1. SPINAL CORD INJURY NEIL BARRY USI: 1009842

2. 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

3. 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

4. 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.

5. FAMILY HISTORY/PAST MEDICAL HISTORY MOTHER HAD HEART BYPASS SURGERY PATIENT SUFFERRED A MINOR ISCHEMIC STROKE APPROX. 1 YEAR PRIOR TO INCIDENT.

6. 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

7. 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

8. CURRENT MEDICATION: VITAMIN A VITAMIN B VITAMIN B6 VITAMIN B12 USED ONCE DAILY, VIA TABLET FORM

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. SENSORIMOTOR AWARENESS TRACKING LOCALIZATION: INTACT TACTILE: IMPAIRED PIN PRICK: IMPAIRED LIGHT MOVING: IMPAIRED LIGHT TOUCH: IMPAIRED AUDITORY AWARENESS TRACKING LOCALIZATION: INTACT

19. PERCEPTUAL PROCESSING DEEP PRESSURE: INTACT TEMPERATURE: INTACT 2 PT DISCRIMINATION: INTACT STEREOGNOSIS: INTACT KINESTHESIA: INTACT PAIN RESPONSE: IMPAIRED

20. 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

21. ASIA CLASSIFICATION SENSORY 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

23. 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

24. 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

25. 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

27. 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

28. 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

30. 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

31. 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.