SPINE Small Group Discussion

Patient Information

• S.B.• 52 M• Married• Roman Catholic• Quezon• Farmer• Right-handed

Chief Complaint

• Fall

History of Present Illness

• DOI: Dec. 23, 2009• TOI: 9 am• POI: Quezon

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

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

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.

• 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

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

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

Past Medical History

• (-) hypertension, DM, CA, goiter, BA, heart disease

• No food/drug allergy• No previous hospitalization or previous

surgery

Family Medical History

• (-) Hypertension, DM, PTB, BA, CA, stroke, other systemic illness

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

Functional HistoryFunction Prior to Injury At Present

Self-care

Eating 7 7Grooming 7 5Bathing 7 1Dressing – Upper Body

7 5

Dressing – Lower Body

7 1

Sphincter Control

7 1

Toileting

Bladder Management

7 1

Bowel Management 7 1Transfers

Bed/Chair/Wheelchair

7 1

Toilet 7 1Tub/Shower 7 1

Social

Social Interaction

7 7

Cognitive Function

Problem Solving 7 7Memory 7 7

Total Score 126 62

LocomotionWalk/Wheelchair 7 1Stairs 7 1Communication

Comprehension 7 7Expression 7 7

Living Conditions

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

Physical Exam

• Awake, conscious, coherent, not in cardiorespiratory distress, bed-ridden

• Vital signs: BP-90/60 mmHg• HR-64 bpm• RR-18 cpm• T-37oC• Pink palpebral conjunctivae, anicteric sclerae,

(-) CLAD/ANM/TPC

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

• 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

Neuro Exam

• GCS 15, conscious, coherent, oriented to three spheres, conversant, able to follow commands

• Cranial nerves are intact

Sensory Examination

PAIN LIGHT TOUCH

R L R L

C2-C8 100 100 100 100T1- T10

100 100 100 100

T11 90 90 90 90T12-L5 0 0 0 0S2-S3 0 0 0 0

Motor ExaminationMuscle Strength Testing

UpperExtremity

Muscles R L Lower

Extremity Muscles R L

C5 Elbow flexors 5/5 5/5 L2 Hip flexors 0/5 0/5

C6Wrist

extensors

5/5 5/5 L3 Knee extensors 0/5 0/5

C7Elbow

extensors

5/5 5/5 L4Ankle

dorsiflexors

0/5 0/5

C8 Finger flexors 5/5 5/5 L5 Long toe

extensors 0/5 0/5

T1Small finger

abductor

5/5 5/5 S1 Plantar flexors 0/5 0/5

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.

ReflexesLevel Reflex Right Left

C5, C6 Biceps 2+ 2+

C5, C6 Brachioradialis 2+ 2+

C7, C8 Triceps 2+ 2+

L3, L4 Quadriceps (knee jerk) (-) (-)

SI, S2 Triceps Surae (-) (-)

Babinski (-) (-)Clonus (-) (-)

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

Assessment

• Spinal cord injury complete ASIA A secondary to fall

• Fracture dislocation of T12 vertebra• UTI, complicated, resolving• CSAP, CCS II

PROBLEM LIST

Medical and Surgical Problems

• Spinal cord injury complete ASIA A secondary to Fracture dislocation of T12 vertebra

• UTI, complicated• CSAP, CCII• Tension Headache

PROBLEM LISTImpairment Disability Handicap

Paraplegia Inability to ambulateComplications of prolonged immobility

Inability to continue working as a farmer and primary breadwinner

Inability to perform ADLs

Inability to take care of his wife

PROBLEM LIST

Impairment Disability HandicapLoss of bladder and bowel control

Inability to control bowel and bladder movement

Inability to go out in public

Constipation

GoalsProblem Short Term Goals Long Term GoalsSCI and Fracture Dislocation of T12

Stabilization of the spine

Paraplegia Physical therapy to avoid contractures and upbuild upper body motor strengthOT for ADL retraining

Independence in ambulation by wheelchair use

Bowel and bladder incontinence

Bowel and bladder training

Regain independence in bowel and bladder movement

GoalsProblem Short Term Goals Long Term GoalsConstipation Mobilization after

surgeryEliminate constipation

Chronic Stable Angina Pectoris

Education regarding maintenance medications and intake

Control and prevent progression and complications

GoalsProblem Short Term Goals Long Term GoalsUrinary Tract Infection

Cure. Prevent recurrence.

Tension-type Headache

Relieve with pain medications. Counseling for stressors.

Prevent recurrence.

Thank you!