LORMA COLLEGES

Initial Evaluation
General Information

Patient’s name: S.P

Age: 23 y/o
Sex: M
Address: Baguio City, Benguet
Civil Status: Single
Handedness: R
Occupation: Taxi Driver
Religion: Roman Catholic
Referring Unit: SLU Intensive Care Unit
Referring MD: Dr. Robert Robertson
Rehab MD: Dr. David Davidson
Date of Admission: March 1, 2018
Date of Referral: April 6, 2018
Date of IE: April 16, 2018
Dx: Acute Epidural Hematoma R Temporal Region, Contusion Hematoma L Temporal Region, Subarachnoid
Haemorrhage, Left Tempoparietal Cerebral swelling, Linear fracture of zygomatico temporal bone, Moderate TBI
S/P craniotomy Parieto-temporal Area

S:
Informant: Parent
Reliability: High
(Note: Pt’s parent was @ work during the incident).
Intra-rater: Neighbor (witnessed the incident)
Reliability: High

C/C: “Mahina yung buong katawan niya, pag tinatayo namin siya nahihirapan siya at di niya mabalanse
yung katawan niya.”
PT Translation: Pt’s wife c/o pt’s generalized muscle weakness c difficulty on standing-balance
tolerance.
HPI: Pt’s present condition started ~2 mos. PTIE @ ~7 o’clock in the morning p attending a birthday
which lasted til’ morning. Pt. was then under the influence of alcohol when walking along the national
highway going home. Pt’s neighbour stated that while the pt. was about to cross, a car that was trying to
overtake a taxi, when it drove towards where the pt. was walking, the impact tossed the pt. ~7 m from
where the pt. was walking to an unlevelled surface where pt was seen lying flat, face down.

Upon closer inspection, pt. was in a conscious-state and seen c severe bleeding from his head, both
hands and both feet. Pt’s neighbour called for help and p ~5 mins., pt was then rushed to SLU ER via taxi
where first aid was administered on the pt’s wound to stop further bleeding. P ~30 min. pt was in a state
of altered consciousness and had a GCS of 8 and underwent different procedures (see Ancillary
procedures) which revealed skull fx c severe subarachnoid haemorrhage which prompted the pt’s
surgeon, Dr. Eloh Ell to perform immediate craniotomy c sutures, the procedure lasted ~30 mins.
~12hrs. p operation pt regain his consciousness, however, pt demonstrated violent behaviour wherein
the pt. removed his all of his attachments. Pt. manifested child-like behaviour, confusion on what is
happening around him and would often, was unable recognize the faces of his family, however, pt can
recall what exactly happened to him during the incident. Pt. stayed @ ICU for 1 wk where there was pt’s
condition improved in response to the medication given to him, pt was then transferred from ICU to
surgical ward where the pt. stayed for another 8 days to be monitored.

During pt’s confinement, pt remained bedbound and only ate soft food such as rice porridge. P 15 days
of confinement, pt was D/C and scheduled for a check-up p ~ 3 wks. During the 3 wks. pt. remained
bedbound c IV line support and continued Rx medication @ home. Pt still manifested child-like
behaviour and confusion, pt also c/o severe headache, gradual localized pn of his both knees, pt’s
parent massaged pt’s head and knees, however, there was no effect. Pt slept constantly lying flat face
on back c 2 pillows supporting his head. Pt’s parent noticed bedsore of the pt. and applied warm water
and cleaned the bed sore. Pt’s parent also noticed decrease body wt.

~3 wks. PTIE, pt. had a check-up @ SLU via taxi, and was said that the pt. had great improvement. On his
way home, pt vomited, and was immediately rushed back to SLU via taxi and underwent tests (SEE AP)
which revealed that the pt. was experiencing hypotension c BP of 50/30 mmHg and hyponatremia. Pt
was then confined to a private room to monitor pt’s condition c new Rx medication given (see
medication). Pt remained bedbound c IV line support. Pt. did not have any solid food intake. Dr. Robert
Robertson noticed muscle weakness of pt’s extremities and then proceeded to refer the pt. to Dr. David
Davidson for PT Rehab @ SLU to have further evaluation and Mx.

