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This is a case of a 22 years old
male who was admitted on December 11,
2011 and diagnosed with Fracture on the
proximal third radius- ulna under the
service of Dr. Gines.
When I have my AM Duty.
There then I saw one patient admitted on
Male Surgical ward, where in I
approached him and asked him about his
condition and he replied that he is in pain
as off the moment due to his injury, where
he fell from a manhole and he committed
this fracture.
A fracture is a break in the
continuity of bone. A fracture occurs when
the stress placed on a bone is greater
than the bone can absorb. The stress
may be mechanical (trauma) or related to
a disease process (pathologic). Muscles,
blood vessels, nerves, tendons, joints,
and body organs may injure whenfracture occurs.
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Hidden name: Mr. Firo
Sex: Male
Age: 22 years old
Birthday: August 07, 1989
Birthplace: Agusan Del Sur
Marital status: Single
Address: Floremer Subdivision,
Banilad, Mandaue CityReligion: Seventh Day Adventist
Nationality: Filipino
Informant: Mr. Firo
Reliability: 100%
Occupation: None
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Date of admission: December 11, 2011
at 1:00 AM
Date of discharge: December 14, 2011
Initial diagnosis: Fracture on theproximal third radius-
ulna
Final diagnosis: Fracture proximal
third radius left ulnar,
S/P ORIFChief complaints:
sakit akong kamot kag nihubag tungod kay nabali as
verbalized by Mr. Firo.
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HiStOrY Of PrEsEnT iLlNeSs
Few hours prior to admission, Mr. Firo accidentally fell in a
hole while walking, He tried to support with his left hand, thus sustaining
fracture and seeks consultation at Vincente Gullas Memorial Hospital
and was advised to be admitted.
PaSt MeDiCaL hIsToRy
Mr. Firo had history of Ulcer 15 years ago and was treated and
eventually cured his illness. He was admitted at one of the hospitals in
Agusan Del Sur. After a week of, he was admitted again due to Dengue
Fever.
Mr. Firo is not known to hypertensive, diabetic and asthmatic.
No known food and drug allergies.
FaMily MeDiCaL HiStOrY wItH gEnOgRaM
Mr. Firo was the third child out of four children in his family. His
father has hypertension. The family had no history of diabetic, Bronchial
Asthma and there were no other significant diseases that could
contribute to his ailment.
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Well16 y.o.
Well25 y.o.
Well
48 y.o.Hypertensive
48 y.o.
Well
27 y.o.
LEGEND:
Patient
Male deceased
Male alive
Male deceased
Female alive
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Mr. Firo viewed health as a very important factor to a very joyous life.
He shown great interest to make his life healthy; he followed the order of his
doctor and he was very cooperative with the plans of the doctor on how to
manage the symptoms, by taking medicines, checking of CBC and undergone X-
ray.
He maintained his good health by refraining from smoking cigarette and
drinking alcoholic beverages and exercising everyday early in the morning with
the duration of 30 min to one hour within the vicinity of the subdivision. And for
him, health is not just only physical, but a balance of emotions, intellectual and
spiritual.
My client seeks medical help whenever he felt some discomforts in his
condition.
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My client was 510 in height and 65 kgs in weight; allegedly,
he said that he had a good appetite before the confinement. He likes
to eat vegetables than meats, because he believed in the teaching of
his religion that it is the best to eat vegetables than meat, so he didnt
eat pork, and some of the fishes without scales, and many more. He
didnt have any problem in chewing, or swallowing the foods. He
drinks water regularly, averaging 8 10 or greater, glasses of water
for a day.
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Mr. Firo had a regular bowel movement, though sometimes he
experienced having diarrhea and constipation and he managed this by
drinking lots of water or taking high-fiber foods, like vegetables.
His urinary pattern was also normal, he claimed that he didnt
felt any dysuria (difficulty urinating), flank pain, or any abnormalities.
According to him, his urine color was yellow to amber.
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He has sufficient energy in completing his desired activities.
During his spare time he reads newspaper, surfing at the net, or
watching TV. He had a regular exercise, which is jogging everyday
with the duration of 30 min to one hour within the vicinity of the
subdivision.
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Mr. Firo had a normal sleep/rest pattern. He usually slept
around 10 pm and wake-up at six in the morning. He didnt have any
sleep disturbances like insomnia. Sometimes he fined time to take a
nap during siesta. He does not need any medications as an aid to
sleep.
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He has normal vision and could see clearly. He had no
problem with hearing, no ear pain or tinnitus and any discharges. He
had also no problem with her ability to feel temperature, pain and
touch sensation. He still has good memory and no difficulty in
learning.
