INITIAL EVALUATION

GENERAL INFORMATION

Name: G.D
Age: 22 y
Sex: Female 
Address: San Fernando, La Union
Civil Status: Single
Citizenship: Filipino
Handedness: ®
Occupation: Teacher
Religion: Christian
Attending Unit: OPD
Attending Dr.: B.Z
Rehab Dr.: A.B
Date of Consultation: September 22, 2020
Date of Referral: September 26, 2020
Diagnosis: 2 and 3 degree burns

SUBJECTIVE:
Informant: Pt
Reliability: Good
Educational Attainment: College Graduate

c/c: pt complains of sustained 2 & 3 degree burns over the ® side of her face and neck, ® side of the
anterior trunk, 2/3 of lower ® thigh, and right arm.

HPI

pt present condition started on September 22, 2021, transferred via ambulance to the hospital after a
fire in pt.'s apartment. pt was asleep when the fire started and managed to make her way out of the
apartment through the smoke. pt sustained 2 and 3 degree burns over the R side of her face and neck,
R side of the anterior trunk, 2/3 of L right thigh, and right arm pt In the emergency department with Dr.
B.Z, pt was on a 100 % oxygen non-rebreather mask.

It was promptly pt received a tetanus shot, morphine for pain, and 2 L of IV fluids. intubated with an oral
7.5 ETT because of suspected inhalation burns. Appropriate analgesics and IV fluids were
administered, and the patient was placed on mechanical ventilation.

pt was immediately taken to the burn unit to begin the resuscitation protocol. Over the course of the
next 4 weeks, the patient slowly improved. pt developed pleural effusion on the R and R upper lobe
pneumonia. Weaning from mechanical ventilation was attempted via CPAP trials. Two weaning
attempts failed. Pseudomonas was cultured from his sputum. Escharotomy was required on all ten
fingers. Debridement and skin grafting proceeded without complications. The patient received a
tracheotomy during the fourth week and is now on a tracheostomy collar throughout the day with
mechanical ventilation support (AC) at night.
MEDICATION:

PAST MEDICATION

Medication Dosage/ Frequency Indication

morphine 10-20 mg PR q4hr TO relief of moderate to

severe acute and chronic pain
where use of an opioid
analgesic is appropriate

Other medication:

2 L of IV fluids.
oral 7.5 ETT

PMHx:

(+) Shortness of breath

(+) lobe pneumonia
(-) Cancer
(-) HTN
(-) Hypertriglyceridemia
(-) CVA
(-) BPH
(-) DM

FMHx:

Paternal Maternal

Asthma (-) (+)

Respiratory Disease (+) (-)

CVAs (-) (+)

Heart Disease (+) (-)

HTN (-) (-)

Cancer (-) (-)

PSEHx:
Pt is a non-smoker, an occasional alcohol beverage drinker (three glasses of wine per week), and no
hx of drug abuse. Pt. drives to work every Monday to Saturday. Pt has an active lifestyle and spends
his time reading and working out at her house and walking the dog.

Pt. Lives in a bungalow type of house c the following home ergonomics:

Home station:

 Bedroom + Comfort Room - 7 meters

 Bedroom + Main door - 11 meters
 Bedroom + Dining Room - 5 meters
 Bedroom + Living Room - 7 meters
 Type of floor: 18 inches of ceramic tiles

Pt’s Goal: Pt wants her body to return to how it was before and breathing will be normal, completing
her daily activities and work.

OBJECTIVE:
Height: 160 cm
Weight: 50kg
BMI: 19.6 (Normal Weight)
V.S
VS: Before During After

BP 120 /80 mmHg right arm 130 /80mmHg 120 /80mmHg

sitting

PR 86bpm 75 bpm 84bpm

RR 28 Breaths per minute 20 Breaths per minute 28 Breaths per minute

T° (36.1°C) (37.2°C) (36.1°C)

Findings: Pt has stable Vital Signs

Sig: Pt will have no problem in pt VS when performing exercises

OI:

Pt is ambulatory
Pt is Alert/ Coherent / Cooperative
Endomorph (50 kg)
Physique: Mesomorph
(+) Shortness of breath

(+) Swelling ® UE & LE

(+) Wound ® UE & LE

(+) Blisters ® UE & LE

(+) Peeling skin ® UE & LE

(-) Diaphoresis

(-) Trophic skin changes

(-) contractures

PALPATION:

(+) Edema ® UE & LE

(-) Pitting edema

(-) Lesions

(-) Muscle Spasms

(-) Adhesions

ROM

All major joints on ® UE / LE, neck and trunk were measured actively and passively, pain free, c (N)
end- feel were WNL

