Orthopedics Surgery Case Presentation

Date July 2, 2018

Time 10pm
Source: Mother
Reliability of 90%

P. J 6 yr old Male, child, Filipino, Roman Catholic, born on March 5, 2012 in Cebu City, currently
resides in Tawagan II Sirao Cebu City, admitted to Vicente Sotto Memorial Medical Center on
June 2, 2018 for the first time

Chief Complaint: pain on Right arm

HPI
NOI: Fall
TOI: 3pm
DOI: July 2, 2018
POI: Sirao

Patient was climbing up a mango tree accidentally fell landing on his right arm PS 10/10
rushed to the hospital for further management.

Past Medical History

Non HTN, DM, Asthmatic
Claimed complete immunizations
Unrecalled childhood illnesses

Personal and Social History

Renting a bungalow house in Sirao
Water supply deep well
No Electricity

Family History
No Heredofamilial diseases as claimed

Physical Examination
General Survey
Conscious, coherent and alert, oriented as to time, place and person, ambulatory
with no abnormalities in gait, posture, sthenic and mesomorphic, no involuntary movements,
no abnormalities in speech, not in respiratory distress.

PHYSICAL EXAMINATION ON ADMISSION

General survey: Patient is awake, responsive and coherent. Ambulatory.
Not in respiratory distress.
Vital signs:
BP – 90/60 mmHg HR – 107 bpm RR – 22 cpm Temp – 36.7
O2 sat – 98% Height: 120 cm Weight: 16 kg BMI:

SKIN: Brown color, no jaundice, visible old scars, warm with good turgor and mobility

HEENT: Normocephalic head, anicteric sclerae, pink palbebral conjuctivae, dry lips, (-) thyroid
enlargement, Trachea midline non palpable lymph nodes

C/L Equal Chest Expansion, Clear Breath Sounds

CVS: Distinct Heart Sounds

Abdomen: Flat, Soft, Nontender, Normoactive Bowel Sounds

GUT: (-) Kidney Punch Sign

Musculoskeletal: Full range of motion on all extremities, except right upper. Limited pronation.
Evidence of swelling. 5/5 muscle strength on all extremities, except right upper extremity, 3/5.

Extremitty: Strong peripheral pulses, CRT < 2 secs., (+) swelling on right elbow. Limitation of
movement noted,

Rectal: Not done

Neurologic: Within normal limits, No deficit

**** Insert Xray

Admitting Impression

1. Fracture, Closed, Complete, Displaced Supracondylar Humerus Right Secondary to Fall