Manila Adventist College

College of Allied Health

Department of Physical Therapy
PHYSICAL THERAPY INITIAL EVALUATION

General information:
Name: D.A
Age: 28 y/o
Sex: Male
Address: Makati City
Civil status: Single
Handedness: R
Weight: 62 kg
Height: 163cm
BMI: 23.34 (N)
Occupation: Electrician
Religion: SDA
Nationality: Filipino
Referring unit: Makati Medical Center
Referring MD: Dr. C.Y
Rehab MD: Dr. M.G
Date of consultation: Nov. 23, 2021
Date of referral: Nov. 23, 2021
Date of IE: Nov. 24, 2021
Type of pt.: ICU
Informant/Reliability: Pt./Good
Dx: Low-voltage electrical burn on R anterior UE, R axilla, anterior neck, upper chest, and B LE c 31%
TBSA using Lund and Browder Chart

S>
C/C: pt ℅ difficulty on doing self care such as dressing/undressing, toileting, and walking d/t contracture
and weakness of the affected extremity (see ROM and MMT)

Pt goal: pt wants to do ADL such as dressing, toileting, and taking a bath and amb s minimum difficulty
and to be discharged from the hospital.
HPI:

6 days PTIE, Pt was working as an electrician when he was fixing a fuse box when he accidentally
touched a live wire c 220v AC on his R hand for ~4 s. Pt was conscious when rushed to the nearest ED. Pt
sustained electrical burn on his R palm (entrance), R anterior UE, R axilla, anterior neck, upper chest, B
LE and B Hind foot (exit). Pt received initial wound care and meds. for infection control (see drug Hx).
Later on he was adm to the ICU and underwent several tests (see ancillary and laboratory test).

5 days PTIE, Pt presents eschar and necrotic tissues on the R anterior UE, anterior neck, upper chest,
and B LE and receives an escharotomy.

3 days PTIE, pt received skin grafting (autograft) on R anterior UE, axilla, upper chest, Sheet graft on
anterior neck and mesh graft on the B LE (Nov. 21, 2021). Skin graft donor was taken from the pt
abdomen.

1 day PTIE, pt observe tightness when moving the R elbow ext, R wrist ext, R fingers ext, B knee flex, B
ankle plantarflexion during bed mobility. Pt also experienced difficulty on walking d/t wound on
hindfoot and contracture of skin on the knee joint. Pt also has weakness when moving unto R shoulder,
elbow, wrist, and finger flexion. Pt also has min difficulty expanding the chest during breathing d/t
burns on the upper chest. Pt felt discomfort and deep pressure on all the wound sites.

At present pt ℅ difficulty on doing self-care such as dressing/undressing, toileting, and walking d/t
contracture and weakness of the affected extremity (see ROM and MMT).

Ancillary Procedures:

Procedure Date Taken Findings

ECG Nov. 18, 2021 (-) Arrhythmia

X-ray Nov. 23, 2021 (+) Slight dec on BMD

Laboratory result:
November 17, 2021
Procedure Normal Values Results
CBC    
  WBC (x103/microL) 3.8-10.4 15.5 (Inc)
  RBC (x106/microL) 3.8-5.0 2.2 (dec)
  Platelet (x103/microL) 153-361 300 (N)
  Hematocrit (%) 40%-52% (men) 30(dec)
36%-47% (women)
  Hemoglobin (g/dL) 13-17 g/dL (men) 8 (dec)
12-15 g/dL (women)
BUN (mg/dL) 6-24 20 (N)
Creatinine (mg/dL) 0. -1.3 1 (N)
Troponin i (ng/L) 0 - 0.04 0.03 (N)
Total serum CK (U/l) 50–400 345 (N)
Serum troponin T (ng/l) < 14 10 (N)
Serum creatinine (µmol/l) 60–100 75 (N)
Serum urea (mmol/l) 3.2–8.1 4.5 (N)
Serum AST (U/l) 15–45 30 (N)
Serum ALT (U/l) 10–70 50 (N)
Amylase (U/L) 40 - 140 100 (N)
WBC differential
Neutrophils (per mm3) 2500-8000 9500 (Inc)
Lymphocytes (per mm3) 1000-4000 5000 (Inc)
Monocytes per mm3) 100-700 856 (Inc)
Basophil (per mm3) 25-100 200 (Inc)
Eosinophil 50-500 550 (Inc)
Electrolytes  
    Potassium (mmol/L) 3.7 - 5.1 10 (Inc)
Sodium (mmol/L) 135 - 145 140 (N)
    Magnesium (mmol/L) 1.7 - 2.2 1.5 (N)
    Chloride (mmol/L) 97 - 105 100 (N)
 Urinalysis
color Pale yellow Pale yellow
pH 4.5-8.0 5.0
Specific gravity 1.001-1.030 1.028
Nitrite Negative Negative

