פוסט זה זמין גם ב:
עברית
Leslie L. Chang, M.D.
A 83-year-old woman with osteoporosis, dementia, hypertension, and atrial fibrillation is brought to the emergency department at your hospital after being found on the ground outside her house. She tells you that she fell while on her way to retrieve the mail. The patient’s son reports that she had seemed increasingly confused while he was speaking to her on the telephone 2 days ago and that he had not heard from her since.
In the emergency department, the patient reports pain in her right leg. She has atrial fibrillation, with a heart rate of 156 beats per minute, and her blood pressure is 147/74 mm Hg. On examination, there is no evidence of head trauma or tenderness at the cervical spine. Her right leg is shortened and externally rotated. Her lungs are clear. She is disoriented, reporting the year to be “2023” and stating that she was “at home.”
Her medications include a beta-blocker to control her heart rate and apixaban to reduce her risk of stroke. Initial laboratory studies are notable for a creatinine level of 1.8 mg per deciliter (160 μmol per liter), from the level of 0.8 mg per deciliter (70 μmol per liter) recorded on her medical record 6 months ago. Radiographs show a femoral neck fracture, and computed tomographic imaging of the head shows no evidence of bleeding.
An orthopedic surgeon is consulted in the emergency department; the surgeon recommends urgent surgical fixation of the femoral neck fracture and requests a consultation from the internal medicine service for preoperative risk stratification and guidance regarding management of the patient’s coexisting medical conditions. As the hospital triage physician, you are asked by the surgery and medicine consultants in the emergency department whether this patient should be admitted to the medicine service with the surgical team consulting or to the surgical service with the medicine team consulting.
