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Examination

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History

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  • Demographic Information:

    The patient is a 49-year-old woman who was referred to outpatient physical therapy with a diagnosis of incomplete spinal cord injury.

  • History of Present Illness:

    About 1.5 years ago, the patient was working as a train conductor and suffered a whiplash injury to her neck while dodging a spitball in a moving train. She went to the emergency room for further evaluation and was discharged home. A few weeks later, the patient experienced pain in her arms, shoulders, and back. Pain persisted, and approximately 2 months later the patient went to the emergency room again. An x-ray was performed with inconclusive findings, and the patient was discharged with pain medication. Over the next couple months, patient began to experience tremor in her hand, bladder incontinence, and difficulty balancing while walking. A neurologist examined her and magnetic resonance imaging (MRI) of the spine was performed. The MRI revealed multiple disc herniations in the cervical spine with spinal cord impingement. The patient underwent C6-C7 decompression and fusion surgery 1 week later. She was unable to move her lower extremities (LEs) after the surgery. The patient remained in the hospital for 4 months and was discharged home with a power tilt-in-space wheelchair and attendant care. She was then frequently readmitted to the hospital for the next year owing to development of urinary tract infections, stage 4 sacral pressure ulcer, and methicillin-resistant staphylococcus aureus (MRSA) in her eye. She was admitted to inpatient rehabilitation approximately 1.5 years after the decompression surgery. She received 1 month of inpatient rehabilitation and then was discharged home. She now presents to outpatient therapy to continue to improve her functional mobility status.

  • Medical/Surgical History:

    Unremarkable

  • Current Medications:

    Baclofen, gabapentin, lorazepam, temazepam, folic acid, docusate sodium, protein liquid for wound

  • Living Environment:

    Patient lives alone in an apartment with one step to enter. She has a ramp to enter building. She utilizes a tilt-in-space power wheelchair, commode, Hoyer lift, and hospital bed with air mattress, leg lifter, and a reacher. She has a home health aide 10 hours per day for 7 days a week. She uses an indwelling catheter. She currently sponge bathes.

  • Social Support:

    Patient has a supportive daughter.

  • Employment:

    Patient is currently on disability. She previously worked as a subway train conductor.

  • Prior Level of Function:

    Patient was independent with all aspects of functional mobility skills, leisure activities, activities of daily living (ADL) and instrumental activities of daily living (IADL), and worked full time as a subway train conductor.

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Systems Review

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  • Cardiovascular/Pulmonary System:

    • Within normal limits

    • Patient has a history of orthostatic hypotension that is now managed with bilateral compression stockings and abdominal binder.

  • Musculoskeletal System:

    • Gross range of motion (ROM): The patient's bilateral upper extremities (UEs) are within normal limits (WNL). Bilateral LEs are WNL throughout except for moderate tightness of hamstrings, hip flexors, and hip internal/external rotators bilaterally.

    • Gross strength (manual muscle test ...

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