Patient’s Biographical Data

Name: Rey Fabillar Gabotero

Case no.:
Room no.
Age: 39 years old
Gender: Male
Address: Sitio Pisok, Poblacio Guihulngan Negros, Oriental
Date of birth: February 04, 1983
Birthplace:
Blood type: O+
Religion: Roman Catholic
Nationality: Filipino
Race: Asian
Occupation: Businessman: buy and sell animals
Health financing:
Date and time of admission: December 23, 2022 @9:35p.m.
Admittted by:
Admitting diagnosis:Open Fracture R femur distal 3rd
Final diagnosis:Fracture Open 3A complete comminuted
intercondylar femur R

Surgery upon arrival: December 23, 2022

Preoperative Diagnosis: Fracture open II complete displaced
supra cordable femur R
Performed surgery: Closed reduction skeletal fracture femur R

Surgery: January 04, 2023

Performed surgery: Open reduction internal fixation and open
external fixation

Physician:

Health History
Chief Complaint:
Lacerated wound right tigh, swelling, deformity,
limitation of motion right tigh.

History of Present Illness:

Mr. Gabotero
Past Health History
Family History