DRUG HX:
Drug Date taken Dosage Indication Side Effects

Silver sulfadiazine Nov. 17, 2021- 1% cream: apply Anti-bacterial, anti Burning
present daily q 12 hours to pseudomonas Itching
burn infection. Rash

Oxandrin Nov. 19-present 2.5-20 mg/day Decrease lean Nausea

mass catabolism, Vomiting
improve wound Headache
healing

Thiopental Nov 21, 2021 50 mg Anesthesia respiratory

Sodium depression,
For skin grafting myocardial
2-4% depression,
Halothane
cardiac
arrhythmias

Erythromycin Nov. 19-24 2021 500 mg q 12 hrs skin infections Nausea

Vomiting

Fenoprofen Nov. 17-19, 2021 200 mg bid Anti-inflammation Nausea

Vomiting

IV RL Nov. 17, 2021 - 100 cc Fluid resuscitation Discoloration,

Nov. 19, 2021 Itching
Difficulty in
breathing

Collagenase Nov. 17, 2021 250 units/g/day Debridement Irritation

(Santyl) Burning sensation
at site of
application

Tetanus Nov 17, 2021 0.5mL Anti tetanus Lightheadedness,

Prophylaxis nausea
FMHx

Condition Paternal Maternal

Pulmonary Disease (-) (-)

DM (-) (-)
OA (-) (-)
RA (-) (-)
Htn (-) (+)

PMHx
● (+) Hospitalization (Nov. 17, 2021)
● (+) Trauma (Nov. 17, 2021)
● (+) Surgery (Nov. 21, 2021)
● (-) DM
● (-) Arthritis
● (-) Thrombosis
● (-) Htn
● (-) Cardiopulmonary dse

PSEHx
● Type A personality
● Active lifestyle
● Non-smoker
● Non-alcoholic
● Balanced Diet
● Hobby: Biking, Basketball

Home situation
● Lives c family
● Lives in a bungalow ~50 sqm
● 3 bedrooms, 1 Bathroom
● Main door ↔ Bedroom ~ 20 steps
● Main door ↔ Bathroom ~ 15 steps
● Bedroom ↔Bathroom ~ 5 steps
● Bedroom ↔ Kitchen ~ 15 steps
● Bedroom ↔ Dining area ~10 steps
● Main Door ↔ Living room ~5 steps
● Bed ht. ~ 40 cm
● Chair ht. ~ 40 cm
● Dining table ht. ~ 70 cm
● Overhead cabinet ~35cm
 ● Door knob: Keyed entrance
● Floor type: Ceramic tiles

Work situation
● Field of work: Household Electrician
● Working hours: 8 hours a day
● Mode of transportation: motorcycle (Honda Wave 100cc)
● Rest day: Saturday
● Work environment: Electrical Hazard

O>

VS:
Before During After

BP 120/80mmHg 130/90mmHg 120/80mmHg

Temperature 36 C° 36.5 C° 36.2 C°

PR 75 bpm 80 bpm 77 bpm

RR 17 cpm 19 cpm 16 cpm

SpO2 99 97 99

Findings: Pt v.s is WNL except of BP during exercise which is on prehypertension

Significance: for baseline purposes and precautionary measures.

OI:
● Mesomorph
● Bed Fast
● A/C/C
● In apparent distress
● R shoulder abducted into 90
● (+) IV on L hand
● (+) Wound on R anterior UE, Anterior neck, upper chest, B anterior LE
● (+) redness on wound site
● (+) pressure dressing on skin graft
● (+) skin graft on R anterior UE, R axilla, upper chest, anterior neck, B LE
● (+) skin graft donor site on abdomen
● (+) stitches on skin graft site, abdomen, R anterior UE, R axilla, upper chest, anterior neck, B
LE
● (+) Gait Deviation (see gait ax)
● (+) Postural Deviation (see Postural analysis)
 ● (-) hypertrophic contraction
● (-) Keloid

Palpation:
● Hyperthermic on Wound site
● (N) Capillary refill
● (+) LOM (see ROM)
● (+) mm weakness (see mmt)
● (+) contractures on R anterior UE, R axilla, upper chest, anterior neck, B LE
● (-) edema
● (-) tenderness
● (-) mm guarding

NEUROLOGIC EVALUATION
Sensory Assessment:
SUPERFICIAL STD USED R UE L UE B LE Result
SENSATION

Light Touch Cotton ball 5/5 Trials 5/5 Trials 5/5 100%

Pain Tip of neuro hammer 5/5 Trials 5/5 Trials 5/5 100%

Temperature 2 Test tube (warm/cold) 5/5 Trials 5/5 Trials 5/5 100%

Deep Pressure Therapist fingertip 5/5 Trials 5/5 Trials 5/5 100%
Findings: Pt has 100% in all superficial sensation on all unaffected sites of burn.
Significance: for precautionary measures
Note: Burned sites was not assessed d/t risk of infection.

