PATIENT IDENTIFYING DATA:

Patient R.B, 27 years old, Male, Filipino, single, currently residing at San Antonio, San Pablo, Laguna.

CHIEF COMPLAINT:
Replacement of AO external fixator with Ilizarov external fixator.

HISTORY OF THE PRESENT ILLNESS:

This is a known case of Patient R.B., who sustained multiple fractures after being involved in a vehicular
accident while driving a motorcycle 2 years ago.

2 yrs PTA, patient endured fractures in the right clavicle, both proximal forearms, and both legs.
Immediate surgical intervention was done, including the insertion of an internal fixator in the clavicle
and external fixators in both forearms and legs. Post-op, patient was given antibiotics (Clindamycin and
Eterocoxib), analgesics, and was advised against weight-bearing by using a wheelchair for a period of
two years. Since then, patient has limited movements and opt to stay on bed. No significant associated
symptoms were reported during this time.

In the interim, several surgeries were performed on the patient (see PMH).

1 month PTA, patient experienced intermittent pain 5/10 on his right leg during a routine follow-up
checkup. Was given Calcium Citrate, Magnesium, Zinc, and Vitamin D3 supplementation once a day.
Upon assessment, patient was advised to replace his external fixator on the right leg.

PAST MEDICAL HISTORY:

 (+) Fatty liver
 No known allergies
 Previous Hospitalization: Dengue (unrecalled date)
 Previous Surgery: Installation of internal fixator (2022), Skin graft (sep 2022), Bone graft (sep
2023)
 Childhood immunization: complete, unrecalled
 Adult immunization: 2 doses Covid Vaccine, 1 booster
 Current Medications: Ca citrate Mg+Zinc with Vit.D3 1xday

FAMILY HISTORY:
 Maternal side: (+) goiter. No hypertension, no diabetes, no cancer or malignancies, tuberculosis,
autoimmune disease, heart disease, bone disease, congenital disorders.
 Paternal side: (+) Diabetes-controlled. No hypertension, no cancer or malignancies, tuberculosis,
autoimmune disease, heart disease, bone disease, congenital disorders.
 Brother- died due to leukemia (2005)
PERSONAL & SOCIAL HISTORY:
 An Electrician
 Lives in a well-ventilated house with 8 relatives
 Non-smoker, non-alcoholic drinker, denies illicit use of drugs.
 Likes to eat fatty foods.

REVIEW OF SYSTEMS:
General:
(+) weight gain, no fever

Skin:
(+) dryness, no color change, no itching

HEENT:
Head: (+) dizziness, No headache, no trauma, no tenderness
Eyes: (+) lacrimation, no pain, no blurry vision
Ears: No changes in hearing, no ear pain, and no discharges, no bleeding
Nose: (+) colds, No epistaxis
Mouth: no bleeding of gums, no mouth sores
Throat: No sore throat, no dysphagia, no odynophagia

Neck:
No pain, lumps, stiffness

Respiratory:
no cough, no difficulty of breathing, no hemoptysis

Cardiovascular:
No palpitations, no chest pain, no cyanosis

Gastrointestinal:
(+) vomiting, (+) abdominal pain, no diarrhea

Genitourinary:
(+) nocturia, (+) polyuria, (+) frequency

Musculoskeletal:
(+) muscle weakness, (+) limitation of motion

Neurologic:
No tremors, numbness, paralysis

Hematologic:
No easy bruising, bleeding, pallor

PHYSICAL EXAMINATION:
General:
Conscious, coherent, not in any form of cardio-respiratory distress.

Vitals:
BP 120/70 mmHg
HR 82 bpm
RR 17 cpm
Temp 36.1 0 C
O2 Sat: 98%

Skin:
(+) 1x2 cm single, elevated, with irregular border well-healed scar on the right clavicle
(+) 2x2 cm single, elevated scar on the right proximal forearm
(+) Pinkish, elevated, with irregular border clustered scars on anterior tibial area (R&L)

HEENT:
Head: Normocephalic, w/o lesions. Hair is thick and fair in distribution
Eyes: Anicteric sclera, pale palpebral conjunctiva, pupils are 4mm non-constricting, equally round, and
not reactive to light and accommodation. Extraocular movements are intact.
Ears: No deformity, no discharge, no obstruction, no inflammation, no lesions on both ear canals. Acuity
good to whispered voice.
Nose: Symmetric, no deformity, no lesions, no discharge.
Throat/mouth: pink oral mucosa, dentition good, pharynx without exudates.

Neck:
Normal in size, symmetrical, no tenderness, no visible mass, no palpable superficial and deep
lymph nodes, no stiffness. Supple with full range of motion.

Chest & Lungs:

Thorax is symmetric with good expansion. Lungs resonant. Breath sounds vesicular; no crackles,
wheezes, or rhonchi.

Heart:
No scars, no lesions, adynamic precordium. PMI is located on Left Midclavicular line 5th ICS. Regular
heart rate and rhythm. No bruit, no splitting of heart sounds heard, no murmur.
Abdomen:
No scars, no lesions, no visible masses. It is protuberant with active bowel sounds. It is soft and
nontender; no palpable masses or hepatosplenomegaly.

Genital and Rectal:

Not performed.

Musculoskeletal & Extremities:

(+) Scars (see skin PE).

Both UE:
Normal tone and bulk, no tenderness
muscle strength 5/5
brachial and radial pulses 2+
full Active and Passive ROM.
DTRs not tested

LLE:
No tenderness, full Active and Passive ROM
muscle strength 4/5
Popliteal, Dorsalis pedis, Posterior tibial pulses all 2+
DTRs not tested

RLE:
(+) tenderness
Limited Active and Passive ROM
muscle strength 3/5
Popliteal pulse 2+
Dorsalis pedis, Posterior tibial pulses 1+
DTRs not tested

PRIMARY WORKING DIAGNOSIS:

Nonunion tibial diaphyseal fracture (R), Fatty liver

DIAGNOSTICS:
CBC, CRP, ESR- to RO infection
CT/BT
PT/APTT
FBS
LIPID Profile
ALT
AST
Na+
K+
Ca2+
Xray R lower leg- AP, lateral, oblique, and weight-bearing view

MANAGEMENT:
Surgical: Replacement of AO external fixator with Ilizarov external fixator
Physiotherapy

For Fatty liver:

Diet change: balanced diet rich in fruits, vegetables, & whole grains; avoid saturated fats, added sugars,
and refined carbohydrates.
Regular monitoring of liver function tests and UTZ (abdomen)