Beirut Arab University

Faculty Of Medicine
Fall Semester 2013-2014
Orthopedics & Traumatology
Clinical Case Report
Tarek Ammoun

Personal History:
Patient name: R.H Age: 91 Years
Sex: F Marital Status: Single
Occupation: None
Personal Habits: Non-smoker, non-alcoholic

Chief Complaint:
Severe Left hip pain after a fall 2 days ago.
Present History:
This is a case of 91 years old female patient, previously healthy? Presented to the ER due the
above chief complaint.
History goes back 2 days ago when patient fell on her left hip when she was walking out of her
room at night, & then she was admitted ambulatory to Makassid hospital, where she had skin
traction, & then transferred to our hospital 1 day ago.
Pain is stabby in nature, severe continuous, localized with no radiation, slightly relieved by
morphine & tramal. She felt in the sitting position on her left hip & then rested on her back.
She is losing weight since the last 5 months (10 Kg), with no fever, no hematuria, dysuria,
diarrhea, constipation or any other associated symptoms.
Past Medical History:
Negative
Past Surgical History:
Negative
Allergy:
No allergy to any drugs or medication
Drug History:
She takes aspirin & concor as a prophylaxis but stopped 5 monthes ago.
Physical Examination:
Weight: 61 Kg Temperature: 37 degree
BP: 110/60 mmhg Pulse: 82 BPM
PaO2: 98%
General Appearance:
Patient conscious, oriented but uncooperative, patient lying in bed.
General Examination:
Head & Neck: There is no bulges all over the skull with regular hair pattern with no focal hair
loss of the eyebrows, there is no examphalmus, slightly deviated nasal septum with no masses
within the nasal cavity. There is no ulcerations in the oral cavity.
There is no pallor or cyanosis or jaundice in the sclera or mucous membranes.
No enlarged cervical lymph nodes or tonsils.
Thyroid & salivary glands are not palpable
No congested neck veins
Carotid artery is felt equally & bilaterally.
Chest: Good bilateral air entry with no adventitious sounds.
Heart: Regular S1S2 with no murmurs.
Abdomen: Soft abdomen, with decreased skin turgor with no tenderness all over the abdominal
areas, with no masses or bulges with no hepatosplenomegally.
Local Examination of lower limb:
Large ecchomotic area over the left hip region with maximum point of tenderness over the
greater trochentiric area, edematous, with no wounds or bullae over the area of injury & no
visible deformities.
There is good peripheral pulse, good perfusion with intact sensation.
Patient cant extend or flex her hips actively & passively, but she can more her ankle & fingers.
Laboratory Results:
WBC: 10,000 mm3 RBC: 4.22 mm3
Hemoglobin: 12.2 Hematocrit: 35.2
INR: 1.07
BUN: 14.61 Creatinine: 0.78
Consults:
Dr. Osman Itani for Pulmonary clearance: intermediate risk patient but can proceed to OR
Dr. Nabil Shasha for cardio clearance: ECG => Normal Sinus rhythm, with no cardiomegaly
=> Impression: intermediate risk patient
X-ray:
Description: This is Pelvic X-ray of R.H Patient in the A.P view showing a proximal fracture of
the left femur that is spiral, non-comminuted, dislocated & overlapping about 0.5 cm between
the greater & lesser trochanter.
Diagnosis: Left intertrochanteric Fracture.
Plan:
In general, this is a high risk elderly patient, & it is recommended to use compression screw
fixation to provide stability with minimum complications.








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