HEADQUARTERS

ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND

VICTORIANO LUNA MEDICAL CENTER
Department of Orthopaedic Surgery and Traumatology
V. Luna Ave., Quezon City

NARRATIVE SUMMARY

Patient’s Name PATAYON, FERREOLUS BONTIA Rank/BOS PVT/PA

Age/Sex 23/M Registration No. 50951
Time of
Date of Admission 13 MARCH 2023 1245H
Admission
TH
FRACTURE OPEN (CLOSED), COMMINUTED, BASE, 5 METATARSAL FOOT, LEFT, WITH CALLUS
ADMITTING DIAGNOSIS
FORMATION; S/P PRIMARY CALLUS (20 DEC 2022); DEBRIDEMENT, FOOT, LEFT (05 JAN 2023)
Time of
Date of Discharge: 20 MAY 2023 0800H
Discharge
TH
FRACTURE OPEN (CLOSED), COMMINUTED, BASE, 5 METATARSAL FOOT, LEFT, WITH CALLUS
FORMATION; S/P PRIMARY CALLUS (20 DEC 2022); S/P SERIAL DEBRIDEMENT, FOOT, LEFT (DEC 22-
Discharge/Final Diagnosis
JAN 2023); S/P ORIF (MULTIPLE PINNING) 5TH METATARSAL, FOOT, LEFT, WITH APPLICATION OF IBG
(22 MAR 2023)
Procedure ORIF (MULTIPLE PINNING) 5TH METATARSAL, FOOT, LEFT, WITH APPLICATION OF IBG (22 MAR 2023)

CHIEF COMPLAINT:

Pain, Foot Left

HISTORY OF PRESENT ILLNESS:
THIS IS A CASE OF PVT PATAYON, FERREOLUZ BONTIA 23 YEARS OLD, MALE, SINGLE, ROMAN CATHOLIC FROM ZAMBOANGA CITY,
ZAMBOANGA DEL SUR, ADMITTED IN OUR INSTITUTION WITH A DIAGNOSIS OF FRACTURE OPEN (CLOSED), COMMINUTED, BASE, 5TH
METATARSAL FOOT, LEFT, WITH CALLUS FORMATION; S/P PRIMARY CALLUS (20 DEC 2022); DEBRIDEMENT, FOOT, LEFT (05 JAN 2023).

3 MONTHS PRIOR TO ADMISSION, PATIENT WAS INVOLVED IN A MULTIVEHICULAR ACCIDENT RIDING A MOTORCYCLE, BUMPED INTO
ANOTHER MOTOCYCLE, SUSTAINING A WOUND ON THE LEFT FOOT.

PATIENT EXPERIENCED LOOS OF CONSCIOUSNESS AND WAS BROUGHT TO A PRIVATE HOSPITAL. PATIENT WAS SEEN AND ASSESSED
AND PRIMARY CLOSURE WAS DONE, ANTIBIOTICS WERE GIVEN FOR 7 DAYS.

2 MONTHS PRIOR TO ADMISSION, HE IMMEDIATELY WENT TO NEAREST HOSPITAL WHERE HE UNDERWENT PRIMARY DEBRIDEMENT.
UNRECALLED IV ANTIBIOTICS WERE ALSO GIVEN.

1 WEEK PRIOR TO ADMISSION, PATIENT WAS STILL ADMITTED AND WAS ASSESSED AS FRACTURE OPEN (CLOSED), COMMINUTED,
BASE, 5TH METATARSAL FOOT, LEFT, WITH CALLUS FORMATION, SURGICAL SITE INFECTION. PATIENT WAS ADVISED TO EVAC TO OUR
INSTITUTION FOR FURTHER MANAGEMENT.

