REHABILITATION MEDICINE PEDIA-ORTHO

1. REHABILITATION MEDICINE PEDIA-ORTHO Cecilia Lim Hipolito Neil Illescas CASE OF CHRONIC HIP DISLOCATION

2. PATIENT PROFILE • Patient is K. R • 8 years old male • Right handed male • Roman Catholic • Grade 2 • 109 Luta Sur, Malvar, Batangas • CC: Right hip deformity/ limping

3. HISTORY OF PRESENT ILLNESS Patient has no known co-morbids and with full and in good functioning capacity until... • DOI: Oct, 2009 (3rd week) • TOI: 2 pm • POI: School in Batangas

4. MOI: While the grade 6 students were playing volleyball, patient tried to get to the ball. Unfortunately, a 40 kg player, also trying to get the ball, collided into him, hitting him at the right side while on all fours; accidentally toppling him. There was noted to have deformity after the accident accompanied by limp and leg shortening. (-) LOC, (-) nausea, vomiting. (-) bleeding. (+) pain ~4/10, nonradiating, dull (pain on movement).

5. Patient was then carried home where he was brought to a local albularyo, with no relief of symptoms. There were no medications taken, and no consult at a medical institution. • Patient’s pain gradually dissappeared (2-3 weeks). During this time, patient was able to walk in a limp,able to do all his ADLs without assistance.

6. 1 ½ months PTA, a free medical mission conducted by a private clinic was conducted at their hometown. Xray showed: hip dislocation of the R. No other lab tests done, no medications taken. He was then refered to PGH for further management. • 1 month PTA, patient consulted at the ER, and was subsequently admitted.

7. REVIEW OF SYSTEMS • (-) Headache • (-) nausea, vomiting • (-) fever • (-) weakness, malaise • (-) chest pain • (-) abdominal pain • (-) change in bowel and urinary habits • (+) mild hip pain of R while in traction.

8. PAST MEDICAL HISTORY • No known illnesses • No known allergy to food and medications • No previous surgeries and hospitalizations

9. FAMILY MEDICAL HISTORY • (+) DM – grandfather • (+) goiter – grandmother • (-) HTN, PTB, Asthma, Cancer

10. PERSONAL/SOCIAL HISTORY • Patient is born FT to a then G2P1(0100) mother via SVD in a house c/o midwife. No fetomaternal complications. • Patient’s development is at par with age. • Patient started schooling at age 6, and is currently in grade 2 at age 8. • Patient is an active child, with hobbies including playing and watching TV.

11. Patient lives in a 1 storey, ~ 40 sqm house in Batangas with his parents and 2 siblings (3 and 1 yr old). The restroom is located around 2 m away from the bedroom; transportation arpund 5 m away from the house; and school around ___m away from house. • Patients mother is a housewife, and his father is a bus driver.Family income is about 500-3000/month. • Currently, patient’s medical bills were paid from money borrowed from relatives.

12. Immunization • Complete EPI from the local health center.

13. Nutrition • Patient likes to eat fruits, meat, and junkfood.

14. FUNCTIONAL HISTORY

17. GENERAL SURVEY Patient was received awake, conversant and speaking in sentences, Not in cardio-respiratory distress, oriented to 3 spheres, GCS 15 VITAL SIGNS • BP:100/80 • HR: 98 • RR: 20 • T: Afebrile to touch

18. HEENT Anicteric sclerae, pale palpebral conjunctivae, (-) nasal or aural discharges, pale buccal mucosa and tongue, pale lips, (-) tonsillopharyngeal congestion (-) anterior neck mass (-) neck vein engorgement. CHEST /LUNGS (-) gross deformities symmetric chest expansion, clear breath sounds (-) crackles (-) wheezes (-) ronchi

19. CVS (-) heaves, (-) thrills, distinct heart sounds, normal rate, regular rhythm ABDOMEN Flabby abdomen, normactive bowel sounds, soft to palpation, (-) masses (-) tenderness (-) organomegaly

20. SKIN and EXTREMITIES Full and equal pulses, pale nail beds, good capillary refill (-) edema (-) cyanosis (-) clubbing. PE on admission: • R lower extermity attitude • internal rotation; • shortened ~ 4 cm, • no sensory deficits • Limitation motion of the R hip due to pain (minimal) • Palpable bony deformity of R hip • Galleazi sign

21. Currently Patient’s R leg on Pin traction, L leg on foam traction. Leg length of L, ___, of R ____.

22. NEUROLOGIC EXAMINATION Patient is awake, coherent, oriented to three spheres, and follows commands. CN I: intact smell II: pupils 3-3mm EBRTL, (+) visual threat; (-) visual field cuts III, IV, VI: full intact EOMs V: brisk corneals, V1 V2 and V3 sensation intact on both sides. Good masseter tone and temporalis. VII: (-) facial asymmetry VIII: intact gross hearing IX, X: Good gag reflex. XI: good shoulder shrug XII: tongue midline Cerebellars: No nystagmus, dysmetria and dysdiadochokinesia; Meningeal Examination: (-) Brudzinski’s, (-) kernig’s

23. Deep Tendon Reflexes

25. RANGE OF MOTION

30. SENSORY:Pain & light touch

31. XRAY RESULTS • Superiorly and posteriorly dislocated, R hips. No acetabular change.

32. LABORATORY RESULTS

33. LABORATORY RESULTS

34. LABORATORY RESULTS

35. ASSESSMENT • Chronic Hip Dislocation, R secondary to trauma

36. PLAN OF ORTHO DEPARTMENT • Skeletal traction, increase in weight for 2 weeks. If failed after maximum weight ~10 kg, would consider OR, possible fixation hip spica?

37. COURSE IN THE WARDS

38. COURSE IN THE WARDS