DEEP STD USED R UE L UE B LE Result

SENSATION

Proprioception Extremity is moved and 5/5 Trials 5/5 Trials 5/5 100%
held in a static position by
PT

Kinesthesia PT moved the extremity 5/5 Trials 5/5 Trials 5/5 100%
passively

Vibration Tuning fork 5/5 Trials 5/5 Trials 5/5 100%

Findings: pt has 100% intact in deep sensation
Significance: for precautionary measures during intervention
ANTHROPOMETRIC MEASUREMENT: Pt was assessed in sitting position
Limb Girth Measurement
Landmark R L Difference

3” Below Lateral Epicondyle 27 cm 30 cm 3 cm

5” Above Lateral Epicondyle 33 cm 34 cm 1cm

6” Below apex of patella 39 cm 41 cm 2 cm

Chest Expansion
Landmark Inhale Exhale Difference

Nipple Level 93 cm 90 cm 3 cm
Findings: All of the measurements are WNL
Significance: for baseline purposes and precautionary measures.

ROM: all major jts on B UE and LE are WNL except for the ff:

Motion AROM Difference PROM Difference N Value End feel

Cervical Extension 10 35 N/A 0 0-45 Firm

R Shoulder Flexion 20 160 50 130 0-180 Firm

R shoulder 90 90 100 80 0-180 Firm

Abduction
R Elbow Flexion 20 130 25 125 0-150 Soft

R Wrist flexion 10 70 20 60 0-80 Firm

R Wrist Extension 10 60 N/A 0 0-70 Firm

R Wrist Radial 10 10 20 0 0-20 Hard

Deviation
R Finger Flexion 20 70 25 65 0-90 Hard

R finger Extension 5 40 10 20 0-45 Firm

 R Thumb Flexion 20 30 30 20 0-50 Hard

R Thumb Extension 10 40 15 35 50-0 Firm

B Knee Flexion 20 115 N/A 0 0-135 Soft

B Ankle 20 30 25 25 0-50 Firm

Plantarflexion

Findings: Pt has LOM on Cervical Extension, R Shoulder Flexion, R shoulder Abduction, R Elbow Flexion,
R Wrist flexion, R Wrist Extension, R Wrist Radial Deviation, R Finger Flexion, R finger Extension, R
Thumb Flexion, R Thumb Extension, B Knee Flexion, B Ankle Plantarflexion

Significance: LOM is d/t contraction, s/p skin graft, and mm weakness. Tx should include AROME and
strengthening exercise.
Note: Some PROM are not assessed for protection of grafted wounds.

MMT: all major mm on B UE and LE are WNL except for the ff:

Muscle Group Grade

R Shoulder Flexor 3-/5

R Elbow Flexor 3-/5

R Elbow Extensor 2/5

R Wrist flexor 2/5

R Wrist Extensor 3-/5

R Wrist Radial Deviation 3-/5

R Thumb Flexor 3-/5

R Thumb Extensor 2/5

R Finger Flexor 3-/5

R finger Extensor 2/5

B Knee Flexor 2/5

B Knee Extensor 2/5

B Ankle Plantarflexor 2/5

Findings: Pt has mm weakness on R UE and B LE

Significance: Pt mm weakness is d/t prolonged immobilization. Tx should include strengthening
exercises.

Gait Analysis:

PARAMETERS N VALUES RESULTS

Cadence 90-120 steps per minute 80 steps/min

Stride Length 57 in 20 in

Step Length 28 in 10 in

Findings: Pt exhibits gait deviation of knee on initial contact, midswing and ankle on initial contact and
loading response. Pt has also ↓ on cadence, stride length, step length. Pt also has ↓ in R UE swinging
during amb.
Significance: Gait deviation is d/t contracture and wounds of B LE. Tx should include ROME and gait
training.
Postural Ax: Pt was assessed in standing position

AP VIEW Landmark Lateral View

Midline Head/neck Slightly extended

Leveled Scapula Protracted

Leveled Shoulder Rounded

Leveled Elbow (R) slightly flexed

(R) Slightly flexed Wrist and Hand neutral

Midline Thoracic Inc kyphosis

Midline Lumbar (N) lordosis

Leveled Pelvis Midline

leveled Hips Aligned

Leveled Knees aligned

Neutral Ankles Neutral

Neutral Foot Neutral

Findings: pt demonstrate postural deviation such as neck slight extension, protracted scapula, rounded
shoulder, R slight flexion of elbow, R slight flex of Wrist and hand, and min ↑ of thoracic kyphosis.
Significance: pt has postural deviation d/t contraction. Tx should include Stretching and proper
positioning.
Lund and Browder Burn Assessment

Findings: pt acquired 31% TBSA full-thickness burn on ant neck, ant trunk, right arm, both LE, and
plantar aspect of foot

Significance: For precautionary measures during the intervention.