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Mr. Firo percepts himself as a son of God, so he treated himself as a
prince. He fully respects his body and believed that beauty is inside your heart.
He is not a moody person and he said he does not know how to get
mad at anyone. If somebody is irritating him he does not react violently but
instead he would make some jokes. He is having mild anxiety about the
physicians decision of whether he has to undergone another operation or not.
His illness didnt affect his perception to himself and his life; he justkeeps on trusting the Lord.
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Mr. Firo is single; his girlfriend broke up with him, 2 months ago.Theyve been 2 years in relationship. Mr. Firo stays at his eldest sister
to find a job here in Cebu City. His Parents was in Agusan Del Sur. Most
of the time their parents used to call them to check out their situation
here in Cebu.
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Mr. Firo was circumcised at the age of 10 years old done by
traditional circumcision by Filipinos locally so called POK POK. He
tried testicular self examination once when he was in college after his
lecture of TSE.
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When I interviewed my client, I asked him, What are the most
stressful things that have happened to you? he simply answered with honesty,
my left hand fracture. Then I had a follow-up question which was how do you
cope up with this stress? he smiled and said, Just by trusting with the Lord
and with the support of his family.
In this simple conversation I could see that he had a huge faith to the
Lord, he believed that God had a right plan for him and the God knew what was
best for him. He didnt relay to humans way on dealing with their stresses, like
drinking or other bad vices.
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Mr. Firo was a Seventh - Day Adventist, he puts God in the
center of his life, in every decision, in every action and in everything he
does. According to him, the only thing he believed in was the message
in the Bible not in any superstitions.
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December 12, 2011
(^) = from the chart (*) = by Lila May (^*) = from the chart/ by Lila
General appearance:
(*) Mr. Firo is conscious and coherent and well-groomed
Vital signs:
(^*) Patient had a T 36 - 37.5 C, P 68 - 112 bpm, R 14 - 24 cpm, BP 120 - 140/70 - 100
mmhgSkin:
(*) Her skin is warm to touch, no pallor and rashes
Head and Neck:
(^*) No lumps on neck, head is normally round with prominence in the frontal area.
Eyes:
(^*) He had pinkish conjunctiva. Round, equal pupils and reactive to light and accommodation.
Ears:(*) No problem with his hearing and no ear discharge, the auricles are level with each other.
Nose:
(*) He had no secretion
Mouth and Throat:
(*) No sore throat, He had dry lips.
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December 12, 2011
(^) = from the chart (*) = by Lila May (^*) = from the chart/ by Lila
Breast:
(^*) No lumps, no discharge
Chest/ Lungs:
(^) Chest movement is symmetric.
Heart:
(^*) Heart was normal with heart rate ranging from 68-112 bpm
Abdomen:
(^) Abdomen was flat, soft flabby NABS, no tenderness
Back:
(*) No lateral deviation
Extremities:(^*) Strong peripheral pulses, fracture left proximal 3rd radius- ulna, CRT < 2 secs, No pedal
edema with equal pulses
Genitalia:
(*) No discharge
Rectal:
(^*) Patent anus
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December 12, 2011
^- from the chart *- by Lila May ^* - from the chart/by Lila May
a. Skin: *
(-) rashes, (-) lumps, (-) itching, (-) dryness, (-) skin turgor
b. Head: *
(-) headache, (-) tenderness
c. Eyes: ^*
(-) pain, (-) double vision, (-) glaucoma, (-) cataracts
d. Ears: *
(-) hearing loss, (-) tinnitus, (-) discharge
e. Nose and Sinuses: *
(-) colds, (-) nasal flaring, (-) nose bleedingf. Mouth and Throat: ^*
(-) mouth sores, (-) hoarseness, (+) dry lips
g. Neck: ^
(-) goiter, (-) lumps
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h. Breasts: ^
(-) lumps, (-) pain, (-) nipple discharge
i. Respiratory: *
(-) cough, (-) sputum, (-) hemoptysisj. Cardiac: ^
(-) heart problem, (-) hypertension, (-) chest pain
k. GIT: ^*
(-) hematemesis, (-) vomiting, (-) melena, (-) abdominal pain
l. Urinary: ^*
(-) nocturia, (-) dysuria, (-) hematurian. Musculoskeletal: ^*
(+) fracture left proximal 3rd radius- ulna
m. Genital: male *
(-) discharge
December 12, 2011
^- from the chart *- by Lila May ^* - from the chart/by Lila May
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