Date Admitted: January 27, 2023

DIAGNOSIS: FRACTURE CLOSED COMPLETE DISPLACED SUBTROCHANTERIC FEMUR RIGHT

Patient is an 83 year old Female residing at Hagonoy, Bulacan brought to POC after having a
slipped fall.

According to the relative, 1 day prior to admission, the patient hit furniture in her path and fell.
The patient verbalized that she tried to stand up and walk but she heard a loud clicking sound in her
affected area. On the same day, they went to provincial hospital in Bulacan for a check up of her pain on
the right hip with a pain scale of 8/10. They were subsequently referred to Philippine Orthopedic Center
for further diagnosis and management.

X-ray was done and revealed fracture of the right femur. HbA1C – 7.20%; CBC, Platelet, RBC and
WBC are all normal except for Eosinophil of 0.70. Patient is known to have a Diabetes and unrecalled
cardiac condition. Patient was equipped with Balance skeletal traction and underwent a Closed
Reduction Internal Fixation Right Femur with Packed Dressing and Elastic Bandage and Indwelling
catheter. During her hospitalization, patient developed bedsore in the sacral area, Grade III.

Medications are: Celecoxib 200 mg/cap BID for 5 days, then PRN for pain, Tramadol 50mg/cap q
6 PRN for moderate to severe pain, Paracetamol 1 G IV q 6 RTC for 5 days, Metoclopramide 10 mg q 6,
Silver Sulfadiazine for bed sore applied BID, Enoxaparin 0.4 cc/ S.C. OD, Calcium + Vitamin D BID,
Cefuroxime 750 mg IV q 8h to complete for 7 days.