53.

The patient is an 88-year-old Caucasian female, household ambulator with a

walker who presents to the emergency department this morning after an incidental
fall at home. The patient states that she was on a ladder on Saturday, and she fell
off the ladder, injuring her left shoulder. She felt some pain in her left hip. It is
unclear how long she was on the floor. She was taken by EMS to the hospital
where she was noted radiographically to have a left proximal humerus fracture and
a nondisplaced hip fracture. Orthopedics was consulted. Given the nature of the
injury and the unclear events, an extensive workup was performed including a
head CT and a CT of the abdomen, which identified no evidence of the
intracranial injury. She presently is complaining of pain in the left shoulder. She
states that she also has pain in the hip with motion of the leg. She denies any
numbness or paresthesias. She states that prior to this, she was relatively active
within her home. She does care for her daughter. The patient denies any other
injuries or back pain.