7/27/2019 Assessment Findings for segmental femural fracture

1/3

PRESENT HEALTH HISTORY

A case of Patient R.D., Female, 43 y.o., Married, from Catmon, Cebu, was admitted toVicente Sotto Memorial Medical Center last o!ember ", #$%3, due to com&lains ofse!ere &ain s&ecifically, on t'e left arm and bot' t'e lower e(tremities.

Patient was dia)nosed wit' 'a!in) *Fracture +Closed, se)mental on t'e -eft Femur and

'as under)one a&&lication of s/eletal traction and cast in t'e left arm in VSMMC0s1mer)ency Room last o!ember ", #$%3.

HISTORY OF PATIENTS ILLNESS

2ours, &rior to admission, &atient was 'it by a branc' of a tree durin) t'e ty&'oonolanda. Patient used left arm to co!er 'erself u& from bein) 'it but unfortunately, 'erlower e(tremities were 'it. Pain in t'e areas 'it became unbearable, t'us, &rom&tedimmediate 'os&italiation.

FAMILY, PSYCHOSOCIAL, AND PERSONAL HISTORY

Patient is a female, was born on o!em %4, %565 in Carmen, Cebu. S'e is a Fili&inocitien, currently li!in) in Catmon, Cebu.

S'e is t'e second c'ild amon) 3 c'ildren. 2er ot'er siblin)s are boys, w'o are alsomarried li/e 'er.

S'e was married at t'e a)e of #%, wit' 7 /ids. 3 of w'om are boys, w'ile t'e rest are)irls.

Patient is 8 feet 6 inc'es, wei)'s 64 /ilo)rams. Patient Patient is unem&loyed but ma/esa li!in) by sellin) ice candy and c'arcoal9ma/in) wit' 'er 'usband, w'o is unem&loyedli/e 'er.

Patient re&orts no si)ns of boredom at 'ome. Patient usually slee&s 697 'ours e!eryni)'t.

Patient family 'ealt' 'istory: Paternal side +; Diabetes Mellitus, 2y&ertension, and

7/27/2019 Assessment Findings for segmental femural fracture

2/3

and de!elo&in) a sense of unity wit' your life &artner are im&ortant accom&lis'ments of t'is sta)e.

Si!$%n& Fr"%&s Psychos"'%al Sa!"# Genital

Durin) t'e final sta)e of &syc'ose(ual de!elo&ment, t'e indi!idual de!elo&s a stron)se(ual interest in t'e o&&osite se(. ='is sta)e be)ins durin) &uberty but last t'rou)'outt'e rest of a &erson>s life.

ASSESSMENT

EYES. Patient does not 'a!e any redness or swellin) in t'e eyes. o e(cessi!ewaterin)or tearin) of t'e eye. Minimal disc'ar)es noted, )reenis' w'ite in color. ='e u&&er lidmar)in is between t'e u&&er mar)in of t'e iris and t'e u&&er mar)in of t'e &u&il. ='eu&&er and lower lids close easily and meet com&letely w'en closed. 1yelas'es are e!enlydistributed alon) t'e lid mar)ins. S/in on bot' eyelids is wit'out redness, swellin) orlesions. ='e eyeballs are symmetrically ali)ned in t'e soc/ets wit'out &rotrudin) orsin/in). ='e iris is round, flat and e!enly colored +dar/ brown. ='e &u&il is centered int'e iris and are e?ual in sie.

EARS.='e auricle ali)ns wit' t'e corner of eac' eye. 1arlobes are free. ='e s/in is

smoot' wit' no lesions, lum&s are lesions@ sli)'tly oily. Color is consistent wit' facialcolor. ='e auricles are not tender u&on &al&ation.

NOSE.Patient0s nose is consistent wit' facial color@ nasal structure is smoot' andsymmetrical@ no &ain and tenderness noted on &al&ation@ wit' no disc'ar)es noted.

LIPS.='e &atient0s li&s are dry@ 'as a com&lete set of teet'.

TONGUE.=on)ue is &in/, moist and moderate in sie. Patient does not smo/e nor drin/alco'ol.Patient brus'es 'is teet' 3( a day, usually after e!ery meal.

GAIT. Client cannot stand on 'eels or toe. Patient 'as been on bed since s'e wasadmitted.

TEMPOROMANDIBULAR JOINT. aw mo!ed laterally. Sna&&in) and clic/in) is felt and'eard. Mout' o&ened and closed smoot'ly. aw 'a full RBM wit' no &ain.

STERNOCLAVIC(LARJOINT.='ere is no !isible bony o!er)rowt', no swellin) orredness@ oint is nontender.

CERVICAL, THORACIC, and LUMBAR SPINE.Cer!ical and lumbar s&ines are conca!e@t'oracic s&ine is con!e( +w'en obser!ed from be'ind. ='ere is &ain in t'e lower bac/ oft'e &atient.

SHOULDERS, ARMS, and ELBOWS. S'oulders are symmetrically round, no redness,swellin) or deformity noted. Muscles are fully de!elo&ed. Cla!icles and sca&ulae are e!enand symmetric. Pain is &resent in t'e left arm. Painful and limited abduction accom&aniedby muscle wea/ness and atro&'y is noted on t'e left arm.

WRISTS.rists are symmetric@ redness and sli)'t swellin) and limited RBM on t'e leftwrist noted, increased &ain wit' e(tension of t'e wrist a)ainst resistance noted.

HANDS and FINGERS.2ands and fin)ers are symmetric@ tenderness and sli)'t swellin)noted on left 'and. ='e client 'as full RBM a)ainst resistance e(ce&t on left &art.

HIPS.Patient is unable to stand. =enderness and decreased RBM noted.

7/27/2019 Assessment Findings for segmental femural fracture

3/3

KNEES.Ri)'t /nee 'as no swellin) or deformities noted@ nontender and muscles arefirm, no &ain or clic/in) sound noted. -eft /nee is wit' cast.

AN)LES an& FEET*=oes on bot' feet &ointed u&ward and lie flat. =oes and feet are inali)nment wit' t'e lower le). S/in is smoot', lesions on ri)'t foot noted.