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PATIENT PROFILE NSG HX NAME : PFC PLANO, ROLLY CALZADO AGE : 21 years old DATE OF BIRTH : 17 SEPT 1990

0 BLOOD TYPE : A+ EDUCATIONAL ATTAINMENT : AUTOMOTIVE UNDERGRAD LANGUAGE SPOKEN : Tagalog,ILLONGGO, CEBUANO, ENGLISH CIVIL STATUS : SINGLE ACTIVITY : BASKETBALL, Watching TV, SOCIAL HABITS : Smoking Habit (-) Alcohol : 5 Bottles (BEER) Last taken Aug 2011 BOWEL HABITS : Everyday SLEEPING PATTERN : 10PM WAKING TIME : 4AM ALLERGY : NKA PREVIOUS HOSPITALIZATION : YEAR AUGUST 2011 ILO-ILO MISSION HOSPITAL DX :VC MEDICAL HISTORY : PREVIOUS SURGERY : ORIF PLATING 06 SEPT 11 FAMILIAL RISK FACTORS : (x ) HPN MOTHERSIDE (x ) DIABETES MOTHERSIDE

IMPRESSION :FRACTURE CLOSED COMMINUTED D/RADIUS (L) ; FX CLOSED, COMPLETED, DATE OF ADMISSION : 07 1540H OCT 2011 CC : Pain on (L) FOREARM ATTENDING PHYSICIAN : DR. DOLETE, CPT. PARLAN

History of Present Illness : 1 month PTA patient was accidentally crashed on a 6 wheel vehicle upon reinforcement sustaining injury to his (L) forearm. Splint was applied and was evacuated to mission HOSPITAL IN iLOiLO where xray revealed fracture of radius-ulna, short arm post mold cast applied. Patient was evacuated on the day of admission on AFPMC where he underwent application wrist sparring external fixator, wrist (L) with multiple cross pinning, distal radius (L) (RAT I) ulna (L) DAY OF ADMISSION to FBGH (20 Aug 2011) : Persisitence of signs and symptoms prompted evacuation to AFPMC. Xray of LS Area revealed (+) Sondylolisthesis. Transferred to FBGH same day & referred to PMRS on 23 Aug 2011 for further evaluation and management. INITIAL VITAL SIGNS : 20 1640H AUG 2011 BP : 130/90 Pulse : 80 RR :16 Temp. :36.7 WT : 71kg HT : 175

Past Medical History : (+) VC AUG 2011 iloilo mission hospital (+) VC sept 2011 AFPMC Family History : (-) Bronchial Asthma (-) HPN (-) DM Personal / Social History : (+) Alcohol Drinker 5 bottles of beer 375ml ADMITTING DIAGNOSIS : Fracture Closed, Comminuted, distal radius left ; fracture closed complete, displaced, transverse distal ulna left (status post failed closed reduction) status post open reduction distal radius, left with cross pinning and application off wrist spanning external fixator, ORIF (plate) ulna, left

Physical assessment HEAD


Skull Generally round, with prominences in the frontal and occipital area. (Normocephalic). No tenderness noted upon palpation. Scalp Lighter in color than the complexion. Can be moist or oily. No scars noted. Free from lice, nits and dandruff. No lesions should be noted. No tenderness nor masses on palpation. Hair Can be black, brown or burgundy depending on the race. Evenly distributed covers the whole scalp (No evidences of Alopecia) Maybe thick or thin, coarse or smooth. Neither brittle nor dry.