NITIAL EVALUATION

GENERAL INFORMATION
Patients Name :
Age :
Sex :
Address :
Civil Status :
Handedness :
Occupation :
Religion :
Referring unit :
Referring Dr. :
Rehab Dr. :
Date of Consultation :
Date of Referral :
Date of IE :
Diagnosis :

K..J.
38 y.o.
M
Irisan, Baguio City
Married
(R)
Government Employee
Roman Catholic
ERD
Dr. P.K.
N/A
November 20, 2016
November 20, 2016
December 10, 2016
Mild Brain Injury and Multiple Skull Fracture

SUBJECTIVE:
Source and reliability: wife (90%)
C/c: nahihirapan akong siyang maglakad ng magisa
PT Translation: Pt c/o difficulty in walking independently .
HPI: Present condition started 20 days PTIE at 5:00 p.m (3 hours Pta). Pt. was on his
way home from a christening party, pt. claimed that he was under the influence of
alcohol. Pt. drives a single motorcycle at a speed of ~ 40 kph and suddenly hit an
electric post on a local road in Brgy. P, SJC. Pt. (source) states that pt. was directly
hit on the head (left frontal aspect) on the concrete post as he is not wearing a
protective helmet. Upon impact, pt. lost his consciousness and could not recall the
actual position p the collision.
7:00 pm (1 hour PTa). Pt. was rushed by the locals to SJ MC and was inserted with a
bag assisted ventilation and was advised to be transferred to SMDPCH for more
comprehensive care.
8:00 pm. Pt. arrived at SMDPCH -Emergency department and regained
consciousness. Pt. attempted to be inserted with a nasogastric tube but as the
attending staff inserts the tube, pt. vomited. Pt. vomitus is ~ 1 cup in quantity, and
was characterized to be blood tinged and contains food particles. D/t vomiting and
possibly through the intentional act of the pt. the ventilator and the NGT was no
longer reapplied. Pt. underwent ancillary procedure (see AP)

Source mentioned that at times, the patient is disoriented and usually would not
respond to some questions due to his condition.
Aside for the vomiting there were no more observations made by the source, there
were no complaints of body/ extremity pains nor any other accompanying
manifestations.
Source furthered that during the dates November 20, 2016 up to December 10,
2016, the pt. condition improved gradually as he's swelling on his left eye subsided
and he could be able to walk to the CR with support.
Ancillary Procedure:

X-RAY
MRI

November 20,
2016
November 20,
2016
November 20,
2016

Unrecall
ed
Unrecall
ed
Unrecall
ed

PMHx:
Allergy to shrimp
Unrecalled immunization.
Childhood illness: chickenpox, mumps. Age unrecalled.
No history of previous hospitalizations & surgery

CT SCAN

FMHx:
Condition
TB
HTN
DM
Heart Dse.

F
(-)
(-)
(-)
(-)

M
(+)
(-)
(-)
(-)

PSEHx:
Pt. is an alcoholic drinker and pt. family does not know how many sticks of
cigarette per day and for how long. Pt. lives in mixed type house with 7 people
residing in it. There are 2 bedrooms and 2 bathroom with a septic tank type with
flush. The house is well ventilated and well lighted.
House Dimension:
Stairs = 25 steps; bedroom bathroom ~20 steps; bedroom dining area ~30
steps; bedroom main door ~30 steps
Note: Pt. is situated on the 2nd floor
Goal: makapaglakad na sana siya mag-isa
OBJECTIVE:

VS:
BP: 140/90mmHg
RR: 17cpm
HR: 76bpm
Temperature: 35.8 C
OI:
Manner of Arrival: Ambulatory s AD
Physique: Mesomorph
(+)Stitches on the left temporal lobe
(+) Racoons eyes with hyphema on the left side
(+) bruised eye B
(-) Facial Asymmetry
(-) Swelling
(-) Attachments
(-) Bony Deformity
(-) Trophic Skin Changes
PALPATION:
Thermal assessment: Normothermic on (B) UE/LE
Tone assessment: Normotonic on (B) UE/LE
(-) Tenderness
(-) Muscle spasm
(-) Edema
MENTAL STATUS EXAMINATION:
Findings:
Appearance casual dress, normal grooming and hygiene
Attitude calm
Behavior some unusual behavior like repeating the same answer
whenever asked a question
Speech Incoherent
Affect normal
Mood neutral
Thought Processes Incoherent
Thought Content incoherent

Perception cannot be assessed/ determined

Orientation not oriented to time, place, and person
Memory/ Concentration Weak
Insight/Judgement cannot be assessed/ determined
Mini mental status examination:
Findings:
Date orientation: patient cannot state the date/ incoherent
Place orientation: patient cannot state the place where he is/
incoherent
Register three objects: patient cannot follow instructions
Serial sevens: patient cannot follow instructions
Naming: can name 3 objects.
Repeating a phrase: cannot repeat any phrase, incoherent
Verbal commands: can follow verbal commands intermittently
Written commands: cannot follow written commands
Writing: cannot write anything
Drawing: cannot draw any shapes or figure
Score: 4/30

