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Examination

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History

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  • Demographic Information:

    The patient is a 43-year-old Caucasian, English-speaking man with a postgraduate education.

  • Social History:

    The patient is married with two teenage children. He recently moved to the state of Washington with the military and participates in social athletics, including baseball, basketball, and ice hockey.

  • Employment:

    Patient is a member of the executive staff in a military medical group as a nurse practitioner and chief of nursing.

  • Living Environment:

    Patient lives in a one-story private home with one 6-in. (15 cm) step to enter.

  • General Health Status:

    Patient is an active, healthy individual.

  • Medical History:

    Hypertension (controlled with lisinopril), bradycardia, basal cell carcinoma (removed without complication), kidney stone several years ago, hyperlipidemia (controlled with Zocor), allergic rhinitis (controlled with Singulair); no known drug allergies.

  • Current Condition/Chief Complaints:

    On November 21, patient was driving a borrowed all-terrain vehicle (ATV) when he lost control. He was thrown from the vehicle and hit his head/helmet on a pipe in a gully. He felt immediate pain in his back. He reports that he had difficulty breathing owing to rib pain and immediately had no feeling in his legs ("I couldn't feel or move my legs"). He was transported by helicopter to a hospital in Reno, Nevada. The patient also reported he was able to contract his quadriceps slightly until just prior to reaching the hospital. He was found to have:

  • L1 burst fracture

  • Left 1st through 10th rib fractures with left pulmonary contusion

  • Left hemopneumothorax requiring chest tube placement

  • Left T1 transverse process fracture

  • T2 to T7 spinous process fractures

  • T10 to T12 right posterior medial rib fractures

  • Left scapular body fracture

    On November 24, the patient underwent surgery for a T11–L3 laminectomy and posterior lateral fixation. He was immobilized in a custom thoracolumbosacral orthosis (TLSO); weightbearing as tolerated (WBAT) on left upper extremity (UE).

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Systems Review

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  • Cardiovascular/Pulmonary System:

    • Heart rate: 79 beats per minute

    • Blood pressure: 104/67 mm Hg

    • Respiratory rate: 16 breaths per minute

  • Musculoskeletal System:

    • Gross symmetry: visible rib deformities on left thorax; left lower extremity (LE) swelling

    • Gross range of motion (ROM): LE ROM generally within functional limits (WFL), with the exception of moderately tight hamstrings and hip rotation bilaterally; contracted left plantarflexors. UE ROM is also generally WFL, with the exception of tightness in bilateral shoulder flexion, abduction, and rotation (greater on left).

    • Gross strength: Grossly normal strength throughout UEs; 0/5 strength in bilateral LEs

    • Height: 6 ft 2 in (1.9 m)

    • Weight: 170 lb (77 kg)

  • Integumentary System:

    • Multiple ecchymoses on all four extremities

    • Prominent ecchymoses on left chest wall and right lateral chest wall

    • Small open wounds on right posterior upper arm and anterior forearm

    • No pressure ulcers

  • Neuromuscular System:

    • Normal reflexes on bilateral UEs

    • Diminished reflexes on bilateral LEs

    • Impaired sensation of lower trunk and LEs bilaterally

    • Diminished rectal tone and no voluntary anal contraction

    • Balance impaired in short- and long-sitting

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