R R L L Nor Differen End feel

Moti ce
AR PR AR PR mal
on R L R L
OM OM OM OM Valu
es
Shoulder Flexion 0- 0- 0- 0- 0- 1 0 FIR FIR
3 100 18 18 180 5 M M
0 0 0 0
Shoulder 0- 0-35 0- 0- 0-60 5 0 FIR FIR
Extension 1 60 60 0 M M
0
Shoulder ABD 0- 0-60 0- 0- 0- 1 0 FIR FIR
4 18 18 180 3 M M
5 0 0 5
Shoulder ER 0- 0-45 0- 0- 0-90 6 0 FIR FIR
3 90 90 0 M M
0
Shoulder IR 0- 0-25 0- 0- 0-70 5 0 FIR FIR
2 70 70 0 M M
0
Elbow Flexion 0- 0-70 0- 0- 0- 1 0 FIR FIR
4 15 15 0
 5 0 0 150 5 M M
Forearm 0- 0-45 0- 0- 0-80 5 0 FIR FIR
Supination 3 80 80 0 M M
0
Forearm
0- 0-30 0- 0- 0-80 5 0 FIR FIR
Pronation 2 80 80 5 M M
5
Wrist Flexion 0- 0-30 0- 0- 0-80 5 0 FIR FIR
2 80 80 5 M M
5
Wrist Extension 0- 0-25 0- 0- 0-70 5 0 FIR FIR
2 70 70 0 M M
0
Wrist Radial
0- 0-10 0- 0- 0-20 1 0 FIR FIR
Deviation 5 20 20 5 M M
Wrist Ulnar
0- 0-35 0- 0- 0-30 0 0 FIR FIR
Deviation
3 30 30 M M
0
MCP Flexion 0- 0-35 0- 0- 0-90 6 0 FIR FIR
3 90 90 0 M M
0
MCP Extension 0- 0-25 0- 0- 0-45 2 0 FIR FIR
2 45 45 5 M M
0
MCP ABD 0- 0-15 0- 0- 0-25 1 0 FIR FIR
1 25 25 5 M M
0
PIP Flexion 0- 0-50 0- 0- 0- 5 0 HA HA
4 10 10 100 5 RD RD
5 0 0
DIP Flexion 0- 0-40 0- 0- 0-90 5 0 FIR FIR
3 90 90 5 M M
5
Hip Flexion 0- 0-50 0- 0- 0- 7 0 FIR FIR
4 12 12 120 5 M M
5 0 0
Hip Extension 0- 0-20 0- 0- 0-20 1 0 FIR FIR
1 20 20 0 M M
0
Hip ABD 0- 0-20 0- 0- 0-40 2 0 FIR FIR
1 40 40 5 M M
5
Hip ADD 0- 0-10 0- 0- 0-20 1 0 FIR FIR
5 20 20 5 M M
Hip ER 0- 0-20 0- 0- 0-45 3 0 FIR FIR
1 45 45 0 M M
5
Hip IR 0- 0-30 0- 0- 0-45 2 0 FIR FIR
2 45 45 5 M M
0
Knee Flexion 0- 0-50 0- 0- 0- 9 0 FIR FIR
 4 13 13 135 0 M M
5 5 5
Knee Extension 0- 0-10 0- 0- 0-10 5 0 FIR FIR
5 10 10 M M
Ankle PF 0- 0-35 0- 0- 0-50 2 0 FIR FIR
3 50 50 0 M M
0
Ankle DF 0- 0-10 0- 0- 0-20 1 0 FIR FIR
5 20 20 5 M M
Ankle Inversion 0- 0-20 0- 0- 0-30 1 0 FIR FIR
1 30 30 5 M M
5
Ankle Eversion 0- 0-15 0- 0- 0-20 1 0 FIR FIR
1 20 20 0 M M
0

Findings: Pt has LOM on R UE and LE

Significance: Pt will have difficulties in performing ADLS; Pt has decreased ROM d/t muscle weakness

MMT

Grade Definition

5 Complete ROM, against gravity c max. Resistance

4 Complete ROM, against gravity c mod. Resistance

3+ Complete ROM, against gravity min. Resistance

3 Complete ROM, against gravity s resistance

3- More than half of ROM, against gravity s resistance

2+ Initiate ROM, against gravity s resistance

2 Complete ROM, gravity eliminated s resistance

2- Initiate ROM, gravity eliminated s resistance

1 Contraction is felt/seen but no motion

0 No muscle contraction is seen/felt.

All on ® UE & LE

MUSCLE// GROUPS GRADE

R SH FLEXOR 3-/5

R SH EXTENSORS 3-/5
R SH ABDUCTORS 3-/5

R SH ADDUCTORS 3-/5

R ELBOW FLEXORS 3-/5

R ELBOW EXTENSORS 3-/5

R FA SUPINATORS 3-/5

R FA PRONATORS 3-/5

R WRIST FLEXORS 3-/5

R WRIST EXTENSIONS 3-/5

R WRIST RD 3-/5

R WRIST UD 3-/5

R HIP FLEXORS 3-/5

R KNEE FLEXORS 3-/5

R KNEE EXTENSORS 3-/5

R HIP EXTENSORS 3-/5

Findings: grade 3-/5 on all muscles on R UE & LE

Significance: 2 to edema

Landmark Anterior View

TRUNK Slightly leans to (R)

PELVIS/HIP hip is slightly higher

KNEE ® knee is slightly flexed

Landmarks Lateral View

HEAD Slight forward head

SHOULDERS Rounded

ELBOW ® elbow is slightly flexed

KNEE ® is slightly flexed

 Landmarks Posterior View

TRUNKS Slightly leans to (R)

SHOULDERS Rounded

ELBOW ® elbow is slightly flexed

KNEE ® is slightly flexed

Findings: Pt has a slight forward head posture, trunk slightly leans to ® elbow is slightly flexed, ® hip is
slightly higher, ® knee is slightly flexed.
Significance: 2 o to muscle weakness and habitual posture

DTR:

Findings: Pt has hyporeflexia on R UE / LE.

