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)