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SPINAL CORD INJURYNEIL BARRY
USI: 1009842
BACKGROUND
• PATIENT PRESENTED WITH SPINAL CORD INJURY, WHEELCHAIR BOUND, INTERVIEWED ON INCLINE TABLE (IN NEUTRAL POSITION) IN SUPINE WITH URINARY CATHETER ATTACHED.
• THE PATIENT USES A WHEELCHAIR BUT NO OTHER ASSISTIVE DEVICE
PATIENT INFORMATION
• INITIALS: M.G.
• ADDRESS: 213 GROVE E.B.D
• D.O.B: 02/10/73
• SEX: MALE
• HANDEDNESS: RIGHT
• SOCIAL HISTORY: CURRENTLY UNABLE TO WORK, LIVES WITH FAMILY MEMBERS ON BOTTOM FLAT.
• CONSUMES ALCOHOL.
• REFERRED BY: SOPD, SEEN AT THE PALMS REHAB CENTRE
FUNCTIONAL STATUS
• IS CURRENTLY ABLE TO USE 5LB DUMBELLS FOR U.E. EXERCISES
• UNABLE TO SIT UNASSISTED FROM A LYING POSITION, AND UNABLE TO TRANSFER FROM BED-CHAIR UNASSISTED.
• APART FROM EATING, THE PT. IS UNABLE TO GROOM/ SELF CARE WITHOUT ASSISTANCE, BUT HAS A MEASURE OF BOWEL CONTROL WITH NOTABLE OCCURANCE OF DIARRHOEA ONCE WITHIN THE PAST 6 MONTHS.
FAMILY HISTORY/PAST MEDICAL HISTORY
• MOTHER HAD HEART BYPASS SURGERY
• PATIENT SUFFERRED A MINOR ISCHEMIC STROKE APPROX. 1 YEAR PRIOR TO INCIDENT.
CURRENT MEDICAL HISTORY
• PATIENT REPORTED THAT HE WAS RIDING A BICYCLE, WHEN HE COLLIDED WITH ANOTHER AND FELL INTO A DRAIN, AFTER WHICH HE COULD NOT FEEL HIS LEGS. HE SAID HE UNDERWENT SURGERY TO HIS SPINE MORE THAN 6 MONTHS AGO.
• FURTHER INFORMATION WITH RELATION TO THE NATURE OF THE SURGERY NEEDS TO BE COLLECTED FROM PHYSICIAN. NO FIXATION NOTED. SURGICAL INCISIONS NOTED AT LEVEL OF C3-C5. CURRENTLY DOES NOT USE ORTHOSIS.
• MOST RECENTLY HAS HAD INCIDENCE OF DIARRHOEA
• STATES THAT HE WANTS TO GET BACK TO WORK AS A FACTORY WORKER, AND THAT HE WANTS TO BE STRONG AGAIN AS A FORMER WEIGHTLIFTER
PAIN
• CURRENTLY EXPERIENCES PAIN IN THE RIGHT INGUINAL REGION, ASSOCIATED WITH SWELLING, LOCATED PROXIMALLY ON THE ANTERIOR RIGHT THIGH. (5/10)
• PATIENT ALSO COMPLAINS OF RIGHT SHOULDER PAIN (6/10)
• SHOULDER PAIN INCREASES BILATERALLY WITH IR/ER MOVEMENTS
CURRENT MEDICATION:
• VITAMIN A
• VITAMIN B
• VITAMIN B6
• VITAMIN B12
• USED ONCE DAILY, VIA TABLET FORM
SYSTEM REVIEW: CARDIOVASCULAR/PULMONARY
• B.P: 127/82 MM/HG
• H.R: 62 BPM
• 02 SATURATION: 97%
• RESPIRATORY RATE: 22 BREATHS PER MINUTE
• EDEMA: PROXIMAL RIGHT KNEE, NEARER TO INGUINAL REGION
