General Information at time of admission:

Name: Mr. Basagulo

Date of birth: March 17, 1991
Age: 22 y/o
Sex: Male
Race: Filipino
Address: Queen of Peace, BC
Marital status:
Occupation:
Height: 59
Weight:
Date of admission: February 15, 2015
Living with: parents

HISTORY OF PRESENT ILLNESS

Mr. Basagulo is a 22 y/o male who was involved in a head on collision. According to his family,
the sudden impact caused him to be thrown forward and hit his windshield. He was not
wearing a seatbelt at that time. He was admitted in the ER and was diagnosed to have a
severe head injury. CT scan revealed hematoma in the subdural spaces.
Pt. was referred to physical therapy 30 days post craniotomy. The neurologist recommended
daily physical therapy and supportive ancillary services. The attending rehabilitative doctor
evaluated him to have a GCS of 8 and recommended that he undergoes PT intervention daily
x 1 month.

PAST MEDICAL HISTORY

No past medical history

PATIENTS FAMILY HISTORY

PATIENTS SOCIAL HISTORY
Occupation: Computer Technician
Marital status: Single
Living conditions:

DRUG HISTORY
Ritalin, Tegretol, Zanaflex and Ativan

PHYSICAL EVALUATION
SUBJECTIVE:
Family reports that pt. is coming in and out of consciousness but unable to recognize them.
His eyes open to pain, his words are incomprehensible, and able to withdraw from pain. They
expressed that they would like to come visit him more often and give support. They have
been praying that he will regain most of his brain function.

OBJECTIVE:
Vital signs:
BP: 130/70
RR: 12bpm
SPo2: 88%
PR: 100 bpm
(+) Bed bound
(+) cannula O2
GCS score: 8
ROM: Assessed all joints in BUE and BLE are WNL. There is soft tissue tightness during
dorsiflexion of bilateral ankles. Mild contracture on bilateral TA.
Integumentary area: Grade 1 sacral area, R/L greater trochanter, scapula

DIAGNOSIS:
TBI S/P craniotomy