ggparker14
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If the patient is unable to communicate, but no mention of why in the physical examination, but dementia mentioned in the assessment, would this be considered a comprehensive examination?
patient took a fall, contusion to elbow, contusion to temple area, unconscious in ER.
physical examination: She is a 70-year old female lying in bed in no apparent distress. She is unable to communicate. She is just alert, making babbling sounds. With reference to her left lower extremity, she is somewhat shortened and flexed. Any movement of left hip creates pain.
Assessment: Displaced subcapital fracture of the hip, demential, severe.
patient took a fall, contusion to elbow, contusion to temple area, unconscious in ER.
physical examination: She is a 70-year old female lying in bed in no apparent distress. She is unable to communicate. She is just alert, making babbling sounds. With reference to her left lower extremity, she is somewhat shortened and flexed. Any movement of left hip creates pain.
Assessment: Displaced subcapital fracture of the hip, demential, severe.