• AUSCULTATION: NORMAL BREATHING SOUNDS
• ANTERIOR CHEST SHAPE NORMAL
SYSTEM REVIEW: MUSCULOSKELETAL
• GROSS SYMMETRY: UNABLE TO OBSERVE DUE TO LACK OF ADVANTAGEOUS VANTAGE POINT. NO VISIBLE SPINAL ASSYMETRY, CLEAR ATROPHY IN BOTH UPPER AND LOWER EXTREMITY
• PALPATION: BILATERAL MUSCLE WASTING, FLACCID MUSCLE TONE IN TRICEPS, BICEPS, QUADRICEPS, HAMSTRINGS AND CALVE MUSCLE GROUPS
RANGE OF MOVEMENT (ALL FIGURES IN DEGREES)
UPPER EXTREMITY LEFT
SHOULDER-
• FLEXION: 120, EXT: 10
• ABD: 90, ADD:90
• ELBOW:FLEX/EXT: 0-80
• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION
• WRIST:FLEX/EXT: 90
• PIPS/DIPS: WFL
UPPER EXTREMITY RIGHT
SHOULDER-
• FLEXION: 120, EXT: 10
• ABD: 90, ADD:90
• ELBOW: FLEX/EXT:0-80
• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION
• WRIST: FLEX/EXT: 90
• PIPS/DIPS: WFL
RANGE OF MOVEMENT (ALL FIGURES IN DEGREES)
LOWER EXTREMITY LEFT
• HIP:
• FLEX: 90
• EXT: 5
• ABD/ADD: 45
• KNEE: FLEX/EXT:0-130
• DF: 5
• PF: 5
LOWER EXTREMITY RIGHT
• HIP:
• FLEX: 90
• EXT: 5
• ABD/ADD: 45
• KNEE: FLEX/EXT:0-130
• DF: 5
• PF: 5
MUSCLE STRNGTH (USING 5 POINT SCALE)
UPPER EXTREMITY LEFT
SHOULDER-
• FLEXION(C5): 3, EXT: 3
• ABD(C6): 3, ADD:3
• ELBOW: FLEX(C5-C6)3, EXT(C6-C8):3
• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION
• WRIST:FLEX/EXT(C6-T1):3
• PIPS/DIPS/GRIP(C8-T1): 3
UPPER EXTREMITY RIGHT
SHOULDER-
• FLEXION(C5): 3, EXT: 3
• ABD(C6): 3, ADD:3
• ELBOW: FLEX(C5-C6)3, EXT(C6-C8):3
• IR/ER: UNABLE TO TEST DUE TO INCREASED PAIN ON ROTATION
• WRIST:FLEX/EXT(C6-T1):3
• PIPS/DIPS/GRIP(C8-T1): 1
MUSCLE STRNGTH (USING 5 POINT SCALE)
LOWER EXTREMITY LEFT• HIP:
• FLEX(L2-L3): 3
• EXT(GLUTEAL NERVE): 3
• ABD/ADD(L2/L4):3
• KNEE: FLEX/EXT(L3-L4):3
• ANKLE
• DF(L5): 3
• PF(L5-S2): 3
LOWER EXTREMITY RIGHT• HIP:
• FLEX(L2-L3): 3
• EXT(GLUTEAL NERVE): 3
• ABD/ADD(L2/L4):3
• KNEE: FLEX/EXT(L3-L4):3
• ANKLE
• DF(L5): 3
• PF(L5-S2): 0
MUSCLE STRENGTH/RANGE OF MOTION
TRUNK ANTERIOR
• FLEXION: 0-40
• SIDE FLEXION : 2/5
• ROTATION: 2/5
• CERVICAL: FLEX/EXT, ROTATION R,L, SIDE FLEXION
• ROM: WFL
• STRENGTH: 4/5
TRUNK POSTERIOR
• 0-10
NOTE: JOINTS GENERALLY EDXHIBITED SOFT END FEELS , WITH THE EXCEPTION OF RT. HAND AND ANKLE, WHICH EXHIBITIED HARD END FEELS
SYSTEM REVIEW: NEUROMUSCULAR
