8/4/2019 Ortho Cmc Ward

1/4

Name of Patient: Ward, Floyd Jr. Anduyan

Date Admitted: 9/18/2011

General Data:

F.W., 48 year old male, single, Filipino, Roman Catholic, born in Manila on Feb. 2, 1963, currentlyresiding at Block 30 Lot 1, Area F, Salud, GMA, Cavite, currently a family driver, was admitted for the firsttime at DLSUMC on Sept. 18, 2011 at around 8:45 AM.

Chief Complaint:

Right Hip Pain

History of Present Illness:

Patient was apparently well until 10 years prior to admission, when he experienced intermittent righthip pain, dull, non-radiating, aggravated by long walks and prolonged standing, relieved by rest. He alsohad 3 episodes of stiffening, locking and pain of the right hip joint, 10/10 PS intensity, radiating to thelower back. He progressively had difficulty in ambulation, associated with a waddling gait. He did nothave any consult, nor take any medications.

1 year prior to admission , the patients symptoms progressively worsened, making him unable to work as a family driver. He consulted the Department of Orthopaedic Surgery at the Philippine GeneralHospital, wherein laboratory workups were done such as Pelvic X-ray, which revealed osteoarthritis of the Right Hip. He was advised to undergo total hip arthroplasty of the affected joint but did not followthe advise, due to financial constraints at the time as well as the distance of the hospital from theirresidence.

4 months prior to admission, symptoms persisted; hence patient consulted the Department of Orthopaedic Surgery at the DLSUMC OPD. He was also advised to undergo Total Hip Arthroplasty, Right.He was prescribed with Paracetamol 500mg tablet PRN for pain. Patient also consulted at theDepartment of Internal Medicine at the OPD for CP clearance. He was then scheduled for operation onSeptember 19, 2011 at 7am hence admission at DLSUMC.

Past Medical History:

Patient had a Right Hip Dislocation secondary to a posterior direct blow to the right thigh in 1979. Heallegedly underwent ORIF with pinning of the Right Hip at the Philippine Orthopedic Center. Otherwise

8/4/2019 Ortho Cmc Ward

2/4

he denies having asthma, allergies, hypertension, diabetes, malignancy, cardiac, renal, hepatic, vascularor CNS diseases. No other previous injuries or hospitalizations.

Family Medical History

The patients elder mother has hypertension. O therwise, there is no family history of asthma, allergies,diabetes, cardiac, endocrine, renal, hepatic, vascular or CNS diseases. Infectious diseases, otherheredofamilial diseases, arthritides, scoliosis or osteoposrosis.

Personal and social history

The patient is a 48 year old single male who currently has a live-in partner. He currently works as afamily driver since 2006. He was previously a jeepney driver for 12 years. He is a smoker with 10 pack

years & an occasional alcoholic beverage drinker.

PHYSICAL EXAMINATION

General

Patient is conscious, coherent, ambulant but with difficulty, not in cardiopulmonary distress and appearshis chronological age of 48.

Vital Signs

BP = 120/80 mmHg RR = 19 cpm Wt. = 63 kg

HR = 82 bpm Temp. = 36 oC

Skin

Patient has no pallor, no jaundice, with good capillary refill, and good skin turgor.

HEENT

Normocephalic head, anicteric sclerae, pink palpebral conjunctiva, full EOMs, no ear, eye or nosedischarges, no CLAD, trachea in the midline

C/L

Symmetrical Chest Expansion, clear and equal bronchovesicular breath sounds, no crackles, wheezesand rales

8/4/2019 Ortho Cmc Ward

3/4

CVS

Adynamic precordium, normal rate regular rhythm, no murmur

Abdomen

Soft, flabby, non-tender

Extremities

Full and equal peripheral pulses, no edema

Apparent leg length: 3.5 cm difference

Left leg = 90.5 cm

Right leg = 86 cm

True Leg Length: 1 cm difference

Left leg = 87 cm

Right leg = 86 cm

(+) waddling gait

(+) tip toeing when standing straight

(+) trendelenburg sign

(+) hypertrophic scar at R hip area

(+) LROM at internal rotation & flexion R hip

(+) pain on internal rotation & flexion R hip

(-) tenderness at the affected area

Neurological exam

CNs intact100%

5/5

100%

5/5

100%

4/5

100%

5/5

100%

5/5

100%

5/5

8/4/2019 Ortho Cmc Ward

4/4

Differentials: JHUN

Please include brief intro about the disease then rule in/out based on the patients history & PE. Dont just focus on arthritides, look for other causes of the pxs S/Sx.

Discussion: MARLA

Please include the following:

-Functional Anatomy

-Etiology (for this case and other possible etiology)

-Pathophysio, Histopath

-Signs & Symptoms

-Shentons line

-True & Apparent Leg Length

Management: LUIS

Please include medical & surgical management with indications. Please include the indication for THAfor this patient. Differentiate partial from THA.

Guys, Ill send the readings nung plates nya sorry kung late.. toxic kasi... xD