REHABILITATION MEDICINE PREOP EVALUATION

REHABILITATION MEDICINE PEDIA-ORTHOCecilia Lim HipolitoNeil Illescas

CASE OF CHRONIC HIP DISLOCATION PATIENT PROFILEPatient is K. R 8 years old male Right handed male Roman CatholicGrade 2109 Luta Sur, Malvar, Batangas

CC: Right hip deformity/ limping HISTORY OF PRESENT ILLNESSPatient has no known co-morbids and with full and in good functioning capacity until...

DOI: Oct, 2009 (3rd week)TOI: 2 pmPOI: School in BatangasMOI: While the grade 6 students were playing volleyball, patient tried to get to the ball. Unfortunately, a 40 kg player, also trying to get the ball, collided into him, hitting him at the right side while on all fours; accidentally toppling him. There was noted to have deformity after the accident accompanied by limp and leg shortening. (-) LOC, (-) nausea, vomiting. (-) bleeding. (+) pain ~4/10, nonradiating, dull (pain on movement).

Patient was then carried home where he was brought to a local albularyo, with no relief of symptoms. There were no medications taken, and no consult at a medical institution.Patients pain gradually dissappeared (2-3 weeks). During this time, patient was able to walk in a limp,able to do all his ADLs without assistance. 1 months PTA, a free medical mission conducted by a private clinic was conducted at their hometown. Xray showed: hip dislocation of the R. No other lab tests done, no medications taken. He was then refered to PGH for further management. 1 month PTA, patient consulted at the ER, and was subsequently admitted.REVIEW OF SYSTEMS(-) Headache(-) nausea, vomiting(-) fever(-) weakness, malaise(-) chest pain(-) abdominal pain(-) change in bowel and urinary habits(+) mild hip pain of R while in traction.

PAST MEDICAL HISTORYNo known illnessesNo known allergy to food and medicationsNo previous surgeries and hospitalizationsFAMILY MEDICAL HISTORY(+) DM grandfather(+) goiter grandmother(-) HTN, PTB, Asthma, CancerPERSONAL/SOCIAL HISTORYPatient is born FT to a then G2P1(0100) mother via SVD in a house c/o midwife. No fetomaternal complications. Patients development is at par with age. Patient started schooling at age 6, and is currently in grade 2 at age 8.Patient is an active child, with hobbies including playing and watching TV.

Patient lives in a 1 storey, ~ 40 sqm house in Batangas with his parents and 2 siblings (3 and 1 yr old). The restroom is located around 2 m away from the bedroom; transportation arpund 5 m away from the house; and school around ___m away from house. Patients mother is a housewife, and his father is a bus driver.Family income is about 500-3000/month.Currently, patients medical bills were paid from money borrowed from relatives. ImmunizationComplete EPI from the local health center. NutritionPatient likes to eat fruits, meat, and junkfood. FUNCTIONAL HISTORYSelf-carePre-morbidityPost-morbidityAt Present Eating777Grooming777Bathing777Dressing Upper Body777Dressing Lower Body777Toileting777Sphincter ControlPre-MorbidityPost-morbidityAt Present Bladder Management777Bowel Management777TransfersBed/Chair/Wheelchair767Toilet777Tub/Shower777LocomotionPre-MorbidityPost-morbidityAt Present Walk/Wheelchair767Stairs767CommunicationComprehension777Expression777SocialSocial Interaction777Cognitive FunctionProblem Solving777Memory777GENERAL SURVEY Patient was received awake, conversant and speaking in sentences, Not in cardio-respiratory distress, oriented to 3 spheres, GCS 15VITAL SIGNSBP:100/80HR: 98 RR: 20T: Afebrile to touch

HEENTAnicteric sclerae, pale palpebral conjunctivae, (-) nasal or aural discharges, pale buccal mucosa and tongue, pale lips, (-) tonsillopharyngeal congestion (-) anterior neck mass (-) neck vein engorgement.

CHEST /LUNGS (-) gross deformities symmetric chest expansion, clear breath sounds (-) crackles (-) wheezes (-) ronchi

CVS(-) heaves, (-) thrills, distinct heart sounds, normal rate, regular rhythm

ABDOMEN Flabby abdomen, normactive bowel sounds, soft to palpation, (-) masses (-) tenderness (-) organomegaly

