History & Physical

History (H)

• Chief Complaint: Left hip pain following a fall at home.

• History of Present Illness (HPI): Mr. Robert Jameson is a 72-year-old male admitted following a fall at home resulting in left hip pain and decreased mobility. Underwent left total hip arthroplasty. Reports ongoing pain at the surgical site rated at 7/10, primarily with movement. Denies nausea, vomiting, or dizziness. No evidence of confusion.

• Past Medical History (PMH):

  • Osteoarthritis

  • Benign prostate hypertrophy (BPH)

  • Hypertension (Well-controlled with medications)

• Past Surgical History (PSH):

  • Left total hip arthroplasty (current hospitalization) - completed without complications

• Family History (FH):

  • Father: Deceased, myocardial infarction at age 78

  • Mother: Deceased, osteoarthritis

• Social History (SH):

  • Lives alone at home, uses cane for ambulation

  • Former smoker, quit 10 years ago

  • Occasional alcohol use, denies illicit drug use

• Allergies: None known

• Medications:

  • Lisinopril 10mg PO daily (for hypertension)

  • Acetaminophen 1g PO q6h PRN (post-op pain)

  • Oxycodone 5mg PO q4h PRN (post-op pain)

  • Enoxaparin 40mg subcutaneously daily (for anticoagulation)

  • Cefazolin 1g IV q8h (for post-op prophylaxis)

Physical Examination

• Vital Signs: BP 140/90, HR 92, RR 16, Temp 98.6°F, O2 Sat 95% on room air

• General Appearance: Alert, oriented, appears uncomfortable due to pain.

• HEENT: Normocephalic, no signs of trauma, mucous membranes moist.

• Cardiovascular: Regular rate and rhythm, no murmurs, peripheral pulses palpable.

• Respiratory: Clear to auscultation bilaterally, no crackles or wheezes.

• Gastrointestinal: Abdomen soft, non-tender, normoactive bowel sounds.

• Neurological: Alert and oriented, no focal neurological deficits.

• Musculoskeletal: Limited range of motion in left hip due to pain; mild edema noted.

• Skin: Mild redness over left heel, no signs of breakdown or infection.