At present, Pt. c/o generalized muscle weakness c problem on ambulation, standing-balance and
has maximum difficulty in all aspects of ADL’s.

Pt. was D/C on his 15th day of confinement and is now on his 8th PT Tx session c e ff Mx:
1. ES (R) UE/LE x20 mins
2. AAROME x 10 reps x 1 set on (L) UE/LE
3. PRES on All 4's using green theraband and 1 lb ankle weights x 10 reps x 1 set on AP
4. Sitting bal/tol
5. Standing Bal/tol

Pt. shows improvement every p PT Mx.

Ancillary Procedures:
Procedure Date & Place Findings/ Impression
X-Ray
AP Only 1-05-17/ Bethany Hospital Unremarkable
Chest
 Both Sh AP
Cranial CT- Scan 1-05-17/Bethany Hospital  Linear fracture, zygomaticotemporal
bone c overlying soft tissue swelling
and lucencies R intra-sinus bleed,
sphenoid sinus
 High parietal scalp swelling,
hematoma
Head CT-Scan 1-07-17/ Bethany Hospital  Contusionhematomas L Temporal
regipn, L Temporoparietal cerebral
swelling
 Acute Epidural hematoma, R
temporal Region
 Subarachnoid haemorrhage
Blood Chemistry 02-10-17/ LORMA Medical  122 meq/L; Hyponatremia
Center

Medications:
(Note: Route of Administration via IV Push – Intravenously)
Medicines Indication Dosage
Citicholine drops CNS Stimulant or a 1 drop BID
Nootropics
Sodium chloride IV Supplemental medication TID
Amlodipine Improves blood flow Qd
Mannitol ↓ ICP Qd

PMHx: Unremarkable

FMHx:
Pathology Father Mother
DM (-) (-)
HTN (-) (-)
Heart Disease (+) (-)
Asthma (+) (+)
CA (-) (+)

PSHx:
Pt. has an active lifestyle, has no hx of substance abuse, an occasional alcoholic-beverages
drinker and a non-smoker. Pt. prefers vegetables over meat and exercising daily. Pt. lives in a bungalow
type of house c his wife, 3 children and 1 maid.

House dimension of:

BR – Door ~ 2m
BR – CR ~ 3m
BR – LR ~ 5m
BR – DR ~7m

Pt. is a regular tricycle driver and a farmer, pt. also do household chores such as cooking, wood
chopping and bathing 3 pigs. Pt. is a loving and caring father and husband; however, p the incident pt’s
youngest child is afraid to see the pt d/t pt’s irritability seeing many people and inability to recognize his
family’s faces. Pt also experiencing maximum difficulty in performing all aspect of ADLs and is needing
+1 assist d/t problem during standing and balance c generalized muscle weakness.
 Pt’s Wife Goal: “Sana gumaling na yung asawa ko, para bumalik na din siya sa normal”.

O:
VS:
BP: 120/80 mmHg
PR: 64 bpm
RR: 10 cpm
T°: 36.7oc

OI:
Manner of Arrival: Pt. is bedbound
Mental status: Disoriented/,,,,
Physique: Ectomorph
(+) suture on the R side of the parietal area of head
(+) scar
Upper left eyebrow
B shoulder
Medial Chest area
R FA
(+) IV-line on L hand
(+) Catheter (condom type)
(+) Diaper
(+) Gr. II pressure sore on sacral area (see wound assessment)
(+) Muscle atrophy on B LE
(+) nail discoloration on L big toe
(-) facial asymmetry
(-) Racoon’s eye
(-) Battle’s sign
(-) abrasions
(-) ecchymoses
(-) dry skin on all exposed areas
(-) rashes

Palpation:
Thermal Assessment: Normothermic on all exposed body parts
Tone Assessment: Hypotonic on all 4’s (see tone assessment)
(+) Edema on R dorsal part of hand
(-) Tenderness
(-) (m) Spasm
(-) Tightness
(-) crepitus
(-) contractures
(-) subluxation

Wound Assessment
Shape: Oval-shaped
Size: 6.2cm (Length) x 4cm (width)
Depth: 2mm
Odor: odorless
Color: Pinkish in color
Findings: Gr. II pressure sore
Sig.: 2oto immobilization
Respiratory Assessment
Findings:
Breathing Pattern: Diaphragmatic Breather
Coughing Mechanism: Functional
Cough and Cough Production: N/A
Chest Expansion: N/A
Sig.: For base line data
(Note: Pt is in supine position)