• COORDINATED MOVEMENTS: HEEL/SHIN/KNEE- SLOW
• GAIT: UNABLE TO WALK
• LOCOMOTION:LIMITED, PATIENT SEDENTARY
• BALANCE: PT LACKS SITTING BALANCE FOR EXTENDED PERIOD UNSUPPORTED
• MOTOR FUNCTION
• PLIABILITY OF SKIN: EXTREMITIES EXHIBIT DECREASED PLIABILITY
• SKIN INTEGRITY: NO EVIDENCE OF PRESSURE ULCERS
• CONTINUITY/TEMPERATURE: 97.5 F
• PRESENCE OF SCAR/FOOT CONDITION: POST SURGICAL SCARS POSTERIOR TO C3/C5. XEROSIS (DRY SKIN) NOTED AT THE FEET
• PIGMENTATION: NO NOTABLE ABNORMALITIES
ACTIVITIES OF DAILY LIVING
• ROLLING: WITH ASSISTANCE
• LYING TO SITTING: WITH ASSISTANCE
• SITTING TO LYING: WITH ASSISTANCE
• SITTING BALANCE: IMPAIRED
• SITTING TO STANDING: UNABLE
• STANDING BALANCE: UNABLE TO STAND
• REQUIRES ASSISTANCE IN TRANSFER FROM WHEELCHAIR TO BED
SENSORIMOTOR AWARENESS
• TRACKING LOCALIZATION: INTACT
• TACTILE: IMPAIRED
• PIN PRICK: IMPAIRED
• LIGHT MOVING: IMPAIRED
• LIGHT TOUCH: IMPAIRED
• AUDITORY AWARENESS TRACKING LOCALIZATION: INTACT
PERCEPTUAL PROCESSING
• DEEP PRESSURE: INTACT
• TEMPERATURE: INTACT
• 2 PT DISCRIMINATION: INTACT
• STEREOGNOSIS: INTACT
• KINESTHESIA: INTACT
• PAIN RESPONSE: IMPAIRED
SYSTEM REVIEW: COMMUNICATION
• ORIENTATION: WELL ORIENTED, AWARE OF DATE/TIME/SELF ETC
• COGNITION: IS ABLE TO MEMORIZE AND SPEAK WELL
• EMOTIONAL/BEHAVIORAL RESPONSE: SHOWS OPTIMISM TOWARDS RECOVERY AND EXHIBITS POSITIVE BEHAVIOR
• LEARNING: IS ABLE TO LEARN HOME CARE PROGRAM , SHOWING NO EVIDENCE OF LEARNING DISABILITY
ASIA CLASSIFICATIONSENSORY MAX:112, MOTOR SYSTEM MAX: 50
SENSORY
• PIN PRICK LEFT: 76
• PIN PRICK RIGHT: 76
• LIGHT TOUCH LEFT: 76
• LIGHT TOUCH RIGHT: 76
• S4/S5 NOT TESTED
MOTOR
• RIGHT UPPER EXTREMITY: 11
• LEFT UPPER EXTREMITY: 15
• UPPER LIMB TOTAL: 26
• RIGHT LOWER EXTREMITY: 6
• LEFT LOWER EXTREMITY: 15
• LOWER EXTREMITY TOTAL: 21
BARTHEL INDEX
• BOWELS: 1
• BLADDER: 0
• GROOMING:0
• TIOLET USE: 0
• FEEDING: 2
• TRANSFER: 1
• MOBILITY: 0
• DRESSING: 0
• STAIRS: 0
• BATHING : 0
• PATIENT’S SCORE: 4/20
PROBLEM LIST. PROGNOSIS: GUIDED
• EDEMA: PROXIMAL RIGHT KNEE, NEARER TO INGUINAL REGION
• BILATERAL MUSCLE WASTING, FLACCID MUSCLE TONE IN TRICEPS, BICEPS, QUADRICEPS, HAMSTRINGS AND CALVE MUSCLE GROUPS
• PAINFUL IR/ER
• PAIN RESPONSE: IMPAIRED
