Stephanie A.

Ballesteros III-C

CASE STUDY

Personal Information

Name: Rosario Fuentes Regalado Age: 80 y/o Address: Tondo Manila Nationality: Filipino Religion: Roman Catholic C/c: Diagnosis: Intertrochanteric Hip Fracture Date of Admission: December 18, 2012 Attending Physician: Dr. Besa History of Past and PresentPast History There is no illness and fracture after accident happen. Family History Hypertention (Father side) Asthma (Father side) Present History Few hours PTCPatient slipped at the bathroom landed on her hips Physician findings: positive pain on pelvis Pelvis AP Lumbosacral APL For SPI Secure Onset

Doctors Order: Endorsing the case of Rosalia De Leon 85 years old admitted December 13, 2008 with case of fall Subjective (+) pain on inguinal area ( - ) DOB Able to seat without difficulty Objective Patient on BST at 14 x 17 Lbs Intast Steinmann pin at inguinal area

PERSONALDATA A 80 year-old female named Rosario Fuentes Regalado, was admitted at PhilippineO r t h o p e d i c C e n t e r E m e r g e n c y R o o m o n t h e 1 8 th o f D e c e m b e r 2 0 0 8 , p l a c e d i n a stretcher. Upon admission, the patient was immediately interviewed and the followingdata was acquired; Born in Tondo, Manila on the day of March 27, 1952, Mrs. Regaladowas raised as a Roman Catholic along with her five siblings. Her highest educational attainment is high school graduate and is presently residing at 1232 Naras o S t . Pandacan Mnla, with her husband and children. She rents the house which they arestaying in and her daily activities include watching TV, cooking and other householdchores. Her average sleeping time is around 2 to 3 hours of continuous sleep at nightand takes 30 minute naps in the afternoons. Her bowel time usually occurs in themorning and she then bathe herself in cold water afterwards. Oral hygiene was alsobeing practiced everyday by the patient. Taking down the patients family history, it wasn o t e d t h a t t h e s h e h a s a h i s t o r y o f H yp e r t e n s i o n . S h e h a s a n a l l e r g y i n e g g s a n d chicken and takes Penicillin as her medication. Upon getting the vital signs, the patientwas determined to be hypertensive, afebrile during admission and with normal pulserate and respiratory rate. After interviewing the patient, physical examination was doneand the following assessments were gathered; the patients physical body built isslender, she is neat and has smooth skin integrity. Her mental status was alert andcoherent and she was calm in her emotional status. After several examinations, theattending physician diagnosed the patient with intertrochanteric femur fracture.