LORMA COLLEGES

Initial Evaluation

General Information

Patients name: J.B

Age: 53 y/o
Sex: M
Address: Brgy. Lioac Sur, Naguilian, La Union
Civil Status: Married
Handedness: R
Occupation: Tricycle Driver
Religion: Roman Catholic
Referring Unit: IPD
Referring MD: DR. NR
Rehab MD: DR. RT
Date of Admission/Consultation: February 10, 2017
Date of Referral: February 15, 2017
Date of IE: February 25, 2017
Dx: Acute Epidural Hematoma R Temporal Region, Contusion Hematoma L
Temporal Region, Subarachnoid Hemorrhage, Left Tempoparietal Cerebral
swelling, Linear fracture zygomatico temporal bone, Moderate TBI S/P
craniotomy Parieto-temporal Area

S:
Informant: Wife
Reliability: High
(Note: Pts wife was @ work during the incident).
Intra-rater: Neighbor (seen all the incident)
Reliability: High

C/C: Mahina yung buong katawan niya, pag tinatayo namin siya nahihirapan siya
at di niya mabalanse yung katawan niya.
PT Translation: Pts wife c/o pts generalized muscle weakness c difficulty on
standing-balance tolerance.
HPI: Pts present condition started ~2 mos. PTIE @ ~7 oclock in the morning p
attending a birthday celebration of his friend which lasted til morning. Pt. was then
in the influence of alcohol when pt was walking along a national highway on his way
going home. Pts neighbor stated that when the pt. was about to cross, a car was
trying to overtake a tricycle when it drove into the path of where the pt. is standing,
the impact threw the pt. c ~7 m distance from where the pt. was standing to a
rocky ground where pt was seen in a manner of lying flat, face downward c the pts
head directly hit a big rock. Pt was in a conscious-state and seen c severe bleeding
on his head, both hands and both feet. A by-stander positioned the pt. to lie on his
back c face upward & a severe bleeding was also seen on the pts chest. P ~5 mins.,
pt was then rushed @ NDH via tricycle by a by-standers where a first aid was
administered on the pts wound to stop further bleeding. P ~30 min. pt was
unconscious and immediately rushe @ Bethany Hospital ER via an ambulance. Pt
had a GCS of 11 and underwent different procedures (see Ancillary procedures) and
revealed skull fx c severe intracranial hemorrhage which prompted the pts doctor
to perform immediate craniotomy operation and sutures which lasted for ~30 mins.
P the operation, pt. was transferred @ Bethany Hospital ICU. p ~12hrs. pt regain his
consciousness, however, pt demonstrated violent behavior wherein the pt. removes
his IV line and all his attachments. To avoid the incident, Pts family ought to just tie
pts both hands to his bed. Pt. also manifested child-like behavior, confusion on
what is happening around him and oftenly, pt. cant recognize the faces of his
family, however, pt can recall what exactly happen to him during the incident. Pt.
stayed @ ICU for 1 wk and pts doctor sees good improvement to the pts condition
wherein the pt. response to the medication given to him, pt was then transfer @
Bethany Hospital Private room where the pt. stayed for another 8 days to monitor
the pts condition. During pts confinement, pt remained bedbound and pt. only eats
soft food such as lugaw. P 15 days of confinement, pt was D/C and scheduled for a
check-up p ~ 3 wks. During the 3 wks. pt. remained bedbound c IV line support and
continued Rx medication @ their house. Pt still manifesting child-like behavior and
confusion, pt also c/o severe headache, gradual localized of his both knees, pts wife
applies mild massage on pts head and knees, however, there were no efficacy
noted. Pt sleeps constantly in a lying flat face upward manner c 2 pillows supporting
his head. Pts wife noticed bedsore of the pt. and applies warm water to clean the
bed sore. Pts wife also noticed decrease of muscle tone of the pt, however, pt wife
assumed that this is d/t pts sudden decrease of wt.

~3 wks. PTIE, pt. had a check-up @ Bethany Hospital via van, and was said
that the pt. had great improvement. On his way going home, pt vomited, and was
immediately rushed @ LMC ER via van and undergone test which revealed that the
pt. is experiencing hypotension c BP of 50/30 mmHg and hyponatremia. Pt was then
confined to a private room to monitor pts condition c new Rx medication given (see
present medication). Pt remained bedbound c IV line support. Pt. does not have any
solid food intake. Dr. NR noticed muscle weakness of pts extremities and was then
referred the pt. to Dr. RT for PT Rehab @LMC to have further evaluation and Mx.

At present, Pt. c/o generalized muscle weakness c problem on ambulation,

standing-balance and has maximum difficulty in all aspects of ADLs.

Pt. was D/C on his 15th day of confinement and is now on his 8th PT Tx session
c e ff Mx:

1. ES (R) UE/LE x20 mins

2. AAROME x 10 reps x 1 set on (L) UE/LE
3. PRES on All 4's using green theraband and 1 lb ankle weights x 10
reps x 1 set on AP
4. Sitting bal/tol
5. Standing Bal/tol

Ancillary Procedures:
Procedure Date & Place Findings/ Impression
X-Ray
AP Only 1-05-17/ Bethany
Unremarkable
Chest Hospital
Both Sh AP
Cranial CT- Scan 1-05-17/Bethany Linear fracture,
Hospital zygomaticotemporal bone c
overlying soft tissue
swelling and lucencies R
 intra-sinus bleed, sphenoid
sinus
High parietal scalp swelling,
hematoma
Head CT-Scan 1-07-17/ Bethany Contusionhematomas L
Hospital Temporal regipn, L
Temporoparietal cerebral
swelling
Acute Epidural hematoma, R
temporal Region
Subarachnoid haemorrhage
Blood Chemistry 02-10-17/ LORMA 122 meq/L; Hyponatremia
Medical Center

Medications:
(Note: Route of Administration via IV Push Intravenously)
Medicines Indication Dosage
Citicholine drops CNS Stimulant or a 1 drop BID
Nootropics
Sodium chloride IV Supplemental TID
medication
Amlodipine Improves blood flow qd
Mannitol ICP qd

PMHx: Unremarkable

FMHx:
Pathology Father Mother
DM (-) (-)
HTN (-) (-)
Heart Disease (+) (-)
Asthma (+) (+)
CA (-) (+)

PSHx:
Pt. has an active lifestyle, has no hx of substance abuse, an occasional
alcoholic-beverages drinker and a non-smoker. Pt. prefers vegetables over meat and
exercising daily. Pt. lives in a bungalow type of house c his wife, 3 children and 1
maid.

House dimension of:

BR Door ~ 2m
BR CR ~ 3m
BR LR ~ 5m
BR DR ~7m

Pt. is a regular tricycle driver and a farmer, pt. also do household chores such
as cooking, wood chopping and bathing 3 pigs. Pt. is a loving and caring father and
husband; however, p the incident pts youngest child is afraid to see the pt d/t pts
irritability seeing many people and inability to recognize his familys faces. Pt also
experiencing maximum difficulty in performing all aspect of ADLs and is needing +1
assist d/t problem during standing and balance c generalized muscle weakness.
 Pts Wife Goal: Sana gumaling na yung asawa ko, para bumalik na din siya sa
normal.