Вы находитесь на странице: 1из 4

Name: Kathleen Jessa R.

Fuerte
Topic : BURNS

Initial Evaluation
GENERAL INFORMATION
PT INITIALS: A.B.D
AGE: 18 y/o
SEX: M
ADDRESS: 143 matimyas st. maceda , sampaloc , manila
HANDEDNESS: R
CONTACT NO.: 09971439090
CIVIL STATUS: Single
OCCUPATION: College student
REFERRING UNIT: SJC hospital
REFERRING DOCTOR: Dr. J.K.
REHAB UNIT: SJC-CBR
REHAB DOCTOR: Dr. N.P.
DATE OF ADMISSION (IF IN-PATIENT):
DATE OF CONSULTATION:
DATE OF REFERRAL:
DATE OF EVALUATION:
DIAGNOSIS:
INFORMANT / RELIABILITY:
PRECAUTIONS:

SUBJECTIVE ASSESSMENT
CHIEF COMPLAINT (C/C):
COMPLAINS OF (C/O):
PATIENT GOALS:
PT TRANSLATION:
HISTORY OF PRESENT ILLNESS (HPI):
~5 wks, PTIE, A.B.D was in the science laboratory for an experiment and accidentally swiped c his (L)
arm the flask containing sodium hydroxide. It spilled some on his (R) upper limb. He was given
immediate first aid by flushing cold water on site of injury for 15 mins. and was rushed to the hospital.
Upon admission, pt. complains of constant, localized, burning, aching pain on posterolateral forearm and
dorsal wrist (R-VAS:10/10) and numbness on anterolateral forearm at the site of injury and received
treatment immediately such as wound cleaning, debridement and medications (see Drug Hx).
~Pt. was diagnosed with 4.5 % TBSA, Full thickness burn on (R) anterolateral forearm and Superficial
Partial Thickness burn on (R) posterolateral forearm and dorsal wrist, 2o chemical burn and herein, he
undergone split thickness skin graft from the pt’s (L) medial thigh on the next day. Before room transfer
of pt, the doctor prescribed additional medications (see Drug Hx), and laboratory examinations (see
Ancillary procedures).

~4 wks PTIE, Pt. was prescribed of splinting and received same tx such wound care and physical therapy
including active and passive range of motion above and below the joints affected, and proper positioning
techniques to decrease further complications on his admission. He was cleared and discharged on July 19,
2016 from the hospital and also discontinued PT treatment.

~2 days PTIE, Pt noticed that his difficulty and pain in moving the (R) forearm and wrist had progressed,
he also noticed a slight misalignment of the (R) hand. He also visited a Psychologist because of his
anxiety attacks and posttraumatic stress d/t the burn incident. After that pt was eager to be healed, so he
requested physical therapy.

At present, the pt. presents c LOM on forearm supination and pronation and wrist flexion, extension,
radial deviation; slightly flexed and ulnarly deviated wrist, skin tightness and mm weakness on the site of
injury adding difficulty in movement.

PAST MEDICAL HISTORY (PMHx):


FAMILY HISTORY (FHx):

DRUG NAME DOSAGE FREQUENCY INDICATION

PRESENT MEDICATIONS:

PROCEDURE DATE RESULTS


ANCILLARY PROCEDURES:
PATIENT’S SOCIO-ECONOMIC AND PERSONAL HISTORY (PSEPHx):

VITAL SIGNS BEFORE C HER DURING C HER AFTER C HER

BLOOD PRESSURE

PULSE RATE

RESPIRATION RATE

TEMPERATURE

OBJECTIVE ASSESSMENT
VITAL SIGNS:
FINDINGS:
SIGNIFICANCE:
MENTAL STATUS:
OCULAR INSPECTION
PALPATION
RANGE OF MOTION
MANUAL MUSCLE TESTING
NEUROLOGICAL ASSESSMENT
TONE ASSESSMENT
DEEP TENDON REFLEXES
FUNCTIONAL ASSESSMENT
ANTHROPOMETRIC MEASUREMENT :
POSTURAL ASSESSMENT
GAIT ASSESSMENT
ASSESSMENT
PT IMPRESSION
REHABILITATIVE POTENTIAL:
FORM ATTACHMENTS
PROBLEM LIST
SHORT TERM GOALS
LONG TERM GOALS
PLAN
PRESCRIBED MANAGEMENTS
ADDITIONAL MANAGEMENTS
HOME INSTRUCTIONS
EVALUATED BY: