1. SPINE Small Group Discussion

2. Patient Information S.B. 52 M Married Roman Catholic Quezon Farmer Right-handed

3. Chief Complaint Fall

4. History of Present Illness DOI: Dec. 23, 2009 TOI: 9 am POI: Quezon

5. History of Present Illness Mechanism Of Injury: Getting a coconut from the tree, 20 feet high he lost his footing and fell he hit his back first when he landed (-) move his lower extremities. (-) head trauma (-) vomitting, (-) blurring of vision

6. He was then brought to a nearby local hospital, and immediately advised to transfer to PGH.

7. Course in the ER The patient arrived at the PGH ER in the evening. Physical exam on admission showed – (+) lax sphincter tone – (+) bulbocavernosus reflex – 0/5 muscle strength on his lower extremities – last intact sensory level was T11.

8. Diagnostic tests done are as follows: – Blood chemistry, CBC, urinalysis, electrolytes, Chest Bucky, CT scan Assessment: – Spinal Cord Injury complete ASIA A secondary to fall, fracture dislocation of T12 vertebra

9. Course in the Wards Orthopedic Plan – Patient is scheduled for Operation: Posterior Instrumentation using pedicels screws C5-C6 level with cross-linking under General Anesthesia – Awaiting for funds January 6, 2010: – tightening headache – from the frontal area radiating to the back – VAS score of 5/10 – nausea and minimal non-projectile vomiting Laboratory results – 4-9 WBCs on urinalysis

10. Review of Systems (-) Loss of consciousness (+) nausea (-) weight loss (+) headache (-) BOV (-) seizure (-) fever (-) anorexia (-) vomiting, (-) chest pain (-) abdominal pain (+) constipation (+) urinary incontinence, (+) paralysis of lower extremities (+) loss of sensation of trunk immediately after umbilicus and lower extremities

11. Past Medical History (-) hypertension, DM, CA, goiter, BA, heart disease No food/drug allergy No previous hospitalization or previous surgery

12. Family Medical History (-) Hypertension, DM, PTB, BA, CA, stroke, other systemic illness

13. Personal-Social History (+) 30 pack year smoking history (+) occasional alcoholic drinker farmer since 1978 primary caregiver of his bed-ridden wife. five children [31 eldest, 19 youngest] Financial support: – patient’s relatives – government agencies

14. Functional History FunctionPrior to InjuryAt Present Self-care Eating77 Grooming75 Bathing71 Dressing – Upper Body 75 Dressing – Lower Body 71 Sphincter Control71

15. Toileting Bladder Management71 Bowel Management71 Transfers Bed/Chair/Wheelchair71 Toilet71 Tub/Shower71

16. Social Social Interaction77 Cognitive Function Problem Solving77 Memory77 Total Score12662

17. Locomotion Walk/Wheelchair71 Stairs71 Communication Comprehension77 Expression77

18. Living Conditions flat one-storey concrete house 15x20 square feet along the highway. bed 10 steps towards the toilet area.

19. Physical Exam Awake, conscious, coherent, not in cardiorespiratory distress, bed-ridden Vital signs: BP-90/60 mmHg HR-64 bpm RR-18 cpm T-37 o C Pink palpebral conjunctivae, anicteric sclerae, (-) CLAD/ANM/TPC

20. Equal chest expansion, (+) kyphosis with prominent thoracic spine, clear breath sounds

21. Adynamic precordium, distinct heart sounds, (-) murmurs Flat abdomen, normoactive bowel sounds, (-) masses/tenderness, (-) bladder distention (+) lax sphincter tone, (+) fecal material per examining finger Full and equal pulses, (-) cyanosis/edema, (+) atrophied lower extremities

22. Neuro Exam GCS 15, conscious, coherent, oriented to three spheres, conversant, able to follow commands Cranial nerves are intact

23. Sensory Examination PAINLIGHT TOUCH RLRL C2-C8100 T1- T10100 T1190 T12-L50000 S2-S30000

24. Motor Examination Muscle Strength Testing Upper Extremity MusclesRL Lower Extremity MusclesRL C5 Elbow flexors 5/5 L2Hip flexors0/5 C6 Wrist extensors 5/5 L3 Knee extensors 0/5 C7 Elbow extensors 5/5 L4 Ankle dorsiflexors 0/5 C8 Finger flexors 5/5 L5 Long toe extensors 0/5 T1 Small finger abductor 5/5 S1 Plantar flexors 0/5

25. Range of Motion: Upper extremities: full range of motion on active and passive motion Lower extremities – with full range of motion on passive motion – no active movement of the lower extremities.

26. Reflexes LevelReflexRightLeft C5, C6Biceps2+ C5, C6Brachioradialis2+ C7, C8Triceps2+ L3, L4 Quadriceps (knee jerk) (-) SI, S2Triceps Surae(-) Babinski(-) Clonus(-)

27. Laboratory Examinations Blood Chemistry BUN 4.66 Crea 66 Na 136 K 4.5 Cl 99 Urinalysis Clear, yellow, sp. Gravity 1.010, (-) sugar/protein/RBC, (+) 4-9 WBC, (-) bacteria, rare epithelial cells, (-) casts/crystals ECG Regular sinus rhythm, normal axis, non- specific STT wave changes

32. Assessment Spinal cord injury complete ASIA A secondary to fall Fracture dislocation of T12 vertebra UTI, complicated, resolving CSAP, CCS II

33. PROBLEM LIST

34. Medical and Surgical Problems Spinal cord injury complete ASIA A secondary to Fracture dislocation of T12 vertebra UTI, complicated CSAP, CCII Tension Headache

35. PROBLEM LIST ImpairmentDisabilityHandicap ParaplegiaInability to ambulate Complications of prolonged immobility Inability to continue working as a farmer and primary breadwinner Inability to perform ADLs Inability to take care of his wife

36. PROBLEM LIST ImpairmentDisabilityHandicap Loss of bladder and bowel control Inability to control bowel and bladder movement Inability to go out in public Constipation

37. Goals ProblemShort Term GoalsLong Term Goals SCI and Fracture Dislocation of T12 Stabilization of the spine ParaplegiaPhysical therapy to avoid contractures and upbuild upper body motor strength OT for ADL retraining Independence in ambulation by wheelchair use Bowel and bladder incontinence Bowel and bladder training Regain independence in bowel and bladder movement

38. Goals ProblemShort Term GoalsLong Term Goals ConstipationMobilization after surgery Eliminate constipation Chronic Stable Angina Pectoris Education regarding maintenance medications and intake Control and prevent progression and complications

39. Goals ProblemShort Term GoalsLong Term Goals Urinary Tract Infection Cure.Prevent recurrence. Tension-type Headache Relieve with pain medications. Counseling for stressors. Prevent recurrence.

40. Thank you!