Allison Wierda, SPT

Physical Therapy Evaluation / Plan of Care Form

Patient Information and Demographics:

Name: Andrew Bectal (prefers: Drew) Age: 18 Gender identification: M

Date of Service: 10/16/2019

Administrative Codes:
PT Diagnosis (ICD-10): R26. 0, R27.8, R26.89, R53.1

Medical Diagnosis (ICD-10): S06.2X9D

Current Procedure Units Duration

Terminology (CPT) Billing
Codes 1

97161 (low complexity) 1 26

97530 1 12
97112 1 14

SUBJECTIVE:

CC / Reason for Referral: Referred for functional deficits secondary to TBI. Pt complains of not being
able to move his L UE and experiences a LOB occasional when ambulating.

Onset and Progression of symptoms: Pt attended a party 2 weeks ago and left with a friend who was
intoxicated. The friend drove off the road, the car rolled several times, and crashed into a telephone pole.
The pt sustained a head injury and was in a coma and his friend died in the emergency room. He began
coming out of the coma yesterday (10/15/2019). He has no memory of the party, the accident, or
anything that has occurred in the hospital. The pt is confused and feels like he is in a “hazy blur.” Pt
complains of having a constant, throbbing headache. Pt is predominantly in severe pain (8/10), with it
being worse in the morning. He also presents with bruises and scrapes on his L UE.

Current Medications:
Medication Reason this patient is taking Dose and Frequency
Phenobarbital sedative 60mg P.O. BID
Haldol (haloperidol) antipsychotic 1-2 mg P.O. QID prn
Decadron (dexamethasone) inflammation 2 1 mg P.O BID x1 more week then d/c
Depakote migraine headaches 500 mg P.O. BID

Level of Activities Prior to Current Onset: Prior to onset pt was a 2 sport athlete at Mt. Pleasant high
school (basketball and soccer) practicing 5x/wk. He also enjoyed walking his dogs and hanging out with
friends.

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 Allison Wierda, SPT

Home /Work/ Other Relevant Environment(s): Pt lives in a large 1-level home with his parents. There is
1 STE, no rail and no other steps in the home. The floors are either wood or tile with occasional rugs
throughout the home.

Psycho-social / Family Support / Family Responsibilities: Pt is easily angered and agitated. His parents
are supportive, visiting every day and at least 1 parent is present during all medical visits.

Client Goals: Pt wants to d/c home as soon as possible. He wants to get back to school, playing sports,
being with his friends, dressing himself and using his L UE. He also misses his dogs.

OBJECTIVE:
Vital Signs:
Position / Arm used BP Pulse RR
Sitting 118/86 60 14

Communication, Cognition, Orientation: Alert and Orientated x2 (person, place). Pt is unable to recall
what he did yesterday. When asked what he did this morning he states he made breakfast at home.

Cranial nerves and related systems: Pt has no signs of cranial nerve involvement. Cranial nerve screen
performed, due to nature of injuries, with no abnormalities. In depth screen not indicated.

Reflexes:
Reflex Right Left
Quadriceps 2+ 2+
Brachio-radialis 2+ 1+
Biceps 2+ 1+
Triceps 2+ 1+

ROM, Strength, Tone, Patterned Movement: AROM and strength assessed through observation (kicking
3
a ball, playing catch, reaching for objects off of his tray table). AROM was WFL in bilateral LE and R
UE. Pt only able to move L UE through partial ROM. Pt at least 3+/5 in bilateral LE and R UE. L UE a
max of 2+/5. Pt has L UE hypotonia.

Coordination: Pt’s coordination was assessed during kicking the ball and playing catch. Pt presents with
mild decreased coordination when attempting to make contact with the ball with his foot and catching
the ball with his R hand.

Sensation: Unable to assess at this time to due to pt being uncomfortable and agitated.

Bed Mobility and Transfers: Pt is able to complete all bed mobility independently and all transfers with
supervision. Pt is at supervision level with transfers due to initial staggering upon standing.

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 Allison Wierda, SPT

Posture: In sitting pt’s L UE hung at his side while holding onto the bed with his R UE. Pt equally
weight bearing through both buttocks. In standing pt presented with a wide BOS and tried to hold onto
surfaces to stabilize himself with R UE.

Balance: Static and Dynamic in both seated and standing.

Pt’s static and dynamic sitting balance was good. He was able to sit at EOB without use of arms upon
request and able to reach for objects on his tray table. Pt’s standing static and dynamic balance was poor.
In order for him to increase stabilization pt widened his BOS and hung on to surfaces with his R UE.
While ambulating pt had LOB with unexpected distractions (noises, people).

Gait/Locomotion: Pt presented with mild ataxia in bilateral LE and R UE. Initial gait, pt was staggering,
but then he adapted a wide BOS to increase stability. He also reached for surfaces with R UE to stabilize
himself. Pt also has difficulty with reciprocal gait pattern.

