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