1. Case Presentation Son Eui Young 2007313075 Sungkyunkwan University School of Medicine

2. Chief Complaint n 20/F n Rehabilitation for quadriplegia –Quadriplegia onset : 15 weeks ago

3. Present illness n Previous healthy n 2012. 02. 15 –PM 1:30 스키장 곤돌라 8m 높이에서 추락 – 이후 후경부 통증 및 전신 마비 증상 발생하여 방문한 – 원주기독병원 에서 시행한 X-ray 와 MRI 상 –C5-6 fracture, dislocation 진단되어 reduction 시행 n 2012. 02. 16 –Further evaluation 위해 본원 ER 통해 OS 입원

4. Present illness n 2012. 02. 20 –Anterior corpectomy C5, 6 anterior fusion C4-7, dural sealing 시행 n 2012. 02. 27 –Desaturation 지속되어 SMART contact –Chest-X ray 에서 관찰되는 LLL 의 dense opacity 있어서 –Atelectasis 의심되어 tazocin + levoloxacin 투여 n 2012. 03. 05 –Spinal cord injury 에 대한 포괄적 management 및 재활치료 위해 REH 전과함

5. Chest X-ray n 2012. 02. 27

6. Past Medical History n HTN / DM / Dyslipidemia ( - / - / - ) n Hepatitis / Allergy ( - / - ) n Medication –Levosulpiride 25mg –Azelastine 1mg –Cetamadol® 325mg –Gabapentin 300mg –Tazocin® 4.5g –Ambroxol 15mg –Levofloxacin 750mg –Ipratropium nebulizer 500mc

7. Personal History n Family history –No family history of –HTN / DM / hepatitis / Tb / allergy / Cancer n Social history –Never-smoker –Never-drinker –Occupation : 대학생 –Residence :

8. Review of system n General appearance –General weakness / Fatigue / Weight change ( + / - / - ) –Fever / Chill / Sweating ( - / - / - ) n Head and neck –Headache / dizziness / vertigo ( - / - / - ) –Cough / sputum / dyspnea ( - / - / - ) n Cardiopulmonary – Chest pain / palpitation ( - / - ) n Gastrointestinal –Anorexia / nausea / vomiting ( - / - / - ) –Abdominal pain / discomfort ( - / - ) –Constipation / diarrhea ( - / - ) n Skin –Rash / easy bruisability ( - / - ) –Tingling sensation : both legs, 다리 전체가 저리다고 함.

9. Physical examination n Vital sign, body measurement –145/68-111-20-37.6, 55kg, 157cm n General appearance –Alert, Good orientation to Person/Time/Place n Head & neck –Neck vein engorgement (-) –Cervical LN enlargement (-/-) n Chest –symmetric chest expansion –regular heart beat s murmur –vesicular breath sound s crackle, wheezing n Abdomen –soft –bowel sound – hypoactive (1 회 /5 분 ) –no tenderness/rebound tenderness –no palpable mass –no shifting dullness n Back and Extremity –no CVAT –no other site tenderness –Leg edema (-/-) n Skin –rash/purpura/erythema (-/-/-) –Pressure sore : sacral sore, grade II, 0.5cm x 0.5cm

10. Neurologic Examination n n Functional mobility – –Rolling : Partially dependent – –Come to sit : Totally dependent – –Sit to stand : ( - ) – –Wheel chair transfer : Totally dependent – –Sitting balance : Poor – –Standing balance : ( - ) n n Motor – –Upper extremity( IV / IV ) – –Hip flexor ( I+ / I+ ) – –Knee extensor( II+ / II+) – –Knee flexor ( II+ / II+ ) – –Ankle DF ( III / III+ ) – –Ankle PF ( III / III+ ) n n Sensory – –Pin Prick : Hypesthesia below T3 – –Light Touch : Symmetrically intact – –Vibration : Hypesthesia below ASIS n n DTR – –Biceps / Triceps / Knee / Ankle jerk : - / - – –Hoffmann's Sign : - / - – –Babinski Sign : - / - – –Ankle Clonus : - / - n Cerebellar function test –Finger-to-nose : dysmetria +/++ –Heel-to-shin : unable to test –Rapid alternating movement : intact n Voiding –Sense : 대부분 없으나 간헐적으로 있다. –Clean intermittent self-catheterization q 5 hrs –No self voiding –Incontinence ( - ) n Defecation –Incontinence ( + ) –Anal sense : ( + ), but decreased –Anal tone : decreased –Voluntary anal contracture : ( + ) n Neuropathic pain –Both lower leg 의 저린 느낌. – 그 전에 잠들기 힘들었으나 현재 자기 전 pregabalin 150mg 먹고 잠은 잘 잔다. – 통증은 여전히 조금 남아 있다. n Musculoskeletal problem –sacral pressure sore, Gr II, 0.5cm x 0.5cm

11. 사진

13. Problem List

14. Assessment

15. Plan

16. Hospital Course

20. Case Review n Spinal Cord Injury –Epidemiology –Classification – ASIA scale –Types –Management of spinal cord injury