BURN
Michael B. Asia
BSPT- III
INITIAL EVALUATION
I. General Information
Pt. Name: N.G
Age:30 yr. old
Sex: M
Address: Rizal, Kalinga
Civil Status: Married
Handedness: R
Occupation: Chef
Religion: Catholic
Referring MD: Dr. H.D
Referring Unit: KPH- Magsaysay Rd. Tabuk City
Rehab Unit: Almora District Hospital- Burn Rehabilitation Unit
Rehab MD: Dr. C.U
Date of admission: April 10, 2021
Date of Referral: April 10,2021
Date of Initial Evaluation: April 10,2021
Diagnosis: Burn (Superficial Partial Thickness Burn) TBSA of Less than 2% BSA full thickness ( not involving eyes, ears, face)
II. HPI
Pt present condition started when pt states that he’s currently working
in the Restaurant’s Kitchen frying dishes when he accidentally split the pan and oil
splash over to his lower abdominal area specifically on his genitalia and both legs. Pt.
felt a burning aching pain (p/s 7/10) and immediately shouts for help and later on he
was discovered by one of his crew in a sitting position in the floor bearing the pain and
assist him to remove his pants and immediately get clean towel soak it in a running
water and damp it to the area. After a few minutes, pt was assisted to stand up and
immediately rushed to Kalinga Provincial Hospital. Upon arrival, pt was attended by Dr.
HD, VS have been assessed and later undergo an assessment to determine the depth
and severity of the burn injury that revealed of superficial partial thickness burn. Pt
later was treated the surface area c antimicrobial and anti-infection (see meds) and
applied pressure garments to the wound. Pt then referred to Almora District HospitalBurn Rehabilitation Unit for further assessment and evaluation.
III. Past Medical Hx
(-) HTN
(-) DM
(+) UTI
-treated last 2018
IV. FMHX
V. PSEHX:
Social/ health habits: alcohol= # N/A of bottles /year
Tobacco= # N/A of sticks/ day/month/year
Exercise habit: Good Exercise Habit for as pt states that he goes to gym 3 x a wk.
Social status: Dependent living with family
VI. Home Situation/Living Environment
-Pt lives with his family (wife & 2 sons) in a bungalow house.
•
Bedroom is 7 steps way to living room
•
From kitchen 10 steps to the dining area
•
From Dining Area 5 steps to CR
•
Financially Stable
•
Restaurant owner (Chef)
VII. Chief Complaint
S:
C/C:
“Mahapdi yung hita ko, diko maigalaw ng Mabuti”
PT Translation:
“Pt. c/o crumping burning aching pain (p/s 7/10) on LE bilaterally and difficulty when attempt to move”
Pt Goal:
“Pt’s goal is to be able to decrease the pain and gets back to its normal BADL again”
O:
I.
Vital Signs:
BP-90/80 mmHg
PR-50 bpm
RR-12 cpm
T- 38.5 C
Significance: Baseline purposes only
II.
Ocular Inspection
•
Bedbound
•
A/C/C
•
Mesomorph
•
(+) Swelling (B R and L Foot)
•
(+) Intact Blisters (B LE)
•
Burn Area Color- Bright pink or red
•
(+) IV Line on dorsum of the R hand
III. Palpation:
•
Hyperthermic on all exposed body parts
•
Moderate Edema (B ankles and feet)
•
Grade 2 tenderness
IV. Manual Muscle Testing
•
All muscles of UE are grossly graded 5/5 except for:
Findings: Muscle weakness 2 to pain
V. Range of Motion
All joints of (B) UE/LE are actively and passively done and within normal end feel
except for the following:
Findings: LOM
Significance: 2° to pain on
(B) active and passive
VI.ADL
Fully Dependent
Partially Dependent
Independent
Self-care
Bathing

Toileting

Grooming

Upper Extremity dressing

Lower extremity dressing

Bed mobility

Supine to side lying

Supine to long sitting

Rolling

Transfers

Findings: Pt. is dependent in all aspects of ADL except for UE dressing which is partially dependent
Sig.: For baseline purposes only
VIII. Rule of Nine
1%
4.5%
4.5%
A:
I.PT Impression:
Pt N.G is a 30 y/o bed bound male dx c Superficial Partial Thickness burn TBSA
of Less than 2% BSA full thickness ( not involving eyes, ears, face), further defined c
swelling and moderate edema on both feet. Grade 2 tenderness, LOM on hip flexion,
extension, knee flexion, knee extension, and ankle DF, PF, MMT grade 2/5 . ADL
dependency, UE dressing.
II. Rehab Potential:
Pt has a good rehab potential because of his age and willingness of the family
including the pt to undergo rehabilitation program.
IV: Problem List:
1.Burning Aching Pain (p/s 7/10)
2.LOM on both LE including Hip flexion, extension, Knee flexion, extension and ankle PF, and DF
3.Muscle Weakness
4.ADL dependency including bathing, toileting, UE and LE dressing, Bed mobility, Rolling, and
Transfers
5.Edema
V. Long Term Goal: 3 months X 3 tx/sessions- M,W,F
1.Attainment of near normal ROM
2.Near normal ms strength
3.Independent to all aspect of ADL
4.Prevention of 2 complications
VI. Short Term Goal: 1 months X 2 tx/ sessions- T,TH
1.Increase c ROM at least 2 degree increments/ tx sessions
2.Increase ms 2/5 - 3/5
3.Improve ADL dependency to c minimal supervision
P:
PT Management:
1.PRE’s on UE – dumb bell, theraband
2.PROME on both L ex 10 reps x 1 set on AP of motions
HEP
Primary
1. Limb elevation for edema
2. Proper positioning- lead to contracture development