ROM:
All major joints of (B) UE and LE are WNL actively & passively done pain-free c
normal endfeel on (B) UE & LE.
Findings: (N) ROM
Sig: For baseline data
MMT:
Not yet assessed due to pt.s current level of consciousness.
NEUROLOGIC EXAMINATION:

SUPERFICIAL SENSORY TESTING:

Device used: pin for pain, brush for light touch and thumb for deep P o
Findings: (+) Pin for pain, (-) Brush for light touch, (+) Thumb for
deep Po
Sig.: Diminished Sensory pathway
DEEP SENSATION
Proprioception
Findings: cannot perceive whether his finger or toe moved up or down
with his eyes closed
Sig.: Diminished Sensory pathway
Kinesthesia
Findings: Pt. was able to level her R arm upon lifting L arm.
Sig.: Intact kinesthesia on B UE/LE
CORTICAL SENSATION:
Tactile Localization:
Findings: Pt. was able to localize touch sensation on B L UE/LE
Sig.: Intact Sensory pathway
Two-Point Discrimination:
Findings: Pt. was able to perceive two points on L UE/LE
Sig.: Intact Sensory pathway
Recognition of Texture:
Findings: Pt. was able to differentiate various textures L UE/LE
(Cotton, Sandpaper)
Sig.: Intact Sensory pathway
Graphesthesia:
Findings: cannot identify numbers, letters, and objects drawn on the
palm of his hand while his eyes were closed
Sig.: Diminished Sensory Pathway
Stereognosis:
Findings: cannot identify ballpen with eyes closed
Sig.: Diminished Sensory Pathway

Barognosis:
Findings: cannot differentiate objects of different weights

Sig.: intact barognosis on B UE

Aphasia:
(+) Wernickes aphasia

ASSESSMENT OF HIGHER CORTICAL FUNCTION

No obvious gaze preference or hemiparesis
Sensory inattention:
(-) visual inattention
(-) tactile inattention
(+) left side lesion:
(+) aphasia
Fluency not impaired (spontaneous speech)
Repetition not impaired (can repeat hello)
Comprehension impaired (cannot follow raise your right
arm)
Naming not impaired (can name ballpen, watch)
Reading impaired (cannot read raise your right arm)
Writing impaired (doesnt know what to do when given
paper and pen)
(-) right side lesion:
(-) apraxia
Agnosia cannot be assessed since patient is suffering from loss
of sensation and language ability is impaired
Parietal lobe function:
intact
Frontal lobe:
(+) grasp reflex and palmomental reflex, glabella tap
(-) optic atrophy
(+) expressive dysphasia

(-) labile emotion, personality changes

Temporal lobe:
(+) receptive dysphasia
Short and long term memory not tested since patient cannot
comprehend
Occipital lobe:
(-) cortical blindness
DTR:

(R)

(L)
Legend: 0

+
+

Areflexia
+

+
+

Hyporeflexia

++

Normoreflexia
+++

++
++
Hyperreflexia
++

++

+
+

+
+

++

++++

Clonus

++

Findings: normoreflexive on (B) UE&LE.

Sig: For baseline data

CRANIAL NERVE TESTING:

Findings:
CN I olfaction intact, can smell
CN II right intact, left pupil dilated, anisocoric
CN III, IV, VI intact EOM, full and equal conjugate eye movements, no
ptosis
CN V- Intact V1-V3, can clench jaw
CN VII intact able to raise eyebrows, and smile

CN VIII intact, gross intact hearing, no nystagmus

CN IX, X intact, uvula midline
CN XI intact, able to raise shoulder
CN XII intact, tongue in midline in phonation and protrusion
PRIMITIVE REFLEXES:
Findings:
(-) Babinski reflex
(-) Chaddocks reflex
(-) Oppenheims reflex
Sig.:(-) Pyramidal tract lesion
COORDINATION TEST:
Test
Finger to nose
Heel to shin
Rapid alternating
movements
Fine motor

L
0
0
0
0

R
0
0
0
0

PA: Not yet assessed due to pt.s current level of consciousness & inability to
sit/stand independently.
GA: Not yet assessed due to pt.s current level of consciousness & inability to
sit/stand independently.

Functional Analysis:
ADLs
FIM LEVELS
Self-care

No Helper

Feeding: 6

7 - Complete Ind.

Grooming: 6

6 - Mod Ind.

Dressing: 6

5 - Min Ind. (subject 100%)

Bathing: N/A

4 - Modified Dep, Min. Asst (75%)

Toileting: N/A

3 - Modified Dep, Mod. Asst

(50%)
Bed mobility

2 - Complete Dep, Max Asst (25%)

Roll to right: 6

1 - Complete Dep, Total Asst

(<25%)
Roll to left: 6
Supine to sit: 3
Sit to supine: 3
Transfer
Bed to chair: 3
Sit to stand: 1
w/c to toilet: N/A
Sitting/ Standing Balance Tolerance
Balanc
e
Sitting
Standin
g
F
G
N

P
P
+
+
+

Toleranc
e
(mins.)
10 min
5 min
+
+
+

Legend:

Assume

Maintai
n

Weight
-Shift

Challeng
e

0
P

+
+