together as one
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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• (+) swelling• (+) gross deformity• (-) open wound• (-) movement• (-) sensory
problems/deficits• “Hilot” for two
months
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
XRAY
XRAY
XRAY
XRAY
XRAY
HPI
6 months PTA
• Persistence of symptoms
• Return consult to POC– Advised surgery– Referred to another
institution– Deferred
HPI
1 month PTA
• Persistence of symptoms
• Patient sought consult with attending physician and was advised surgery
• Referred to DM
ADMISSION
Past Medical History
• Unremarkable
• 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)