Significance: For baseline purposes

ADL: 
ADL Score

MOTOR ITEMS

Self-care

Feeding 7

Grooming 7

Bathing N/A

Upper Garment 6
Dressing
 Lower Garment 7
Dressing

Mobility

Bed Mobility

● Roll to Right 6

● Roll to Left 6

● Supine to Sit 6

● Sit to Supine 6

Chair Mobility 7

Toilet Transfer 7

Ambulation 7

COGNITIVE ITEMS

Communication

Comprehension 7

Expression 7

Reading 7

Writing using R hand 7

Writing using L hand 7

Speech Intelligibility 7

Psychosocial Adjustment

Social Interaction 7

Emotional Status 7

Adjustment to Limitation 7

Employability 7

Cognitive Function

Problem Solving 7

Memory 7

Orientation 7

Attention 7
Finding: pt has In upper garment modified index in ADL as to bed mobility specifically in rolling to right
and left, supine to sit , sit to supine.
Significance: 2 to burn injury and edema
Wound Assessment

Location ® UE & LE

Full-thickness burn
Type of wound

Shape Irregular

Size Length: 13 cm

Width: 10 cm

Depth: 5 cm

Odor Without odor

Deep red to waxy white to leathery gray or
Color charred black.

Body Temperature Warm

Exudate Amount Moderate

Rules of Nines:

Body Part Percentage

Head and Neck 9%

Right Arm 9%
Left Arm 0%

Right Hand 9%

Left Hand 0%

Trunk 18%

Groin 0%

Right Leg 18%

Left Leg 0%

Total: 63%

Findings: All R parts of body has 9% but trunk and R leg has 18%, shows signs of Full-
thickness burn.
Sig. Pt’s has TBSA percentage of 63% full-thickness burn on R UE & LE

ASSESSMENT

PT Impression:

G.D is 22 y/o Filipino, female who complains of sustained 2 & 3 degree burns over the right side
of her face and neck, right side of the anterior trunk, 2/3 of lower right thigh, and right arm. Pt.
has shortness of breath, swelling R UE, wound R UE, Edema R UE. Pt has LOM on R UE and
LE. pt has In upper garment modified index in ADL as to bed mobility specifically in rolling to
right and left, supine to sit, sit to supine. Pt has hyporeflexia on R UE / LE. Pt has a slight
forward head posture, trunk slightly leans to ® elbow is slightly flexed, ® hip is slightly higher, ®
knee is slightly flexed. MMT grade 3-/5 on all muscles on R UE /LE

Rehab Potential and Prognosis: Pt have a good rehabilitation because pt is willing to undergo
therapy, she is still young and have supportive family

Procedural Intervention: PT will make up for any remaining strength, in order to accomplish
the patient's goal and avoid further complications that could worsen the patient's current
condition.
PROBLEM LIST STG ( 3x for 1 years ) LTG ( 3x for 2 years )

Pt. shortness of breath To increase shortness of To get normal shortness of

breath breath

Pt has swelling on R UE To decrease swelling on R To eliminate swelling on R

UE UE

Pt has LOM on R UE and LE To increase in ROM by 10• in To improve an full ROM on R

R UE and LE UE and LE

Pt has grade 3-/5 on R UE To increase MMT from 3-/5 to To get to normal MMT on R
and LE 4/ 5 on R UE and LE UE and LE

Pt 2 and 3 degree burn To improve wound from 2 To get normal skin, no burn
wound and 3 degree to 1 and 2 or wound
degree

PLAN

 Whirlpool bath for 103-110 F on R UE for 20 minutes to reduces pain and stimulate
wound healing.
 Positioning with dynamic splint on the R UE&LE to minimize edema formation.
 Deep friction massage on the R UE to decrease scar thickness and improve scar
appearance.
 Stretching exercises on R UE hold for 30 sec x 3 sets to increase flexibility.
 Deep breathing exercises hold for 30 sec x 10 rep, to strong breathing muscles.
 AROME exercises on R UE&LE for 10 rep x 1 set to increase ROM

HIP:
 Pt & family education about the pt.’s condition
 Postural and positioning re-education
 Proper transfers and early mobilization
 Family education about how to assist the pt through AROME, resistance exercises, and
other
 elements of the management program.
  Risk factors re-education

HEP
 Proper Bed Positioning
 Breathing exercises
 Holding squeeze small ball
 Balance exercises

Precaution:
 Do not soak the burn in water or apply ointments or butter, which can cause infection.