Pediatric Orthopedic Conditions

1. Pediatric Orthopedic Conditions Block 5A January 6, 2010

2. MA • 6 years old, Female • Filipino, Roman Catholic • Right handed • From Isabela • c/c gross deformity of R leg Identifying data

3. DOI: Dec 2006 • TOI: 10 AM • POI: House, Isabela • MOI: Fall History of Present Illness

4. 4 years PTA (Dec 2006) • Patient was then 2 years old, can already maintain balance in running and walking • Patient was running in their house when she slipped and fell on a one step approximately half a foot high in a kneeling position • Patient was then brought to a hospital in Isabela • X-ray of the R foot showed fracture of the Distal third of the Tibia • Casting was then done from ankle to above the knee and was maintained for 6 months • No traction done • Patient was not allowed to walk by parents at this time • Cast was then remove with a note of small mass at the site of the fracture History of Present Illness

5. 2 years PTA (May 2008) • Patient underwent Intramedullary nailing of the fracture • In the Interim • patient was able to walk, still with R leg shorter than L • Patient’s foot was progressively bending at the site of the fracture with noticeably increased leg length discrepancy • No consults were done due to financial constraints

6. (-) DOB • (-) chest pain • (-) palpitation • (+) occasional aspiration • (-) cough, colds • (-) fever, malaise, anorexia, • (-) edema • (-) abdominal pain • (-) urinary changes • (-) bowel changes Review of systems

7. Chicken Pox (sept 2009) • “combulsion” at 1 year old described as very high fever, which required hospital admission and was subsequently given unrecalled IV antibiotics • (-) bronchial asthma, recurrent fever, coughs colds • (-) food and drug allergy • (-) PTB Past Medical History

8. (-) congenital anomaly • (+) BA- Father • (+) Pulmonary TB- grandfather, completed 6 months of medication • Allergy to chicken- younger brother • (-) HPN, DM, Ca, Kidney, liver diseases Family Medical History

9. Grade 1 • Eldest of 2 • Hobbies include playing with siblings and female playmates Personal Social History

10. Born FT to a then24 year old mother G1P0 • via Ceasarian Delivery secondary to fetopelvic disproportion, pelvimetry was inadequate • Regular prenatal check –up c/o OB with no known comorbidities • Denies smoking, alcohol intake, drug use • Patient was already noticed with leg length discrepancy with no other gross deformities and congenital anomalies • (-) FMC Birth and Maternal History

11. Completed EPI given at the local health center Developmental History • At par with age Immunization

12. Awake, alert, cooperative, ambulatory NICRD, comfortably sitted in bed with obvious gross deformity of the Distal third of the R leg • BP 90/60 • HR 96 • RR 24 • Temp afebrile Physical Examination

13. HEENT: no gross deformities, structural congenital anomalies on the head, face and neck, anicteric sclerae, pink palpabral conjunctivae, (-) tonsilopharyngeal congestion (-) cervical lymphadenopathies • CHEST & LUNGS: (-) gross deformities, symmetric chest expansion, clear breath sounds (-) wheezes (-) crackles (-) rhonchi PHYSICAL EXAMINATION

14. CVS: adynamicprecordium (-) heaves (-) thrills distinct heart sounds, normal rate, regular rhythm (-) murmurs • Abdomen: flat abdomen, normoactive bowel sounds, soft to palpation (-) organomegaly (-) tenderness on deep and light palpation PHYSICAL EXAMINATION

15. Lower extremity, right: • Full and equal popliteal, anterior and posterior dorsalispedis pulses • No sensory deficits • Pink nail beds on all digits ,(-) clubbing, cyanosis • (+) scar 5 inches x 1 cm at the site of the operation • Attitude of the foot: Distal third of leg is angulated approximately 45 degrees posteriorly EXAMINATION OF THE EXTREMITIES

16. Gross Picture

17. Radiographs

18. EXAMINATION OF THE EXTREMITIES

19. Assessment