WOUND ASSESSMENT:
Wound Type: Electrical Burn
Number: 5
Location: R UE, R axilla, Anterior neck,
Upper chest, B LE, B Plantar of foot
Margin: well-defined
Depth: full thickness burn
Size: 31% TBSA
Granulation: (-)
Pain: (-)
Bleeding: (-)
Odor: (-)
Exposed Bone: (-)
Exposed ms, tendon/ligaments: (-)
Underminings: (-)
Pigmentation: Red
Signs of Infection: (-)
Significance: For wound care mx and precautionary measures during intervention.
Functional Ax:

FIM:

Self Care Activities Grade

Eating 6

Grooming 4

Bathing 1
Dressing – UE 2

Dressing – LE 2

Toileting 4

Sphincter Control

Bladder 7

Bowel 7

Transfers

Bed, chair, wheelchair 5

Tub, shower 1

Locomotion

Walk/wheelchair 3

Stairs 1

Communication

Comprehension 7

Expression 7

Social Cognition

Social Interaction 7
Problem Solving 7

Memory 7
FIM Levels:
Grade 7: Complete independence
Grade 6: Modified independence (device)
Grade 5: Supervision
Grade 4: Minimal Assistance
Grade 3: Moderate Assistance
Grade 2: Maximal Assistance
Grade 1: Total Assistance
Findings: Pt has a score of 78 and must continue In pt rehab
Significance: Used to decide in adm of pt for in-pt rehab and describe changes on rehab.

Psychological Ax
Findings: Pt has a poor quality of sleep and a total score of 1
Significance: to assess psychological distress

A>

PT IMPRESSION: Pt is dx c low-voltage electrical burn on R anterior UE, anterior neck, upper chest, and B
LE c 31% TBSA, manifested c LOM, mm weakness, contracture, ↓ superficial sensation on the affected
sites leading to difficulty to do the following: self care such as dressing, toileting, and amb. PT mx will
focus on regaining ROM, mm strengthening, contracture prevention, gait training and functional
activities.
REHAB POTENTIAL: Pt has a fair prognosis d/t the following reasons

Favorable Non-favorable

● Pt’s age ● Irreversible scarring

● Physically fit ● Full thickness burn
● Received early Intervention ● TBSA of 31%
● no comorbidities
● no internal organ affectation
● Balanced diet
● no psychological problem

PROBLEM LIST:
1. LOM on cervical extension, R shoulder flexion, abduction, R elbow flexion, R wrist flexion,
extension and radial deviation, R finger flexion, extension, R thumb flexion, extension, B Knee
flexion, B ankle plantarflexion
2. Difficulty c amb
3. Mm weakness
4. Postural deviation
5. Pt has low FIM level
6. diminished superficial sensation on all burned sites
7. Pt has 31% TBSA

LTG: in 3 wks, pt will exhibit an increase in doing ADLs and amb and will be discharged from the
hospital.

STG:

In 1 wk PT session 7x/wk pt will be able to:

1. Pt will demonstrate increase in ROM on all affected joints by 5-10 degree increments
2. Pt will demonstrate increase in cadence, stride length, step length by 10 increments
3. Pt will demonstrate increase in mm grade by 1 increments
4. Pt will manifest proper posture
5. Pt will demonstrate increase in FIM score (78 - 85)
P>

PT Mx

1. Gentle AROME towards, shoulder flexion extension abduction, elbow flexion extension, wrist
and hand flexion extension, knee flexion extension, and ankle plantar flexion x 10 reps x 2 sets.
2. Ambulation c cane on left hand in 5 m
3. Pressure Dressing on wound sites
4. Positioning and splinting:
● Anterior neck - use of double mattress; position neck in extension.
● R Shoulder-axilla - airplane splinting
● R Elbow - splint in extension
● R Wrist - Extension
● R Hand - Wrap fingers separately, elevate, position in intrinsic plus position.
● B Knee – Extension
● B Ankle – Plantigrade splint

Progression

● PRE

Ward Exercise

● Gentle B LE ankle pumps x 10 reps x 2 sets

● AROME on L UE x 10 reps x 2 sets
● PRE on L UE c dumb bell (10 kgs) 10 reps x 2 sets

Pt Education

1. Extremity elevation of R UE and B LE

2. maintain proper body posture
3. Proper joint positioning
4. Protect wound
5. Monitor capillary refill

PT-In-Charge:
Jereme Nayve, PTRP
Samantha Rarugal, PTRP
Duff Azaula, PTRP