Initial Evaluation

General Information
Patients Name: R.E.A
Age: 46 y/o
Sex: Female
Address: Pugo, Bauang, La Union
Civil Status: Married
Citizenship: Filipino
Handedness: Right handed
Occupation: Lawyer and Part-time Instructor
Religion: Catholic
Referring Unit: IPD
Referring Dr.: Dr. B.R.
Rehab Dr.: N/A
Date of Referral: N/A
Date of Consultation: Sept. 16, 2016
Date of Evaluation: November 10, 2016
Diagnosis: Acute Respiratory Failure 2 to severe exacerbation of Bronchial
Asthma
S:
C/c:
Pt. Verbatim: Nahihirapan ako huminga, sumisikip and dibdib ko Nagpupuff ako ng Symbicort (2/3 puffs a day) para matanggal ang nararamdaman
ko. Lumalala pag nakakalanghap ako ng usok at alikabok.
PT Translation: Pt c/o difficulty of breathing and narrowing of airway. It is
alleviated by sniffing from a Symbicort puff for 2/3 puffs a day. Ans is
aggrevated by breathing in smoke and dust.
HPI:
Present condition started 2 mo PTIE when pt. Had dry cough and colds
which was assumed to be acquired from her husband who also have dry cough
and colds for ~ 2 wks. Pt. Dry cough and colds are aggravated during
exposure to air pollution such as smoke and dust. Pt. Took Congestril Forte
325 mg. Tid to lessen dry cough and colds ~4hrs. Pt.s dry cough and colds
may trigger her asthma since she was an infant. Pts condition was still not
resolved p 3 days of taking Congestril Forte 325 mg tid. while on their way to
work c his husband who is driving Pt felt chest discomfort which causes her to
have difficulty in breathing. This condition is aggravated by inhaling smoke
and dust and is lessen by inhaling Symbicort which was prescribed by Dr. B.R.
2 yrs. Ago. Pt.s husband observed worsening pts condition & immediately
rushed his wife to the near hospital ITRMC Emergency Department
Pt was attended by Dr. B.R. who immediately prescribed Duavent 5 ml
inhaled through a nebulizer . P ~15 mins, of inhaling 15 ml Duavent, pt felt
slightly improved breathing for ~ 1 hr but is not enough to breath normally.

Dr. B.R. requested for chest PA x-ray, ABG analysis and hematology
tests (see AP) as part of the hospitals protocol. Pt was diagnosed c Acute
Respiratory Failure 2 to severe exacerbation of Bronchial Asthma and HTN
Stage II, JNC8. Pt was advised to be admitted for further treatment and
observation.
Pt was admitted for 3 days in a private room in ITRMC which is an
airconditioned room located on the second floor. Pt. was given medications
(unrecalled) administered through IV and oxygen as a management prescribed
by Dr. B.R. During the 3 days of duration of admission in the hospital, pt. was
advised to bedrest. Pt visitation and talking is also prohibited to the pt. by the
doctor as much as possible to prevent the patient to get tired and to get
enough rest. But pt abides to the doctors advice. Pt also had visitors but are
only limited to 2 visitors a day and pt is also talking but is only very limited
when needed. During the 3 days of admission, pt was very weak. Pt can only
walk for ~ 10 steps for 5 mins performed only when going to bathroom.
P the pt was D/C, pt was advised to rest for 7 days and was given some
medications (see medications). As a part-time instructor she was also advised
to use white board marker than chalk to prevent the asthma to be triggered.
Pt cannot perform some IADL that she usually do before the onset of
symptoms such as going to market, cleaning the house and cooking. Also,
when she works as an instructor she easily gets tired p 2 hrs. Of class which is
unusual for her.
At present, pt cannot still perform the IADL that she can perform before
the onset of symptoms such as going to market, cleaning the house, and
cooking.
Ancillary
Procedure
Chest AP x-ray

Date/ Hospital

Hematology
ABG Analysis

9/16/16/ ITRMC
9/16/16/ ITRMC

9/16/16/ ITRMC

Medications
Indication
Budesonide 320 mg
Bronchodilator
Salbutamol
+ Bronchodilator
Ipartropum 1 neb
Cefuroxime 500 mg
Antibiotic
Feledipine 5 mg
Calcium
Channel
Blocker
Aprovel 200 mg
Angiotensin II receptor
anatagonist
Pmhx:
(+) Hospitalization (see Hospitalization)

Dosage
Bid
Qd
Bid
Qd
Bid

Findings/
Interpretation
(+)Hazy
infiltrates
are seen in both
lower lungs
No sig. Findings
Increased po2

(+) Bronchial Asthma

(+) HTN
(-) DM
(-) Heart Dse
Hospitalizations
Date
2
years
ago
(unrecalled)
September 16, 17,
18

Hospital
Bethany Hospital

Reason
(+) Bronchial Asthma

ITRMC

(+)Acute
Respiratory
Failure 2 to severe
exarcerbation
of
Bronchial Asthma
(+) htnstage II, JNC8

Fmhx:
Asthma
HTN
Heart Disease
DM

F
(-)
(-)
(-)
(-)

M
(+)
(+)
(+)
(-)

Pshx:
Pt. Has an active lifestyle, exercising daily by jogging for ~5 kms for 45
mins while praying the Holy Rosary. At present, pt is a non-smoker but she has
a hx of smoking for ~ 2 sticks a day when she was reviewing for bar exams for
6 mo while drinking coffee to stay awake until 2:00 a.m. Pt is a non-alchoholic
beverage drinker and has no hx of substance abuse. Pt lives in a two storey
house along a barrio street c her husband, 2 sons and 2 stay-out helpers. Pt.
Stated that their house is near to a poultry farm. Pt bedroom is located
upstairs ~ 30 steps from main door to bedroom and ~ 10 steps on the stairs.
Goal:
Pt. Verbatim: Mawala ang sakit ko.
PT Translate: Pt.s goal is to resolve her asthma condition.
O:
VS
BP: 120/80mmhg
PR: 76 bpm
RR: 18 cpm
T: 36.4 C
OI
Amb s AD
A/C/C