• BARTHEL IDEX SCORE LOW (4/20)
• PT IMPRESSION: CERVICAL TRAUMA WITH PARTIAL COMPRESSION INJURIES TO C3-C5, L5/S1
• DF/PF ROM: 5
• PIPS/DIPS/GRIP(C8-T1): 1
• RIGHT PF(L5-S2): 0
• SITTING BALANCE: IMPAIRED
• SITTING TO STANDING: UNABLE
• STANDING BALANCE: UNABLE TO STAND
• TACTILE: IMPAIRED
• PIN PRICK: IMPAIRED
• LIGHT MOVING: IMPAIRED
• LIGHT TOUCH: IMPAIRED
ASIA IMPAIRMENT CLASSIFICATION:D- INCOMPLETE INJURY, MOTOR FUNCTION IS PRESERVED BELOW THE NEUROLOGICAL LEVEL, AND AT LEAST HALF OF KEY MUSCLES BELOW THE NEUROLOGICAL LEVEL HAVE A MUSCLE GRADE OF 3 OR MORE
PLAN OF CARE
SHORT TERM GOALS
• PAIN MANAGEMENT
• DEEP BREATHIG EXERCISES TO MAINTAIN LUNG FUNCTION
• TRANSFER TRAINING
• DECREASE EDEMA AT RIGHT LEG
LONG TERM GOALS
• INCREASE MUSCLE STRENGTH TO 4/5 AT U.E AND L.E.
• INCREASE SITTING BALANCE TO INDEPENDENT LEVELS
INTERVENTION
CLINICAL • HOT PACK 20’’ FOR PAIN
MANAGEMENT (SHOULDER)
• INCLINE TABLE (80 DEGREES)
• OCCUPATIONAL THERAPY
• ICE, COMPRESSION, ELEVATION OF RIGHT LEG
• ACTIVE ASSISTED U.E AND L.E. EXERCISES
• PROPRIOCEPTIVE STIMULATION
HOME CARE
• ASSISTIVE DEVICES SUCH AS POWER WHEELCHAIRS, REACHERS, SHOWER CHAIRS ETC WOULD BENEFIT THIS PATIENT
• BALANCED FOREARM ORTHOSIS(BF0) TO ASSIST WITH GROOMING ETC
• POSTURAL AND POSITIONAL EDUCATION
SPINAL CORD INJURY
POINTS TO NOTE• NEUROLOGICAL LEVEL: THE MOST DISTAL
LEVEL AT WHICH BOTH MOTOR AND SENSORY MODALITIES ARE INTACT
• SKELETAL LEVE: THE LEVEL AT WHICH, BY RADIOLOGICAL EXAM, THE GREATEST VERTEBRAL DAMAGE IS FOUND
• MOTOR LEVEL: THE MOST DISTAL KEY MUSCLE GROUP THAT IS GRADED 3/5 OR GREATER WITH THE SEGMENTS PROXIMAL GRADED NORMAL 5/5 STRENGTH
• THE MOST DISTAL DERMATOME TO HAVE NORMAL SENSATION FOR BOTH P AND LT ON BOTH SIDES
LIMITATIONS
• PATIENT WAS ONLY ASSESSED ONCE
• UNABLE TO OBSERVE IN PRONE
• UNABLE TO CARRY OUT O.T. EXAMINATION
• UNABLE TO SECURE DETAILS OF SURGICAL INTERVENTION
• DID NOT SECURE ENOUGH ADL AND HOME ENVIRONMENT INFORMATION
REFERENCES
• DELISA, J. (2010). PHYSICAL MEDICINE AND REHABILITATION. BALTIMORE: LIPPINCOTT WILLIAMS AND WILKINS.
• AMERICAN SPINAL INJURY ASSOCIATION. INTERNATIOAL STADARDS FOR NEUROLOGICAL CLASSIFICATION OF SPINAL CORD INJURY. CHIGACO,IL:ASIA;1992.
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