Neurologic Examination:

Glasgow Coma Scale:

Score
Eye movements
Spontaneous 4
To speech 3
To pain 2
None 1
Pt. response: pt. opens eyes spontaneously 4
Motor
On command 6
Localizes 5
Withdraws 4
Abnormal 3
Extensor Response 2
None 1
Pt. response: pt. can follow command 6
Verbal
Oriented 5
Confused 4
Inappropriate 3
Incomprehensive 2
None 1
Pt. response: confused 4
TOTAL: 14/15
Findings: Minor head injury
Sig: for baseline data

TOTAL SCORE (SUM OF SCORES

FOR EACH OF THE THREE GROUPS) INTERPRETATION

Normal 15
Minor head injury 13-15
Moderate head injury 9-12
Severe head injury 3-8
Coma ‹7
Deep coma or brain death 3

Rancho Los Amigos:

I No response
 II Generalized response to stimulation
III Localized response to stimuli
IV Confused and agitated behavior
V Confused with inappropriate behavior (non-agitated)
VI Confused but appropriate behavior
VII Automatic and appropriate behavior
VIII Purposeful and appropriate behavior
Findings: Pt. was confused but appropriate behavior (Gr. VI)
Sig: For baseline date

Sensory Testing:
Findings: N/A
Note: pt. was disoriented

DTR:

(R) (L)
Legend: 0 areflexia
N/A ++ + hyporeflexia
++ normoreflexia
++ +++ hyperreflexia
N/A ++++ clonus
++

++ ++

++ ++

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

Sig: intact reflex arc
Note: N/A on R UE dt (+) IV Line on R hand

Tone assessment:

Legend

0- No response (flaccidity)
1+ Decreased response (hypotonia)
2+ Normal response
3+ Exaggerated response (mild to moderate
hypertonia)
4+ Sustained responses (severe hypertonia)

Findings: All exposed major m. of B UE/LE are assessed and found to be hypotonic c grade 1 m tone
Significance: 2 to immobilization
 Cranial Nerve Testing:
Findings:
CRANIAL NERVES METHOD RESPONSE SIGNIFICANCE
CN I  Identify smell of  No response to  Pt. is disoriented
familiar odor stimulus given
(coffee and
alcohol)
CN II  Count fingers (3  No response to  Pt. is disoriented
tries) stimulus given
 Color acuity  No response to  Pt. is disoriented
(using Ishihara stimulus given
Plates)
CN III, IV, VI  Eye Tracking  Pt was able to  Intact conjugate
do finger eye movement
tracking
CN V  Facial sensation  No response to  Pt. is disoriented
(cotton) stimulus given  N (m) for
 Resist jaw  Pt was able to mastication
opening open jaw c strength
resistance
CN VII  Facial  Pt. was able to  Functional (m) of
expression imitate facial facial expression
expressions
CN VIII  Tuning fork  No response to  Pt. is disoriented
stimulus given
 Tandem walking  N/A  Pt. is bed bound
CN IX, X  Open mouth  Pt has (-) uvula  (+) gag reflex
deviation
CN XI  Sh. shrugging c  Pt was able to  N Sh. shugging
resistance shrug her B
shoulder
CN XII  Tongue  Pt has (-) tongue  Intact control of
protrusion deviation tongue
movement

ROM:
Findings: All motions are WNL and were actively and passively done, pain-free c N end feels.
Except:
Joint & laterality AROM N Diff Endfeel

