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TOGETHER AS ONE

This case study presents a detailed account of a 15-year-old right-handed student from Mandaluyong City who suffered a significant left arm injury during a fall while playing. The patient reported limitations in movement, persistent symptoms, and functional difficulties in daily activities following the accident. Initial treatments and consultations are documented, highlighting the importance of medical intervention. The study also explores the patient's personal, family, and social history, which may impact recovery outcomes. Follow-up recommendations and potential surgery are discussed.

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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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