X.

Initial Evaluation
Patient’s Name: J.M.
Age: 22 y/o
Sex: Male
Address: San Nicolas, San Esteban, Ilocos Sur
Civil Status: Single
Handedness: Right
Occupation: On call crew
Religion: Iglesia Filipina Independente
Referring Unit:
Attending M.D.: Dr. E.F.
Date of Admission: September 17, 2016
Date of Evaluation: November 12, 2016
Diagnosis: Thermal burn, partial thickness on ® thigh and leg

S:
c/c:
Pt. Verbatim: “masakit na may kasamang kirot (PS 2/10) yung likod ng hita ko pero mas lalong lumalala
sa tuwing maglalakad, matagal na nakatayo, magbubuhat ako ng timba at sa tuwing mabibinat o bigla
kong maigagalaw yung likod ng hita ko (PS 4-5/10), tapos makati yung binti at hita ko”

Pt. Translate: Pt. c/o constant aching pain on ® lower posterior part of the thigh c PS 2/10 and is
aggravated upon ambulation, prolonged standing, carrying objects, and when there’s sudden movement
and stretch at the post. part of the thigh c PS 4-5/10 and feeling of itchiness at the ® thigh and leg.

HPI: Pt. present condition started ~2 mos. PTIE when pt. had a thermal burn accident. Pt. narrated that
last September 17, 2016, around 8:00-9:00am, he was sitting in a motor shop and his friend was
vulcanizing and tried to apply more kerosene to his work, where the flame of the torch followed the
direction of the kerosene and an explosion happened which caused the flame to scatter where his shorts
caught the flame resulting to burn on his ® thigh and leg. He extinguished the fire by running and rolling
to the ground. The pt. felt constant aching pain on his ® thigh and leg c PS of 10/10. Pt. was then hurried
to municipal health center where in no treatment was done, however, via their ambulance, pt. was rushed
to the nearest hospital, Candon General Hospital. Pt. was brought immediately to the E.R. where his
wound was cleaned, they injected him 1 anti-tetanus vaccine and other 2 injections were unrecalled. Dr.
E.F recommended the pt. to be admitted but he refused because he doesn’t want hospital environment.
Pt.’s mom signed a waver form, Dr. E.F prescribed him to take medications (see medications). The pt. go
home at six on the afternoon. At home, Pt. ask assistance from his live-in partner when cleaning his
wounds. Pt. continue his medications until November 6.
At present, pt. c/o constant aching pain on R lower posterior of thigh c PS of 2/10 and itchiness. Pt. states
that pain is aggravated during weight bearing activities such as carrying a bucket ~2kg, prolonged standing
~15mins, and sudden movements or stretched at the post. part of the knee c the PS of 4-5/10, Pt. relieved
it by slightly flexing his leg. PS decreased to 3-2/10. Pt. has a min. difficulty in doing ADL’s such as toileting,
doffing and donning of lower garments, and ambulating.

Medications:
Medication Dosage Indication
Cefuroxime 500 mg (100tablets) 1 tablet bid For infection
Tramadol 50 mg (150tablest) 1 tablet tid For pain
Mupirocin ointment Bid on affected areas For infection

PMHx:
(+) Hospitalization: Typhoid fever (Sto. Niño Hospital yr. 2007)
(+) Motor vehicular accident (year unrecalled)

FMHx:
Mother Father

Htn (-) (+)

Arthritis (-) (+)

DM (-) (-)

Heart dse. (-) (-)

PSEHx:
Pt. lives in a semi-concrete 2 story house with his parents, brother, live-in partner and 2 sons. Pt
has no hx of substance abuse and is an occasional alcohol beverage drinker, a smoker with 5 sticks per
day. Pt. sleeps in a sofa bed in supine position c his ® knee slightly flexed as his comfortable position. At
present, pt. stopped smoking, drinking alcohol beverages and now lives a sedentary lifestyle, doesn’t play
basketball anymore, d/t his present condition.

House Dimension:
Stairs = 12 steps (10 in height of stairs); bedroom ↔ bathroom ~25 steps; bedroom ↔ dining area ~22
steps; bedroom ↔ main door ~17 steps
Note: Pt. is situated on the 2nd floor

Goal: “Gusto ko nang gumaling yung sugat ko para makapag lakad na ako ng maayos”

O:
VS: BP: 110/80 mmHg
PR: 70 bpm
RR: 17 cpm
Temp.: 36.6 °C

OI: Manner of arrival: Amb. s AD

Mental status: A/C/C
Physique: Ectomorph
(+) Trophic Skin Changes (Pinkish in color, dryness, hair loss)
(+) Fibrosis
(+) Blisters
(+) Postural deviation (See PA)
(+) Gait deviation (See GA)
(+) Scar on ® forearm, (L) dorsal hand (Keloids)
(+) Eschar on ® post thigh and anteroposterolateral leg
(+) Exudate on ® post thigh and anteroposterolateral leg
(-) Swelling
(-) Atrophy
(-) Others

