Case Presentation Script

Good afternoon/evening doctors, I am_______________________, a representative of

group 4, presenting to you the case of R.P., a 37 year old, Male, married, a farmer from Payao,
Zamboanga Sibugay, a Filipino, bisaya, a high school graduate and a Roman Catholic who came
in with a chief complaint of LEG PAIN.

Patient was apparently well until, hours prior to admission, about 1:00pm, patient was
riding as a passenger on a motorcycle when they were involved in a motor vehicular accident
and sustained a direct brushing impact from the approaching truck on the medial aspect of the
distal left thigh, immediately resulting in a severe 10/10, sharp & persistent leg pain
accompanied by gross deformity characterized by internal rotation of the lower leg and
abduction of the thigh, inability to mobilize the affected extremity, with noted antero-medial
protrusion of bone, swelling and active bleeding from a lacerated wound on the distal aspect of
the left thigh. Furthermore, the patient also sustained injuries on the long and ring finger
accompanied by abrasions on the left forearm. No noted, blunt trauma to the head, chest and
abdomen. No nausea and vomiting, headache, LOC, chest pain and abdominal pain noted.

EMT arrived on the site within 30 minutes and provided first-aid. A splint was applied on
his injured leg and hand and was transported to Zamboanga Sibugay Provincial Hospital. A
persistent sharp pain with a score of 10/10, paleness and cool to touch left leg with no fever
and dyspnea were reported. IM pain reliever with unrecalled name and dosage was given which
afforded temporary relief. He underwent X-ray and other blood work-ups. The patient was
consequently brought and admitted to ZCMC the same day for further orthopedic evaluation
and management.

For past medical history,

Patient has no history of previous hospitalization, no allergies to any medications or

food, not diagnosed with any chronic diseases such as Hypertension, DM, TB, and Cancer, blood
disorders, renal diseases, musculoskeletal and autoimmune disorders and no history of blood
transfusion. He has no maintenance drugs and denies any intake of vitamins and mineral
supplements.

For family history,

There is no heredofamilial diseases reported such as HTN, DM, Arthritis, CVD and
autoimmune disorders.
 For personal and social history,

Patient is a farmer and is living together with his children and with his wife who is
working abroad. He is a smoker of 9.5 pack years and admits drinking alcohol approximately
twice a month and denies illicit drug use. Patient has no daily exercise.

Pertinent symptoms in the review of systems include, cough, leg cramps, numbness of
hands and tingling sensation.

For physical exam, pertinent findings are the following:

--Patient is lying on bed, awake, conscious and cooperative. He is afebrile and not in
pain and respiratory distress.

--Has a temperature of 37C, a pulse rate of 60 beats/ minute, a respiratory rate of 19

breaths/ minute, a blood pressure of 120/80 mmHg and an oxygen Saturation of 98% at room
air.

--For HEENT,

His head is atraumatic, no deformites, pink palpebral conjunctiva and buccal mucosa.
Neck is supple with no visible lumps. Clavicles are symmetrical

--Patient’s chest and lungs, heart and abdomen were unremarkable however there is a
right winged scapula noted.

--For the extremities,

Patient’s left forearm has a long arm cast. There is swelling and tenderness. No pallor
and cyanosis. ROM of the elbow, wrist and fingers limited due to pain and clamdigger cast.

(+) Claw hand

(-) Allen’s test

(+) Scratch test

(-) Tinel’s sign

His left leg is on skeletal traction (with 20 lbs counterweight) and Steinnman pin in
place, with good alignment and kept immobile. No swelling, erythema or abnormal discharges,
loss of sensation and with good plantar and dorsiflexion of the toes. ROM of the knee and ankle
limited.
 --For the peripheral pulses of the left leg- popliteal +2. Dorsalis pedis +3, posterior tibial
+2.

--Right extremities were unremarkable.

--On neuro exam, Patient is awake, oriented to 3 spheres and obeys to commands. GCS
15

Cranial nerves are intact

Muscle strength on all extremities are 5/5 except for the affected left arm and
left leg due to existing pain.

There is also intact sensation to light touch and pain.

For reflexes there is absent primitive reflexes; Babinski reflex negative.

Finger to nose test was intact and done with ease.

No Nuchal rigidity. (-) Kernig’s and Brudzinki Signs

Based on the history taken and PE results, our group has come up with a clinical impression of:

---Fracture, Open IIIB, Distal third, Femoral shaft, Left, secondary to MVA

---Fracture, Closed, Distal phalanges of 3rd and 4th digits, Left, secondary to MVA

---Soft tissue injuries, forearm, Left, secondary to MVA

Flashed on the screen is our basis and for our differentials we have considered the following:

1. Fracture of the femoral head

2. Fracture of the femoral condyle
3. Posterior cruciate ligament tear
4. Dislocation of the knee Joint
5. Lateral collateral ligament tear

To further confirm our diagnosis and to aid our treatment plan, our PARACLINICALS to
be requested are:

● Complete Blood Count

 ● Blood Typing and Cross Matching
● X-Ray
● MRI of the Lower Extremity
● ESR and CRP
● and Electromyogram

Our plan of management include:

• Admit the patient to ward.
• Secure consent
• ABC’s, primary survey and resuscitation if needed
• Start IVF of PNSS at 1L to run at 20 gtts/min
• Insert Foley catheter and monitor I and O
• Maintain on NPO
• Irrigate wound with normal saline if grossly contaminated
• Systemic antibiotics: Ceftriaxone 2 g IV q 24h or Cefazolin 2 g IV q 8hrs plus gentamicin
5mg/ kg IV q 24 hours at least 3 days.
• Tetanus toxoid or immunoglobulin as needed
• NPO and prepare for OR (Blood work, consent, ECG and CXR)
• PAIN management
• FRACTURE management
• And refer to Rehabilitation Center

Lastly, flashed before you is our algorithm of the patient’s case. Once again, I am
____________________. Thank you and good afternoon/evening.