together as one
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TOGETHER AS ONE
Bolintiam, Cruz, dela Cruz, Lu, Que, Rivera, Sioco, Tai, Valera, Veloso
Identifying Data
• ML• 15 F• Mandaluyong City• RC• Student• Right handed
Chief Complaint
“Hindi maigalaw mabuti ang kaliwang braso” (limitation of movement of the Left arm)
HPI14 months PTA(October 2011)
• Playing on top of a rolling drum
• Fell with an outstretched left arm
• (+) limp L arm
HPI14 months PTA(October 2011)
• (+) swelling, gross deformity
• (-) open wound• (-) numbness and
other sensory deficits• “Hilot” for two months
HPI
12 months PTA
• No improvement of symptoms
• Limitation of flexion of elbow to only about 30deg
• Sought consult in POC• Xray
XRAY
XRAY
XRAY
XRAY
XRAY
HPI
12 months PTA
• No improvement of symptoms
• Limitation of flexion of elbow to only about 30deg
• Sought consult in POC• Xray
• Advised to follow-up after 6 months
HPI
6 months PTA
• On follow-up:– Advised surgery– Referred to another
institution– Deferred
HPI
1 month PTA
• Patient sought consult with attending physician and was advised surgery
• Referred to DM
ADMISSION
Past Medical History
• No asthma, lung, heart, kidney, liver and other congenital diseases
• No previous hospitalizations• No previous surgeries• No allergies to food and medications
• DPT x 3• OPV x 3• Hep B x3• BCG• Measles
Immunization
Developmental History
• At par with age– Cognition, motor, verbal
Functional History (Activities of Daily living )
Prior to accident• Bathing• Dressing• Grooming• Oral care• Toileting• Transferring• Eating
After accident• Difficulty in
– Bathing– Dressing– Grooming– Eating
Functional History (Instrumental Activities of Daily living)
Prior to accident• Shopping• Food preparation• Housekeeping• Laundry• Transportation• Finances
After accident• Difficulty in
– Food preparation– Housekeeping– Laundry
Family History
Family History
• (+) Diabetes- father of patient, osteoporosis- grandmother of patient
• (-) Hypertension, Dyslipidemia, Stroke, MI, Cardiac Problems, Renal Problems, Cancer, Asthma
Personal and Social History
• Non-smoker• Non-alcoholic beverage• No illicit drug use
Personal and Social History (HEADSSS)
• Home– Close to family
• Education– Incoming 1st year high
school student– Forced to stop school this
year• Activities
– Loves to watch TV • Diet
– 3 meals: rice and meat
• Suicide– None
• Sex– None
• Substance– None
Review of Systems
• General: (-) fever, weight loss, loss of appetite• Musculoskeletal/Derma: No skin lesions or changes• HEENT: (-) history of head injury. (-) BOV, tinnitus,
epistaxis, (-)dysphagia or enlarged lymph nodes• Respiratory: (-) cough or colds, wheezing,
hemoptysis• Gastrointestinal: (-) abdominal pain, changes in
bowel habits, diarrhea, or constipation• Genitourinary: (-) dysuria or hematuria,
Physical Exam
• Awake, alert, coherent• Vitals: – 42 kg, 142; BMI 18.2 Normal– BP 100/60– HR 86– RR 19 – Temp 36.4– Not in pain (0)
PHYSICAL EXAMINATION
GENERAL APPEARANCE
Alert, coherent, cooperative, medium-build
VITAL SIGNS BP: 100/60 Temp: 36.4 VAS: 0/10HR: 86 RR: 19Wt: 42g Ht: 152 cm BMI: 26.06
SKIN AND HAIR warm, good skin turgor, (-) no thinning of hair
EYES Pink palpebral conjunctiva, Anicteric sclerae, EBRTL, (-) lid lag
PHYSICAL EXAMINATIONMOUTH (-) Lesions in the buccal mucosa, (-) TPC, (-)
enlargement of the tongue NECK (-) CLAD, non-enlarged thyroid,
(-) thyroid noduleCHEST No intercostal retractions, No use of
accessory muscles, equal chest expansion, Clear breath sounds, (-) rales and wheezes
CARDIOVASCULAR
Adynamic precordium, no heaves thrills and lifts. Normal rate and regular rhythm, Good S1 and S2 sounds, no murmurs, full and equal pulses on all extremities
PHYSICAL EXAMINATION
ABDOMEN No lesions, NABS, tympanitic upon percussion, no organomegaly, (-)tenderness
GU (-) CVA tenderness
Extremities (+) gross deformity of the Left arm(+) limitation of movement• Maximum flexion: 30 degrees• Extension: 0 degrees• Slight limitation on pronation and
supination
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