Ortho Patient Write Up
General: WH is a 49 year old female, single, Roman Catholic, from Frisco, Quezon City, admitted for the first time in Philippine Orthopedic Center on July 26, 2013. Informant is the patient herself with good reliability.
Chief Complaint:
Left Foot Pain
I. SUBJECTIVE A few hours prior to consult, patient was about to go home and was seated when a colleague accidentally pulled the trigger of a 9mm caliber from 5 feet away, hitting her left foot. Patient was brought in General Hospital and was referred to the Philippine Orthopedic Center for further management, thus prompting consult.
ROS (-) fever, dyspnea, nausea and vomiting
PMI: (-) HPN, DM, asthma, blood dyscrasia (+) allergies to seafood and chicken Surgery for intestinal obstruction (2010), Appendectomy (2007)
Review of current medications: None
Present Labs done: x-ray, wound gram stain, blood typing
Vaccinations
Patient was given an anti-tetanus shot and tetanus toxoid upon arrival in the POC ER
Family History unremarkable .
Personal/ Social Patient is currently a security guard in the SSS Compound. She is single and she lives with 11 other household members (siblings, nieces, nephews) in a bungalow house in Frisco. She is a non-smoker and non-alcoholic.
Stake holder analysis Patient is single and takes care of her own medical bills. She is also the primary decision maker and financier when it comes to matters involving her health. Her 2 younger sisters are her caretakers.
II. OBJECTIVE
General: Patient is awake, stretcher-borne, coherent Vitals:
Height: 5’4” Weight: 58 kg, HR: 78 beats/min, RR: 20 breaths/min, Temp: 36.0 C BP: 120.80
HEENT:
(-) Cervical lymphadenopathy
Pale Palpebral Conjunctiva no oral and nasal lesions and deviations
Cardiovascular:
Adynamic precordium, PMI at the 5th ics MCL, no heaves o thrills, no lifts, no murmur
Chest and Lungs: Clear breath sounds, resonant on percussion in all lung fields
Abdomen:
Chief Complaint:
Left Foot Pain
I. SUBJECTIVE A few hours prior to consult, patient was about to go home and was seated when a colleague accidentally pulled the trigger of a 9mm caliber from 5 feet away, hitting her left foot. Patient was brought in General Hospital and was referred to the Philippine Orthopedic Center for further management, thus prompting consult.
ROS (-) fever, dyspnea, nausea and vomiting
PMI: (-) HPN, DM, asthma, blood dyscrasia (+) allergies to seafood and chicken Surgery for intestinal obstruction (2010), Appendectomy (2007)
Review of current medications: None
Present Labs done: x-ray, wound gram stain, blood typing
Vaccinations
Patient was given an anti-tetanus shot and tetanus toxoid upon arrival in the POC ER
Family History unremarkable .
Personal/ Social Patient is currently a security guard in the SSS Compound. She is single and she lives with 11 other household members (siblings, nieces, nephews) in a bungalow house in Frisco. She is a non-smoker and non-alcoholic.
Stake holder analysis Patient is single and takes care of her own medical bills. She is also the primary decision maker and financier when it comes to matters involving her health. Her 2 younger sisters are her caretakers.
II. OBJECTIVE
General: Patient is awake, stretcher-borne, coherent Vitals:
Height: 5’4” Weight: 58 kg, HR: 78 beats/min, RR: 20 breaths/min, Temp: 36.0 C BP: 120.80
HEENT:
(-) Cervical lymphadenopathy
Pale Palpebral Conjunctiva no oral and nasal lesions and deviations
Cardiovascular:
Adynamic precordium, PMI at the 5th ics MCL, no heaves o thrills, no lifts, no murmur
Chest and Lungs: Clear breath sounds, resonant on percussion in all lung fields
Abdomen: