Case 3 – Jimmy James - Inpatient Rehab

HPI: Jimmy James is a 64-year-old male admitted to the hospital on 4/21 after tripping
over his dog. He was found to have a R femoral neck fracture and was taken for a R THR
on 4/22. On 4/24 he was triggered for mental status changes, fevers, tachycardia, and
hypertension. He was transferred to the ICU and was placed on a CIWA scale for
Delirium Tremens, requiring Ativan. He was also started on antibiotics for potential
infection.

On 4/26 he was transferred back to the floor and then to a SNF level rehab on 4/27. He
is being seen by PT for initial evaluation in rehab.

Activity Orders: Weight bearing as tolerated, Posterior Dislocation Precautions

Past Medical/Surgical History:

Heavy ETOH use
Asthma
HTN
Depression
Osteoarthritis
Chronic LBP

Labs 4/26:
WBC: 7.7
HGB: 9.3*
HCT: 26.8*
Plt Count: 77*

Radiology:
Hip 4/21:
Two views of the right hip were provided.  An acute fracture is seen involving
the right femoral neck at a mid cervical level.  The fracture appears slightly
impacted and with the distal shaft slightly superiorly displaced. 
Degenerative changes at the right hip include mild marginal spurring and mild
loss of joint space.

4/21: CT C-spine w/o contrast:

1. No acute fracture or traumatic subluxation.
2. Diffuse moderate to severe degenerative changes as described
above.

4/21: Head CT
1. No acute intracranial findings.
2. Age advanced involutional changes.

Medications:
Lisinopril 5', Hydrochlorothiazide 25', Albuterol MDI prn, Azmacort MDI 2 puffs q4,
Symbacort, Dilaudid PRN

Social History: Patient does not work—he worked at a paper mill in the past. He is
divorced and does not have a relationship with his 2 daughters. Reports no family
support. He lives with a friend (sleeping on the couch) and his dog.
+Tobacco – ½ PPD

Living environment: Friend’s house is a 3rd floor walk up apartment—3 flights to enter,
then level. Has had difficulties with stairs to enter due to bilateral knee OA, so doesn’t
often go out, but is able.

Prior level of function: Patient independent with ADL and IADLs. No regular exercise,
no DME

New Mobility Score for Pre-fracture Functional Level:

Indoor Walking: 3
Outdoor Walking: 3
Shopping: 3
Total Score: 9/9

OBJECTIVE TESTS
Arousal, Attention, Cognition, Communication: Patient alert, fidgety, easily frustrated
with questioning
Oriented to self, location, and situation but further questioning not attempted
Able to follow commands

Safety Awareness/Insight: Patient required cues for decreased safety awareness during
functional mobility including hand placement and management of environmental
obstacles. Patient requires cues for safety awareness regarding need for assist with
mobility.

Hemodynamic Response/Aerobic Capacity

Position HR BP
Rest Supine 109 112/66
Sit 118 114/74
Stand Unable to assess
Activity
Recovery 106 114/74
Integumentary:
incision with postoperative dressing C/D/I

Vascular: edema noted RLE

Sensory Integrity: intact to light touch

Pain: Patient declined use of verbal analog scale. Responded “of course I have pain”
when asked. Pre-medicated with Dilaudid by nursing. Significant muscle guarding with
ROM

Limiting Symptoms:
pain
generalized fatigue

Posture: lateral lean away from operative hip at edge of bed, but
otherwise stable

Range Of Motion: RLE

Hip flexion supine: 88
Hip extension in supine -10
Hip abduction supine: 12
BLE and LLE grossly WFL

Muscle Performance: bil UE and LLE grossly 5/5 t/o

RLE limited by pain: R hip flexion 3-/5, abduction/adduction 2-/5, extension able to
palpate contraction; R knee extension 4-/5

Motor Function: moves all extremities in isolation, no coordination deficits noted during
functional mobility

Functional Status
Rolling: Min A with use of rail
Supine/sidelying to sit: min A with rail
Sit to Stand: mod A x 1
Ambulation: Unable to attempt due to pain
Stairs: NT
Functional Activities: Patient stood for approx. 30 seconds – able to maintain standing
with rolling walker and CG – patient refused to attempt taking steps due to pain

Gait: Unable

Balance: static edge of bed without UE use intact; static stance with RW and CG