sweats. • No bowel or bladder incontinence. • No new weakness or sensory deficits. Past Medical History: • Osteoporosis, diagnosed 5 years ago. • Hypertension, well controlled on medication. • Type 2 Diabetes Mellitus, managed with oral agents. • Previous appendectomy (1985). Medications: • Amlodipine 5mg once daily • Metformin 500mg twice daily • Alendronate 70mg once weekly • Calcium Carbonate/Vitamin D 500mg/400IU twice daily Allergies: • Penicillin (rash) • Codeine (nausea) Social History: Patient is a retired teacher, lives alone in a single-story house. Non-smoker, rarely consumes alcohol (socially). No recreational drug use. Receives support from a neighbour for shopping. Family History: Mother had osteoporosis. Father had hypertension and type 2 diabetes. No family history of sudden cardiac death or genetic disorders. Examination: A - Airway: Patent and protected. No stridor or drooling. B - Breathing: Respiratory rate 18 breaths/min. Symmetrical chest expansion. No increased work of breathing. Oxygen saturation 98% on room air. Clear bilateral breath sounds on auscultation. No crepitations or wheezes. C - Circulation: Hr 88 bpm, BP 145/85 mmHg, CRT <2 seconds. Peripheral pulses palpable and strong. No murmurs or gallops on cardiac auscultation. D - Disability: Alert and oriented to person, place, and time (GCS 15). Pupils equal, round, and reactive to light (3mm bilaterally). Motor function intact in upper extremities. Right lower extremity shortened and externally rotated, painful to any movement. Sensation intact bilaterally. E - Exposure: Temperature 36.8. Skin warm and dry, no rashes. Obvious deformity of the right hip with shortening and external rotation. No open wounds or ecchymosis noted at this time. Abdomen soft and non-tender. Investigations: Blood results: • Hb 12.5 g/dL • WBC 8.2 x 10^9/L • Platelets 250 x 10^9/L • Na 138 mmol/L • K 4.0 mmol/L • Creatinine 75 µmol/L • Glucose 6.5 mmol/L • CRP 5 mg/L ECG: Sinus rhythm, normal axis, no acute ischaemic changes. VBG: Not performed. POCUS: Not performed. Impression: Right hip fracture (likely femoral neck fracture) secondary to fall in an elderly patient with osteoporosis. Plan: • Analgesia: IV Paracetamol 1g and IV Morphine 2mg aliquots as needed for pain control. • Immobilisation: Right leg immobilised with a splint. • Imaging: Urgent X-ray right hip and pelvis. CT scan of the hip if X-rays inconclusive or for surgical planning. • Consult Orthopaedics for urgent surgical review. • Admit to orthopaedic ward for further management. • Pre-operative bloods and ECG. • Review bone health and fall prevention strategies post-operatively. Discussion with family - Patient's daughter, Mrs. Sarah Davies, was contacted by phone and updated on her mother's condition. The clinical impression of a fractured hip and the need for urgent orthopaedic review and potential surgery was explained. The risks and benefits of surgery, including anaesthetic risks, were discussed. Mrs. Davies understood the situation and agreed with the proposed plan of care. She will be coming to the hospital to be with her mother. Dr. Alex Carter, Emergency Medicine Consultant