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Examination

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History

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  • Demographic Information:

    The patient is a 50-year-old, married, Caucasian, English-speaking man.

  • History of Present Illness:

    The patient slipped and fell backward while walking his dog outside the home. He did not lose consciousness, but was immediately unable to move his arms or legs and experienced altered sensation below the neck. Magnetic resonance imaging (MRI) revealed a spinal cord contusion, cord stenosis, and cord compression between C2 and C4. He underwent spinal fusion of C2-C4 with posterior cervical laminectomy and lateral plating.

  • Admitting Diagnosis:

    The admitting diagnosis was C4 spinal cord injury (SCI). Based on the American Spinal Injury Association Impairment Scale (AIS), the lesion was designated as a Category C: Incomplete. Sensory and motor function is preserved below the neurological level and includes the sacral segments S4-S5. The patient was admitted wearing a cervical orthosis (Fig. CS14.1).

  • Medical History:

    Hypertension and hyperlipidemia (no medications prior to admission)

  • Surgical History:

    None prior to admission

  • Social History:

    The patient enjoys his work, family, grandchildren, and attending college athletic events. He works at a nuclear power plant full time as the director of maintenance.

  • Living Environment:

    He lives in a ranch-style home with one step to enter with a tub/shower combination in the bathroom.

  • Prior Level of Function:

    He was fully independent prior to the accident and stayed active by walking his dog daily.

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FIGURE CS14.1

The patient was admitted to the inpatient rehabilitation unit wearing a cervical orthosis. He was provided with a sip-and-puff call light in his room.

Graphic Jump Location
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Systems Review

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  • Cardiovascular/Pulmonary System:

    • Heart rate: 49 beats per minute (BPM)

    • Respiratory rate: 18 BPM

    • Blood pressure: 128/69

  • Musculoskeletal System:

    • Gross range of motion (ROM):

      • Bilateral upper extremities (UEs): within normal limits (WNL)

      • Bilateral lower extremities (LEs): WNL except for straight-leg raise bilaterally owing to hamstring tightness; tightness also noted in hip rotation

    • Gross strength: Significant weakness noted in bilateral UE and LE (Fig. CS14.2).

  • Neuromuscular System:

    • Sensation: light touch intact bilateral UEs and right LE; reduced light touch noted in left LE

    • Normal reflexes (2+) on bilateral UE and LE

    • Rectal tone present with voluntary anal contraction

    • Coordination: unable to perform owing to decreased strength

    • Postural control: requires maximal assistance

    • Balance: requires maximal assistance

    • Gait: nonambulatory

  • Integumentary System:

    • No abrasions noted

    • No pressure ulcers noted

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FIGURE CS14.2

Sensory and motor scores American Spinal Injury Association. International Standards for Neurological Classification of Spinal Cord Injury, rev 2013. Atlanta, GA, American Spinal Injury Association, 2013, with permission.

Graphic Jump Location
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Test and Measures

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  • Sitting Balance:

    • Maximal assistance for short-sitting balance on mat without UE support

    • Minimal assistance for short-sitting balance on mat with bilateral UE support for 30 seconds

    • Modified Functional Reach Test: unable ...

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