(R) Sh. flexion 0-158 0-180 22 Firm

(L) Sh. flexion 0-160 0-180 20 Firm
(R) Sh. extension 158-0 180-0 22 Firm
(L) Sh. extension 160-0 180-0 20 Firm
(R) elbow flexion 0-144 0-150 6 Soft
(L) elbow flexion 0-146 0-150 4 Soft
(R) elbow extension 144-0 150-0 6 Hard
(L) elbow extension 146-0 150-0 4 Hard
(R) elbow pronation 0-69 0-80 11 Firm
 (L) elbow pronation 0-70 0-80 10 Firm
(R) elbow supination 0-70 80-0 10 Firm
(L) elbow supination 0-68 80-0 12 Firm
(L) wrist flexion 0-72 0-80 8 Firm
(L) wrist extension 72-0 0-80 8 Firm
(R) hip flexion 0-104 0-120 16 Soft
(L) hip flexion 0-100 0-120 20 Soft
(R) hip extension 104-0 120-0 16 Firm
(L) hip extension 100-0 120-0 20 Firm
(R) Knee flexion 0-115 0-135 20 Soft
(L) Knee flexion 0-115 0-135 20 Soft
(R)ankle dorsiflexion 0-5 0-20 15 Firm
(L)ankle dorsiflexion 0-5 0-20 15 Firm
(R)ankle plantar flexion 0-17 0-50 33 Firm
(L) ankle plantar flexion 0-19 0-50 31 Firm

NOTE: R Wrist flex. and ext N/A d/t (+) IV line

Sig: LOM 2o to weakness

MMT:
Findings: All major (m) are graded 5/5 except for:
Muscle Group Grade
(R) Sh. Flexor 3+/5
(L) Sh. Flexor 3+/5
(R) Sh. extensor 3+/5
(L) Sh. extensor 3+/5
(R) elbow flexor 4/5
(L) elbow flexor 4/5
(R) elbow extensor 4/5
(L) elbow extensor 4/5
(R) elbow pronator 3+/5
(L) elbow pronator 3+/5
(R) elbow supinator 3+/5
(L) elbow supinator 3+/5
(L) wrist flexor 3+/5
(L) wrist extensor 3+/5
(R) hip flexor 3/5
(L) hip flexor 3/5
(R) hip extensor 3/5
(L) hip extensor 3/5
(R) Knee flexor 3/5
(L) Knee flexor 3/5
(R)ankle dorsiflexor 3-/5
(L)ankle dorsiflexor 3-/5
(R)ankle plantar flexor 3-/5
(L) ankle plantar flexor 3-/5

Note:
Sh abd. Sh. Add. Sh IR, sh.ER, hip abd. Hip add. Hip IR Hip ER, Ankle inversion and ankle
eversion N/A d/t pt.’s discomfort.
R Wrist flex. and ext N/A d/t (+) IV line.
Sig: M weakness 2° to prolonged immobility
Primitive Reflexes:
Findings:

Reflex Stimulus Response

Babinski reflex Stroking of lateral aspect of (+) ext. Of big toe and
sole of foot fanning of four small toes

Chaddock’s Stroking of lat. Side of foot (+) ext. Of big toe and
reflex beneth lat. Malleolus fanning of four small toes

Oppenheim’s Stroking anteromedial tibial (+) ext. Of big toe and

reflex surface fanning of four small toes

Sig: (+) UMNL

Anthropometric Measurements:

Muscle Bulk Measurement:

Findings: N/A
Sig: Pt. refusal d/t perception on tape measure

PA: Not assessed due to pt.’s current level of consciousness & inability to sit/stand independently.

GA: Not assessed due to pt.’s current level of consciousness & inability to sit/stand independently.

Functional Analysis: 7- Complete independence

Findings: 6- Modified independence
Helper-Modified dependence
ADL GRADE 5- Supervision (subject 100%)
Self care 4- Min. asst (75%)
 Feeding N/A 3- Mod. Asst (50%)
 Grooming N/A Helper-Complete dependence
 Bathing N/A 2- Max. Asst (25%)
 Upper Garment Dressing N/A 1- Total Asst or not testable (less
 Lower Garment Dressing N/A than 25%)
Sphincter Control
 Bladder Mx N/A
 Bowel Mx N/A
Mobility
 Bed mobility 1
 Chair mobility 1
N/A
 Toileting
1
 Transfer

ADL GRADE
Locomotion
  Gait N/A
 Expression N/A
Communication
 Comprehension 5
 Expression 4
Social Cognition
 Social Interaction 3
 Memory 2
 Problem Solving N/A