Ecdomorph
(+) Postural Deviation (see postural Analysis)
(-) Swelling
(-) Trophic skin changes
(-) Gait Deviation
(-) Deformities
(-) Digital Clubbing
Palpation:
Afebrile to touch
Normotonic on all major m of B UE/ LE
(+) Increased tactile fremitus on A/P R upper lobe
(-) Tenderness
(-) Muscle Spasm
(-) Edema
(-)Chest wall pain
(-)Mediastinal shift
(-)Muscle Spasm
Mediate Percussion:
(+) dull and flat sound
Auscultation:
Findings:
(+) adventitious wheezing on T2, T6, and T10 landmarks
Significance:
2o to Bronchial Asthma
Respiratory Assessment:
Breathing Pattern: Upper Chest Breather
Coughing Mechanism: Weak Functional
Cough and Cough Production:
Tight, usually nonproductive then productive of benign sputum
Significance: pt had experienced difficulty in breathing when coughing
and when trying to excrete secretion.
Chest Expansion:
Findings:
Landmar
Maximum
Maximum
Differenc
ks: (cm)
Inhalation
Exhalation
e
Axilla
65 cm
63 cm
2 cm
Xiphoid
72 cm
71 cm
1cm
Process
Sig.: decreased chest expansion 2 to acute respiratory failure

Neurologic Evaluation:
Sensory Testing:
Device Used: Pin for pain, brush for light touch, thumb for deep pressure
Findings: 100% intact Sensation
Significance: For baseline purposes
DTR:
R

++

++
++

++

++
++
++

++

Legend:
areflexia
+ hyporeflexia
++
normoreflexia
+++ hyperreflexia
++++ clonus
0

++

++

Findings: All reflexes are normal

Significance: Intact reflex arc
ROM:
Findings: All major muscle groups of cervical and (B) UE and LE are WNL, actively
and passively done pain free and with normal end feel.
Significance: For baseline purposes
MMT:
All major muscle groups of cervical and (B) UE and LE are grossly graded 5/5 except
for the ff:
Trunk Flexor : 4/5
Trunk extensor : 4/5
Findings: Pt has weakness on trunk flexor and extensor
Significance: 2 to postural deviation

Postural Assessment
Pt was assessed in standing position in Ant., Post., and Lat views and are
found to be in N alignment except
Findings:
Ant. View
R clavicle is higher than the left
Lat. View
Pt. Has round back posture
Significance:
Pt has postural deviation 2 to difficulty in breathing
Functional Analysis:
ADLs

FIM LEVELS

Self-care

No Helper

Feeding: 7

7 - Complete Ind.

Grooming: 7

6 - Mod Ind.

Dressing: 7

5 - Min Ind. (subject 100%)

Bathing: 7

4 - Modified Dep, Min. Asst (75%)

Toileting: 7

3 - Modified Dep, Mod. Asst (50%)

Bed mobility

2 - Complete Dep, Max Asst

(25%)
Roll to right: 7

1 - Complete Dep, Total Asst

(<25%)
Roll to left: 7
Supine to sit: 7
Sit to supine: 7
Ambulation: 7
6-minute Walk Test
Pt was able to walk 258 m
Findings: Pt was able to do the test without any problems
12-minute Walk Test
Pt was able to walk 336 m
Findings: Pt felt fatigue and difficulty in breathing after walking 932
A:
PT Impression:

Pt has postural deviation 2 to chest discomfort difficulty in breathing

Procedural Intervention:
PT proposes a restorative and preventive intervention since the pt, active &
cooperative during PT Mx. Pts N function can be restored through proper
medications and PT Mx.
Rehabilitation Prognosis:
Pt. has good rehab potential because she adhere to all tasks given on him and have
supportive husband.
Problem Lists

STG (3 weeks Tx

LTG (5 weeks Tx

1. Max difficulty in

Session)
Pt will exhibit max ->

Session)
Pt will exhibit min.

breathing

mod difficulty in

difficulty in breathing &

breathing & inc in

inc in cardiopulmonary

cardiopulmonary

endurance to be able to

endurance to be able to

do 20 continuous

do 10 continuous

aerobic exercises p tx

aerobic exercises p tx

session

2. Productive cough d/t

session
Pt will show the regress

Pt will show no sign of

present condition

productivity of the

cough p tx session

cough p tx session
3. Muscle weakness on
Trunk Flexor ,Trunk
extensor

Pt. will report an in

Pt will achieve near to

(m) strength in Trunk

(N) muscle strength p 8

Flexor and extensor (m)

tx session

from 4/5 5/5 on

MMT
4. Postural deviation

Pt will correct faulty posture

upon PTs verbal cues &
instructions during tx for 2 tx
session/wk for 2 wks

Pt will achieved a N posture

p 2 tx sessions/wk for 2
wks

P:
PT Mx:
1. Breathing exercise: Pursed-lip breathing in sitting position x 7 reps x 3 sets.
2. HMP on B upper back x 15
3. Postural drainage: percussion x 10 secs x 4 sets on B upper back, vibration x 10 secx 3 sets
on B upper back

4. Deep & effective cough exercise x 2 reps x 3 sets

5. Repeat breathing exercise: pursed-lip breathing in sitting position x 7 reps x 3 sets
HEP
1. Breathing exercise: pursed-lip breathing in sitting position x 7 reps x 3 sets
2. Proper Body Mechanics Education

Joanna Eden A. Gurtiza