SKIN and EXTREMITIESFull and equal pulses, pale nail beds, good capillary refill (-) edema (-) cyanosis (-) clubbing. PE on admission:R lower extermity attitudeinternal rotation; shortened ~ 4 cm, no sensory deficitsLimitation motion of the R hip due to pain (minimal)Palpable bony deformity of R hipGalleazi signCurrentlyPatients R leg on Pin traction, L leg on foam traction. Leg length of L, ___, of R ____. NEUROLOGIC EXAMINATIONPatient is awake, coherent, oriented to three spheres, and follows commands. CN I: intact smellII: pupils 3-3mm EBRTL, (+) visual threat; (-) visual field cuts III, IV, VI: full intact EOMs V: brisk corneals, V1 V2 and V3 sensation intact on both sides. Good masseter tone and temporalis. VII: (-) facial asymmetry VIII: intact gross hearingIX, X: Good gag reflex.XI: good shoulder shrug XII: tongue midline Cerebellars: No nystagmus, dysmetria and dysdiadochokinesia; Meningeal Examination: (-) Brudzinskis, (-) kernigsDeep Tendon ReflexesDEEP TENDON REFLEXESRightLeftC5, C6Biceps2+2+C5, C6Brachioradialis2+2+C7, C8Triceps2+2+L3, L4Quadriceps (knee jerk)NT NTSI, S2Triceps SuraeNTNTBabinski(-)(-)ClonusNTNTMANUAL MOTOR TESTINGRightLeftC5Elbow flexors55C6Wrist extensors55C7Elbow extensors55C8Finger flexors55T1Finger abductors 55L2Hip flexorsNTNTL3Knee extensorsNTNTL4Ankle dorsiflexorsNTNTL5Long toe extensorsNTNTS1Ankle plantar flexorsNTNTTotalRANGE OF MOTIONROMACTIVEPASSIVENeckRLRLExtension (0-45)0-450-450-450-45Lateral Rotation (0-60)0-600-600-600-60Lateral Bending (0-45)0-450-450-450-45 ShoulderFlexion (0-180)0-1800-1800-1800-180Extension (0-60)0-600-600-600-60Abduction (0-180)0-1100-1200-1200-120Internal Rotation (0-90)0-900-900-900-90External Rotation (0-90)0-900-900-900-90ElbowFlexion (0-150)0-1500-1500-1500-150Extension (150-0)150-0150-0150-0150-0ForearmPronation (0-90)0-900-900-900-90Supination (0-90)0-900-900-900-90WristFlexion (0-80)0-800-800-800-80Extension (0-70)0-700-700-700-70Radial Deviation (0-20)0-200-200-200-20Ulnar Deviation (0-30)0-300-300-300-30PIPFlexiongoodgoodgoodGoodDIPFlexionGoodgoodgoodgoodFingersAbduction (0-20)0-200-200-200-20Adduction (0-20)0-200-200-200-20Flexion (0-150)0-1500-1500-1500-150Extension (0-45)0-450-450-450-45SENSORY:Pain & light touchRIGHTLEFTC2-C622C7-T322T4-T1222L1-L52NTS1-S52NTXRAY RESULTSSuperiorly and posteriorly dislocated, R hips. No acetabular change.

LABORATORY RESULTSDATETESTRESULT/INTERPRETATIONDec 16, 2009ESR25Dec 16, 2009CRP < 6 : same as reference valueDec 18, 2009GS of pusPMN 0-1, no org seenDec 15, 2009PT13.1/12.3/1.0/1.18LABORATORY RESULTSDATETESTRESULT/INTERPRETATIONDec 15, 2009PTT33.6/40Dec 14, 2009BUN2.65Crea48 (low)Na140K4.1Cl103Dec 15, 2009BTO+LABORATORY RESULTSDATETESTRESULT/INTERPRETATIONDec 14, 2009UrinalysisYellow, slightly hazy, sp g 1.030, CHO (-), CHON (-). Rbc, wbc, epi cells, bact, mt, cast, crystals = negative. ASSESSMENTChronic Hip Dislocation, R secondary to traumaPLAN OF ORTHO DEPARTMENTSkeletal traction, increase in weight for 2 weeks. If failed after maximum weight ~10 kg, would consider OR, possible fixation hip spica?

COURSE IN THE WARDSDATEWhat was doneDec 14, 09Patient admitted. Xrays requested: B hips AP, XTL B. Labs requested: CBC, BT, Pt/PTT, UA, BUN, crea, Na, K, Cl, CXR PAL,ESR, CRP. planned to start tractionDec 18, 09

Ketorolac (18-22)Cloxacillim (18-22)s/p application of skeletal traction of R femur/GA. Started onkg on Dec 20.Dec 26, 096 kg weight appliedCOURSE IN THE WARDSDATEWhat was doneDec 28, 2009

Ibuprofen 200 mg/5 ml, 5 ml q 8.

Repeat Xray: femoral head hinging on superior shoulder of acetabulum. 9 kg weight applied; abduct R LE. Dec 30, 2009Traction maintainedJan 07, 2009For repeat xray