Fall with hip injury
Complete SOAP example
Example narrative
82-year-old woman from HOME, normally independent with walker, reports tripping and falling onto left side 45 minutes ago. Denies presyncope or LOC; reports head strike and takes apixaban. Hip pain 8/10; cannot weight-bear.
Primary survey intact. Patient found supine on floor, GCS 15. Left leg shortened and externally rotated; distal CSM present. No open injury. Head and spine findings documented; serial vitals stable by measured values.
Differential considerations: 1) proximal femur or hip fracture, 2) pelvic injury, 3) occult intracranial injury given head strike and anticoagulation. No current neurovascular compromise.
Analgesia provided per applicable guideline, reducing pain to 4/10. Patient moved with appropriate device; distal CSM unchanged. Transported to ED with mechanism, anticoagulant use and reassessment findings handed over.