INSTITUTION: MASINDE MULIRO UNIVERSITY OF SCIENCE AND TECHNOLOGY

SCHOOL:PUBLIC HEALTH AND BIOMEDICAL SCIENCES

DEPARTMENT:HEALTH PROFFESION AND EDUCATION

NAME: JUNIOUR RICHMAN AKELLO

REGNO: SPR/B/01-03759/2021

YEAR TWO

CLINICAL PLACEMENT 1

CODE: BSP 228

SIGN

ROTATION: BURNS UNIT

CASE FILE

CLINICAL INSTRUCTOR: sign:

NAME: D.N

AGE: 21

LOCATION: ESHIKHUYU

OCCUPATION: STUDENT

RELIGION: CHRISTIAN

MARITAL STATUS: SINGLE

NEXT OF KIN

CONTACT

CLINICAL DATA

IP NO: 250877

D.O.A:

CLERK:

CHIEF COMPLAINT

Pain on the left and right arm

Pain on the knee joint

Difficulty in walking due to pain

PRESENT MEDICAL HISTORY

Know epileptic patient since 2016 presented with 5 days history of burn wound that she sustained while
preparing lunch hour meals at her boyfriends home she had gotten the fall after an epileptic attack while
no one was present at that particular time she felt on the fire while using the traditional three stone
cook she sustained burn at both left and right arms and the knee region.after an hour the boyfriend
came back and he sorted for help and the patient was taken to the nearby health facility the mumius
center . where she was admited as an inpatient , and the burns were dressed and the limb pain
management, she was then refered to kakamega general hospital , where she was received at the
casualty sicklooking and malnuourished , she was then taken as an inpatient for further burn
management at the burn unit and placed under fluids .she has pains on her left right and knee region
which mainly start at night and mainly when she tries to turn walk up and during bathing , the pains are
usually sharp and do not radiate rather are felt on the site of burn, on pain episodes the patient is always
given analgesics IV, she state the pain at worst to be 8/10 and after painkiller to be 2/10.
PAST MEDICAL HISTORY

No history of surgery

History of epilepsy.

No history of admission

No history of chronic illness

No history of blood transfusion.

DRUG HISTORY

The patient has been under phenobarbitone and tegretol for epilepsy management.

Paracetamol , metranidazol, ceftriaxone, tramadol, omeprazole, carbamazapinr, phenobarbitone

FAMILY HISTORY

The patient is the second born of a family of 5, having three siblings, a boy (deceased),and an elder
sister.both parents are deceased.The father past due to diabetes ,while the mother died on sleep.

There is no history of any chronic illness .

SOCIALHISTORY

She is a Christian and a form four leaver with no history of alcohol or cigarette use.she lives in a
permanent house in shikhuyu.

She has no NHIF cover that will cater for his treatment , she uses money to cater for the bills .

PERSONAL HISTORY

She is allergic to cabbage , not allergic to any medication.

COGNITIVE HISTORY

The patient is alert, can communicate and of good cognitive history.

PSYCHOLOGICAL HISTORY
The patient is in a bad emotional state, due to pain and fear of the new skin cosmetic changes that the
burns may have caused

OBJECTIVE ASSESMENT

General observation

.The patient is lying supine on the bed, on a fair general looking condition

.The patient has a good mood , and cooperative

.No head injuries

.Scar on the face close to the mouth on the outer aspect of the lip .

.Has cannula

.No catheter present

.Bandages present on the burn sites

VITALS

Blood pressure- 140/100

Temperature- 35.5

Pulse rate- 112beats per minute

CARDIOVASCULAR SYSTEM

On inspection the patient looks healthy, no cyanosis observed, no finger clubbing observed, no edema,
no deep venous thrombosis.

On auscultation, the regular lub dub sounds are heard and absence of murmurs.

RESPIRATORY SYSTEM

There is equal chest wall expansion and no chest deformity observed on inspection.

No scars present also around the thoracic region.

The patient has a normal spine setting and no scoliosis.

The trachea is not shifted and is in the correct position and feels no pain on palpation.
No secretions present on percussion and resonant sounds heard.

Vesicular breath sounds bilaterally on auscultation.

ABDOMINAL EXAMINATION

There are no visible scars present o

The bowel sounds are heard

MUSCULOSKELETAL SYSTEM

The patient experiences pain when trying to walk due to the burn on the knee joint specific left leg

Reduced range of motion on the lower limb the left leg in specific.

The patient experiences pain on the left and right arms due to the burns .

Decreased muscle strength due to immobility .

No muscle wasting present .

Muscle power 2/5 for the left and right hand and the left leg.

PROBLEM LIST

1.Pain on walking .

2.Pain on flexion of right and left arm

3.Reduced muscle strength

4.Reduced ROM for left and right elbow joints and the left knee joint.

PHYSIOTHERAPY IMPRESSION

Under muscoskeletal system

Reduced range of motion for the upper limb on the left and right elbow , difficulty in flexion and
extension Due to immobilization and pain on attempt to achieve full range of motion.

Reduced range of motion for the left knee joint due to immobilization and pain on flexion .and full
extension.

TREATMENT PLAN
SHORT TERM GOALS

1.Pain management- by reducing the severity of pain from 7/10 to 2/10 during the first three sessions.

2.Increase ROM- by giving the patient passive and active assisted exercises

3.Improve muscle strength by giving the patient passive and stretching exercises and strengthening

4.Enhance Mobility by ambulation getting up from a bed and bending forward and bed sitting while
legs are lowered .

5.Strengthen Core Muscles: Strengthening core muscles (including abdominal and back muscles) to
provide stability and support for patients spine.

LONG TERM GOALS

1.patient to be able to attain full range of motion

2. the patients muscle strength to be increased and endurance also

3. patient education on how to maintain good posture and self care techniques such as breathing
exercises to help alleviate and promote muscle relaxation

4.scar management after full wound recovery .

5.psychological and emmotional support. Mainly on acceptaince due to skin cosmetic changes brought
by the scars.

INTERVENTIONS

Upper limb range of motion exercise

Stretching , hold for 10 seconds and release both in extension and flexion

Left and right elbow flexion and extension, 10 reps for every three sets

Active and active assisted strengthening of the flexors and extensors of the elbow joint , use of resistant
bands

Lower limb

Left and right elbow flexion and extension range of motions for the knee joint , 10 reps for every 4

sets.
Strengthening for the flexors and extensors of the knee joint using active assisted exercises

Use of the theraband 10rep 4 sets .

Straight leg raises , 5 reps two sets .

EVALUATION

On evaluation the patient the patients elbow and knee joint affirmed an increased range of motion

Reduced pain on walking due to ambulation and out of bed practice

Their was an increased muscle strength from 2/5 to 3/5.

FOLLOW UP

Continue with the range of motion exercises for upper and lower limp In specific the left and right arm

Continue with active and active assisted strengthening exercise to increase muscle strenght.