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TRAUMA SGD

TRAUMA SGD. De Jesus, De Robles, De Silos, Dela Victoria, Deogracias , Detoya , Diaz. FB, 74/M, right-handed, unemployed, from Malate, Manila Admitted last November 11, 2009. CC: hip pain. History. DOI : November 1, 2009 TOI : 8:00 PM POI : Quirino Avenue MOI : FALL. History.

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TRAUMA SGD

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  1. TRAUMA SGD De Jesus, De Robles, De Silos, Dela Victoria, Deogracias, Detoya, Diaz

  2. FB, 74/M, right-handed, unemployed, from Malate, Manila Admitted last November 11, 2009. CC: hip pain

  3. History • DOI : November 1, 2009 • TOI : 8:00 PM • POI : Quirino Avenue • MOI : FALL

  4. History • While on his way home, patient tripped on a cemented pavement, fell on his left side, elbow first then hip. (-) LOC, vomiting. • Patient rode a pedicap home. He couldn’t walk due to pain on the left hip area. (+) ice pack and rest, self-medicated with Celecoxib 200mg • After 2 days  (+) swelling and warmth and persistence of pain prompter consult at the OspitalngMaynila  x-ray done revealed a femoral fracture  referred to our institution

  5. Physical Examination • Awake, alert, not in cardiorespiratory distress • BP 160/70, HR 90, RR 20, T afebrile • PC, AS, (-) NVE/CLAD, (+) hyperpigmented mass on the nose • ECE, CBS, (-) adventitious sounds • AP, DHS, (-) murmurs • Soft, flat abdomen, NABS • (+) 3cm scar on the left elbow

  6. Physical Examination • Left LE seen externally rotated • (-) wound/scar/pigmentation • (-) swelling (+) warmth (+) redness • (+) tenderness on the left hip area • Pink Nail Beds, CRT < 2s

  7. Physical Examination • Sensory • 100% intact on light touch • Motor • Patient able to move toes • Distance from ASIS to Tibial Plateau • Left – 42 cm • Right – 44 cm

  8. X-ray

  9. Assessment • HIP : Fracture, closed, complete, transverse, displaced, femoral neck, transcervical, left

  10. Treatment • Ice Compress • Foam Traction, left • Celecoxib 200mg BID prn for pain

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