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TOGETHER AS ONE

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). HPI.

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TOGETHER AS ONE

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  1. TOGETHER AS ONE Bolintiam, Cruz, dela Cruz, Lu, Que, Rivera, Sioco, Tai, Valera, Veloso

  2. Identifying Data • ML • 15 F • Mandaluyong City • RC • Student • Right handed

  3. Chief Complaint • “Hindi maigalawmabutiangkaliwangbraso” • (limitation of movement of the Left arm)

  4. HPI • Playing on top of a rolling drum • Fell with an outstretched left arm • (+) limp L arm • (+) swelling • (+) gross deformity • (-) open wound • (-) movement • (-) sensory problems/deficits • “Hilot” for two months 14 months PTA (October 2011)

  5. HPI 12 months PTA • Limitation of flexion of elbow to only about 30deg • Sought consult in POC • Xray • Advised to have follow-up after 6 months

  6. XRAY

  7. XRAY

  8. XRAY

  9. XRAY

  10. XRAY

  11. HPI 6 months PTA • Persistence of symptoms • Return consult to POC • Advised surgery • Referred to another institution • Deferred

  12. HPI 1 month PTA • Persistence of symptoms • Patient sought consult with attending physician and was advised surgery • Referred to DM ADMISSION

  13. Past Medical History • Unremarkable

  14. Immunization • DPT x 3 • OPV x 3 • Hep B x3 • BCG • Measles

  15. Developmental History • At par with age • Cognition, motor, verbal

  16. Functional History (Activities of Daily living ) Prior to accident After accident Difficulty in Bathing Dressing Grooming Eating • Bathing • Dressing • Grooming • Oral care • Toileting • Transferring • Eating

  17. Functional History(Instrumental Activities of Daily living) Prior to accident After accident Difficulty in Food preparation Housekeeping Laundry • Shopping • Food preparation • Housekeeping • Laundry • Transportation • Finances

  18. Family History

  19. Family History • (+) Diabetes- father of patient, osteoporosis- grandmother of patient • (-) Hypertension, Dyslipidemia, Stroke, MI, Cardiac Problems, Renal Problems, Cancer, Asthma

  20. Personal and Social History • Non-smoker • Non-alcoholic beverage • No illicit drug use

  21. 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

  22. 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, (-)dysphagiaor enlarged lymph nodes • Respiratory: (-) cough or colds, wheezing, hemoptysis • Gastrointestinal: (-) abdominal pain, changes in bowel habits, diarrhea, or constipation • Genitourinary: (-) dysuria or hematuria,

  23. 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)

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