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Spinal Cord Injury Patient's Discussion Case Study

Explore a comprehensive case study of a 52-year-old, right-handed married farmer with a history of a spinal cord injury after a fall. The text includes detailed medical history, physical exam findings, diagnostic tests, and treatment plans. It covers the patient's initial presentation, progression, and ongoing care. This resource provides valuable insights into managing spinal cord injuries and associated complications.

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Spinal Cord Injury Patient's Discussion Case Study

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Presentation Transcript

  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 • (+) bulbocavernosusreflex • 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

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

  16. 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, anictericsclerae, (-) CLAD/ANM/TPC

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

  18. Adynamicprecordium, 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

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

  20. Sensory Examination

  21. Motor ExaminationMuscle Strength Testing

  22. 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.

  23. Reflexes

  24. 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

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

  26. Problem list

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

  28. PROBLEM LIST

  29. PROBLEM LIST

  30. Goals

  31. Goals

  32. Goals

  33. Thank you!

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