Palpation:
Thermal assessment: Normothermic on (B) UE/LE
Tone assessment: Normotonic on (B) UE/LE
(+) Tenderness grade 3 on the ® popliteal fossa
(-) Muscle spasm
(-) Edema

Burn Assessment:
Rule of Nine:

Location: Anteroposterolateral part of the ® knee and lower posterior part of the thigh
Findings: 11.25% of total body burn

ROM:
Findings: All jts. of (B) UE/LE are actively and passively done WNL pain free c N EF except:
Motion Active Passive Normal Differences Endfeel

Active Passive

Trunk Flexion 0-20° 0-30° 0-80° 60° 50° Empty

Trunk Extension 0-12° 0-20° 0-25° 13° 5° Empty

® Trunk Lateral 0-12° 0-20° 0-35° 23° 15° Empty

Flexion
(L) Trunk Lateral 0-11° 0-16° 0-35° 24° 19° Empty
Flexion
® Hip Flexion 0-92° 0-104° 0-120° 28° 16° Empty

® Hip Hyperextension 0-10° 0-16° 0-30° 20° 14° Empty

® Hip Abduction 0-25° 0-30° 0-45° 20° 15° Empty

® Hip Adduction 0-20° 0-28° 0-30° 10° 2° Empty

® Hip IR 0-16° 0-20° 0-45° 39° 25° Empty

® Hip ER 0-30° 0-34° 0-45° 15° 11° Empty

® Knee Flexion 0-38° 0-44° 0-135° 97° 91° Empty

® Knee Extension 38°-0 44°-0 135°-0 97° 91° Empty

 Sig: LOM 2° to pain

MMT:
Findings: All major (m) of (B) UE/LE are grossly graded 5/5 except,
Motion Grade
Hip Abductors 4
Hip Adductors 4
Hip Hyperextensors 4
Hip ER 4
Hip IR 4
Knee Flexors 3
Knee Extenxors 4
Ankle eversors 4
Sig: 2° pain

ST:
Findings:

PA:
Findings: Postural landmarks are assessed in ant., post., and lat. views in standing position and
are found to be in N alignment except:
Anterior Posterior Lateral
- (L) shoulder is higher than - (L) shoulder is higher than ® - Slouched posture
the ® - (L) scapula is more
- ® knee is higher than the prominent than ®
left - ® knee is slightly flexed

Sig:

GA:
Findings: No heel strike on ® foot
Sig: 2° to pain

Neurologic Examination:
Sensory Testing:
Device used: brush for light touch
Findings: 80-90% intact sensation on anteroposterolateral part of the ® thigh and leg
Hyperestitia on ® lower posterior part of the thigh
Sig: (+) Eschar, 2° to pain

DTR:
 Legend:

0 Areflexia

+ Hyporeflexia

++ Normoreflexia

+++ Hyperreflexia

Findings: pt. is normoreflexive on (B) UE/LE

Sig: intact reflex arc

Leg Length Measurement

Landmarks: ALL: umbilicus ↔ medial malleolus
TLL: ASIS ↔ medial malleolus
R L Difference
ALL 88.5 90 1.5
TLL 80 81.5 1.5
Sig: 2° to pain upon (m) stretch

Functional Analysis:
ADL’s FIM LEVELS
Self-care No Helper
Feeding: 7 7 - Complete Ind.
Grooming: 7 6 - Mod Ind.
Dressing: 6 5 - Min Ind. (subject 100%)
Bathing: 6 4 - Modified Dep, Min. Asst (75%)
Toileting: 6 3 - Modified Dep, Mod. Asst (50%)
Bed mobility 2 - Complete Dep, Max Asst (25%)
Roll to right: 6 1 - Complete Dep, Total Asst (<25%)
Roll to left: 7
Supine to sit: 6
Sit to supine: 6
Transfer
Bed to chair: 7
Sit to stand: 7
 w/c to toilet: N/A
Ambulation: 7

Sitting/ Standing Balance Tolerance

Balance Tolerance Legend: Assume Maintain Weight- Challenge
(mins.) Shift

Sitting N >60 min 0 - - - -

Standing N ~15 min P + - - -

F + + - -

G + + + -

N + + + +

A:
PT Impression:
Procedural Intervention:
Rehabilitation Prognosis:

Problem List STG ( Tx Sessions) LTG ( Tx Sessions)

P:
PT Mx:
Suggested Mx:
Precaution:

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STUDENT’S SIGNATURE