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Ward Case Presentation

Ward Case Presentation. General Data. MGV 9/F From Occidental Mindoro Born with congenital absence of right leg. History of Present Illness. Born PT at 7 mos AOG due to profuse vaginal bleeding via SVD at home assisted by a traditional birth attendant to a 22 y/o G3P2 (2002)

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Ward Case Presentation

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  1. Ward Case Presentation

  2. General Data • MGV • 9/F • From Occidental Mindoro • Born with congenital absence of right leg

  3. History of Present Illness • Born PT at 7 mos AOG due to profuse vaginal bleeding via SVD at home assisted by a traditional birth attendant to a 22 y/o G3P2 (2002) • Regular PNCU at LHC • No maternal illness/medication/exposure to radiation • Good cry, suck, activity • Note of multiple congenital anomalies • Absent R leg • Fused fingers B hands • Fused toes L foot • Esotropia

  4. History of Present Illness • 5 years PTA, fitted with Jaipur prosthesis at PGH • 2 years PTA, fitted with a new Jaipur prosthesis • Currently, (+) difficulty ambulating due to ill-fitting prosthesis • Desires a new prosthesis hence present consult

  5. Pediatric History • Birth history • As described • Feeding history • Fed Milkmaid powdered milk via dropper for first 2 weeks of life • Shifted to breastfeeding up to 2 years old • Introduced to solid food at 8 months old • Currently no food prefences

  6. Pediatric History • Developmental history • At par with age except for difficulty in ambulation and fine motor skills • At present can read and write, run, walk up and down the stairs • Currently a grade 3 student with average class standing • Immunization history • BCG, DPT3, OPV3, HepB3, measles c/o LHC

  7. ROS • Unremarkable • PMHx • Previously hospitalized for prosthesis fitting • FHx • HTN, DM, BA – maternal side • PSHx • Lives with maternal grandparents, 13 y/o brother, 6 y/o sister • Parents separated when she was 5 y/o

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