PERTINENT SIGNS AND

SYMPTOMS IN
ADMISSION
(click applicable box/es)

(enter pain site in space

provided)
 HEADQUARTERS
ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND
VICTORIANO LUNA MEDICAL CENTER
Department of Orthopaedic Surgery and Traumatology
V. Luna Ave., Quezon City

(enter pain site in space

provided)

PHYSICAL EXAMINATION

GENERAL (if selected, enter details below)

SURVEY

BP HR RR TEMP OTHERS
VITAL SIGNS
110/90 87 20 36.3 O2 Sat: 97

HEENT
Others: (enter details below)

CHEST/LUNGS
Others: (enter details below)

CVS Others: (enter details below)

ABDOMEN Others: (enter details below)

GU (IE) Others: (enter details below)

SKIN/EXTREMITIE
S

NEURO-EXAM
Others: (enter details below)
 HEADQUARTERS
ARMED FORCES OF THE PHILIPPINES HEALTH SERVICE COMMAND
VICTORIANO LUNA MEDICAL CENTER
Department of Orthopaedic Surgery and Traumatology
V. Luna Ave., Quezon City

COURSE IN THE WARD

DATE TIME
(Provide a description of the care received by the patient during confinement or episode of care. Also includes the
(mm/dd/yyyy) (hh:mm)
list of PNF drugs bought outside.)
PATIENT WAS ADMITTED AT WARD 3B UNDER THE SERVICE OF MAJ GARROTE AND TEAM D. CONSENT
FOR ADMISSION AND MANAGEMENT WAS SECURED. PATIENT WAS PUT ON DIET AS TOLERATED.
3/13/2023 1630H DIAGNOSTICS WAS REQUESTED SUCH AS COVID 19 RTPCR AND RAT, CXR PA, FOOT APOL LEFT, 12L
ECG, CBCQPC, PT, PTT, INR, SERUM ELECTROLYTES, BUN, CREA, ESR, AND CRP. PATIENT WAS GIVEN
CELECOXIB 200MG/CAP, 1 CAP BID AS NEEDED FOR PAIN.
PATIENT UNDERWENT ORIF (MULTIPLE PINNING) 5TH METATARSAL, FOOT, LEFT, WITH APPLICATION OF
IBG UNDER GENERAL ANESTHESIA AND TOLERATED THE PROCEDURE.VITAL SIGNS AND I/O WERE
DONE QSHIFT AND RECORDED. MEDICATIONS GIVEN WERE AS SUCH: PAIN MEDS C/O ANESTHESIA
3/22/2023 1943H
SERVICE, CEFAZOLIN 1G TIV Q8H, ASCORBIC ACID 500MG/TAB, 1 TAB BID, CELECOXIB 200MG/TAB, AND
CALCIUM + VIT D3 TAB, 1 TAB BID. REGULAR WOUND CARE WAS ADVISED. PATIENT WAS REFERRED
ACCORDINGLY.
POST OP DAY 29. REGULAR WOUND CARE WAS CONTINUED. ADVISED ROM EXERCISED OF ANKLE AND
4/20/2023 0700H
KNEE, AS WELL AS TO KEEP LEG ELEVATED.

POST OP DAY 34. PINS WERE REMOVED. CEFAZOLIN WAS SHIFTED TO CEFUROXIME 500MG/TAB Q12 X
4/25/2023 1615H
7 DAYS. TRAMADOL 50MG TIV WAS GIVEN FOR PAIN.

POST OP DAY 56. PATIENT WAS SEEN AND EXAMINED AND WAS DEEMED FIT FOR RETROEVAC TO MNH
5/17/2023 1757H
ON 19 MAY 2023. HOME MEDICATIONS AND INSTRUCTIONS WERE GIVEN AND WELL ENDORSED.

HOME MEDICATIONS
1. ASCORBIC ACID 500MG/TAB, 1 TAB TWICE A DAY
2. CALCIUM + VIT. D3 TAB, 1 TAB THRICE A DAY
3. CELECOXIB 200MG/CAP, 1 CAP EVERY 12 HOURS FOR PAIN
REMARKS
1. MAINTAIN ON AIRCAST BOOT
2. MAY PERFORM PARTIAL WEIGHT BEARING WITH AIRCAST BOOT
3. AVOID STRENOUS ACTIVITIES SUCH AS PROLONGED STANDING, JOGGING, RUNNING, JUMPING, BENDING, AND LIFTING
HEAVY OBJECTS.
4. FOR FOLLOW-UP ON 04 JULY 2023 AT ORTHO OPD C/O TEAM D

PUZON / POTENCIANO / MEJIA / MALICSE

TOREJA

RESIDENTS IN-CHARGE

MAJ EULER KERN V GARROTE MC

Ward Officer, 3B