Sig: For Baseline Data

A:
PT Impression: Pt is a 53 y.o. male, a bedbound pt. manifested c generalized muscle weakness c atrophied
muscle on B LE, and pressure sore on sacral area d/t inability of the pt to roll and do sidelying. Pt. needs total
assistance in performing ADLs and has maximum difficulty on ambulation and standing and balance tolerance
d/t injury to parts of CNS 2° to moderate traumatic brain injury.
Procedural Intervention: PT proposes restorative and preventative interventions. Restorative because PT Mx
given adheres to the impairment of the pt. and preventative because PT mx can be included so as to prevent
further complications. 3 tx session/wk for 1 yr

Rehabilitation Prognosis: Rehabilitation prognosis is good. Pt. is cooperative, has good support system and
shows improvement to PT Mx given. Pt’s N function can be restored through proper medications and PT Mx.

Problem List
1. Pt. c/o generalized muscle
weakness
2. Hypotonic on all exposed
body parts
3. (+) Muscle atrophy on B LE
4. Limitation of Motion on R &
L sh. Flex.,ext., elbow
flex.,ext. pronation,
supination, wrist flexion,
ext., hip flex. Ext., knee flex.,
ankle dorsiflexion and
plantar flexion.
5. Maximum difficulty on
performing all aspects of
ADLs
6. Maximum +1 assist in ADL’s
as to self-care, mobility &
transfer.
7. Gr. II pressure sore on sacral
area
STG (54 Tx sessions in 3 mo) LTG (104 Tx sessions in 1 year)
Pt will inc. atleast 50% of m Pt will achieve N m strength within
strength within 3 mos of tx session 1 yr of tx session
To increase tone from gr. 1 m tone To achieve and maintain N muscle
to gr. 2 m tone within 3 mos of tx tone p 1 yr of tx session.
session
To inc m bulk on B LE within 3 mos To achieve N m bulk within 1 yr of
of tx session tx session
To inc ROM atleast 75% on R & L To achieve N ROM on R & L sh.
sh. Flex.,ext., elbow flex.,ext. Flex.,ext., elbow flex.,ext.
pronation, supination, wrist pronation, supination, wrist flexion,
flexion, ext., hip flex. Ext., knee ext., hip flex. Ext., knee flex., ankle
flex., ankle dorsiflexion and plantar dorsiflexion and plantar flexion.
flexion. Within 3 mos of tx session Within 1 yr of tx session
Pt will demonstrate max. difficulty Pt will actively perform ADL’s s any
 mod. difficulty in all aspects of restrictions within 1 yr of tx session
ADL’s p 3 mos of tx session
Pt. will demonstrate max  mod. To attain complete independence
assist in ADL’s as to self-care, on ADL’s as to self-care, mobility &
mobility & transfer. p 3 mo. transfer p 1 yr.
Pt will dec. pressure sore from Gr II To eliminate pressure sore within 5
to  Gr I within 2 mos mos tx session

P:
PT Mx:
1. ES (R) UE/LE x20 mins
 2. AAROME x 10 reps x 1 set on (L) UE/LE
3. PRES on All 4's using green theraband and 1 lb ankle weights x 10 reps x 1 set on AP
4. Sitting Bal/tol
5. Standing Bal/tol

Suggested PT Mx:
1. FES x 15’ on (B) UE&LE
2. AAROME → AROME x 10 reps x 2 sets on (B) UE&LE
3. Sitting B/T (short sitting) x 5’
4. Standing B/T inside // bars
5. Deep breathing exercise x 10 reps x 1 set
6. Gait training c assist on leveled ground x 10m

HIP:
1. Proper bed positioning every hour
2. Patient and family education
3. Energy conservation

HEP:
1. AROMEs toward all planes on (B) UE and (L) LE x 10 reps x 1 set
2. Deep breathing exercise x 10 reps x 1 set
3. Ankle pumping on (B) ankle joints x 10 reps x 1 set

Precautions:
1. Fall
2. BP
3. Respiratory Rate
4. Burn

Referrals:
1. Recreational Therapist to restore lifestyle of patient
2. OT to restore functional ability
3. Psychiatrist to prevent depression

Prepared by:

Campos, Bianca Joyce Gurtiza, Joanna Eden

Garcia, Jennie Ross T. Picazo, Judy Fe J.

Pioquinto, Renzdolf