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Examination

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History

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The patient presents with incomplete paraplegia, secondary to an anterior spinal cord infarction that occurred while he was snowboarding. The patient was admitted to a pediatric acute trauma center and then completed a 4-week stay in an acute rehabilitation facility. He was referred to a locomotor training clinic for outpatient therapy and initiated this therapy 4 months after his injury.

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  • Demographic Information:

    The patient is a 17-year-old Caucasian boy.

  • Medical History:

    Patient history is unremarkable except for occasional migraine headaches and delayed sleep phase syndrome (dissociation between the patient's circadian rhythm and the external environment).

  • Social History:

    The patient is a junior in high school. Prior to his injury, he ran cross-country and played lacrosse. He is an honors student and is active in his church youth group. At the time of the initial outpatient locomotor training evaluation, the patient was being home-schooled.

  • Living Environment:

    The patient lives with his parents and three older siblings in a two-story house with a stair glide to the second floor. There is a ramp at the main entrance to the house. The patient has a Quickie TNT ("Takes No Tools") manual wheelchair, as well as a tub bench and a commode at home.

  • Current Medications:

    Baclofen, 10 mg twice a day; gabapentin/Neurontin, 600 mg twice a day; aspirin, 80 mg daily; and Detrol LA twice a day

  • Patient Goals:

    Patient has identified the following goals for the physical therapy episode of care:

    • Ambulate independently with or without an assistive device

    • Return to high school at an ambulatory level

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Systems Review

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  • Cardiovascular/Pulmonary System:

    Heart rate (HR): sitting at rest in manual wheelchair, HR = 82 beats per minute; supine on flat mat, HR = 71 beats per minute

    Blood pressure (BP): sitting at rest in manual wheelchair, BP = 108/65

    Orthostatic Testing:

    • BP resting in supine = 105/61

    • Immediately upon passive return to upright supported sitting, BP = 66/42

    • After 2 minutes of upright supported sitting, BP = 90/60

    • After 5 minutes of upright supported sitting, BP = 99/58

    • After 10 minutes of upright supported sitting, BP = 101/63

  • Musculoskeletal System:

    • Gross range of motion (ROM): within normal limits (WNL) in both upper extremities (UEs) and lower extremities (LEs).

    • Gross strength testing: both UEs are symmetrical and strength is WNL. The left LE has good to fair voluntary movement, and the right LE has trace to absent voluntary movement.

    • Height: 5.75 ft (1.75 m)

    • Weight: 138 lb (62.6 kg)

  • Integumentary System:

    Skin is intact with no open lacerations, abrasions, or pressure ulcers. There is no history of pressure ulcers.

  • Neuromuscular System:

    Balance: The patient is able to sit unsupported in a chair but is unable to stand without support.

    • Sitting posture: In a relaxed seated position with UEs resting on thighs, the patient demonstrates increased thoracic and lumbar kyphosis (Fig. CS3.1). When asked to sit fully upright, the patient ...

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