Presentation Germe

8/3/2019 Presentation Germe

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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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