Functional Independence Measure Scores:

Activity Score NA = Not Applicable (does not occur)
Transfers: 5 NT = Not Tested (mention why)
1 = Total Assistance (0-24%)
2 = Maximal Assistance (25% - 49%)
Gait: 5 3 = Moderate Assistance (50% - 74%)
4 = Minimal Assistance (75% - 100%)
5 = Supervision or Set-up (safety concern / takes more than reasonable time)
6 = Modified Independence (assistive device)
Stairs: NT – pt
7 = Complete Independence
was
RULE for GAIT (and W/C): distance modifies the scoring as follows:
irritable
3 = to get this or higher must go 150 feet or greater
and
2 = 50 to 149 feet (see household exception)
refused to
1 = less than 50 feet
do
Household Exception rule: Client who can walk 50 feet independently with
complete
or without a device can get a 5
stairs.
RULE for STEPS:
3 = to get this or higher must go 12 – 14 steps
2 = 4 to 6 (or less than 12)
1 = less than 4 steps
Household Exception rule: Client who do 4 – 6 steps independently with or
without a device can get a 5

Standardized Tests Used: Planned to administer mini-mental state examination. Unable to assess at this
time due to pt irritability. Will attempt to administer next session.

Today’s Interventions: Initial examination performed followed by extensive patient education regarding
diagnosis, plan of care and treatment goals. The patient verbalized understanding and gave consent to
treat. Treatment included the following:
- Pt sitting EOB shooting tennis balls into bucket (3ft away) with R hand – 1 minx3
- Pt sitting EOB shooting tennis balls into bucket (1.5ft away) with L hand (R hand assisting) –
1minx3

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 Allison Wierda, SPT

- Pt sitting EOB kicking ball with R or L foot between goal (3 ft away) – 1 minx3
- Pt sitting EOB tapping foot between 2 colored circles on the floor. – 30sx2 (each foot)
- Pt ambulated 200ft with supervision, cueing pt to stand up straight, look straight ahead, and
working on reciprocal gait pattern

ASSESMENT:
Pt experienced a TBI 2 weeks ago and is just coming out of his coma. Due to his coma lasting between
1-2 weeks, pt’s young age, and prior activity level, he has a moderate – good outcome for recovery. The
cerebellum was affected with the pt’s TBI confirming why he presents with ataxic gait. Pt’s reciprocal
gait is also altered by his decreased strength on his L UE. Pt presented with incoordination in bilateral
LE and R UE secondary to TBI. Pt would benefit from skilled PT to address gait impairments,
incoordination, and decreased L UE strength. Pt was irritable and angry with tasks requested that were
not salient to him. However, engaging him with kicking and throwing activities allowed for observation
and improved his mood.

Precautions: Pt at risk of falls secondary to ataxic gait 4and staggering stance upon standing/initial gait.

Rehabilitation Prognosis: Pt has fair rehab potential to meet expected outcomes of therapy due to coma
lasting between 1-2 weeks, young age, and prior good health/activity level. Pt also has support at home
from parents. Pt’s rehab prognosis is not excellent due to time in coma, his irritability and decreased
motivation to participate in therapy.

GOALS:
Short Term (3 days)
- Pt will ambulate 300ft down the hallway with people and unexpected distractions without LOB
so can ambulate in the halls of the hospital with modified independence using walking sticks.
- Pt will be able to complete 1 platform step with no AD or railing so the he can independently go
5
in and out of his house to take his dogs outside.
- Pt will be able to demonstrate knowledge of two exercises completed in therapy session so he
can complete them on his own while not in therapy.
- Pt will be able to complete car transfer independently in order to d/c home with parents.
- Pt will be able will be able to put on non-button pants and a shirt independently so he is able to
dress himself while at home to get ready for the day.

PLAN:
Plan to see pt daily while still in house. Treatment will include gait training, neuromuscular re-
education, therapeutic exercise/activity, and education. Pt’s progress will be re-evaluated daily, plan to
d/c home with parents (10/19/2019) pending clearance from all other medical staff. Plan to begin
outpatient rehab 3x/wk after d/c, pending progress.

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 Allison Wierda, SPT

I certify / recertify that the above therapy services are necessary, and I agree with the plan of care above.

__________________________________ ___________ _________________10/16/2019__

Physician Name/Signature Date Therapist Name/Signature Date

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 Allison Wierda, SPT

Physical Therapy
Hi I’m Alli, your Student Physical Therapist (SPT). I go to Central Michigan University. I will be
completing all PT with you and I am excited to learn more about you.
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I will see you every day after breakfast. Make sure to eat breakfast at least 30 minutes before I arrive so
you are fueled and ready to go.

With me we will work on moving, exercising, walking, and getting stronger. We will make it as fun for
you as possible! My goal is to help you gain independence and help you progress back to doing what
you enjoy.

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Comment Summary
Page 1
1. I would probably rate this as a moderate complexity evaluation given the multiple systems involved (weakness,
balance, coordination, cognition).
2. This med is probably also being taken to prevent seizure activity
Page 2
3. Nice description of how you determined gross muscle strength without formal manual muscle testing
Page 4
4. His impulsivity and distractibility could put him at increased risk for falls as well, correct?
5. Beautiful functional, measurable, appropriate goals. NICE JOB.
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6. Would be nice here to include a picture of yourself, due to the patient's short term memory issues.