1. Initial examination/evaluation:1.
1. Patient’s information anddemographics: Name: ahmad hamed Nationality: lebanese Telephone: 70/634107 Sex: male Profession: None Medical order: PT sessions Weight: 75 kg Case date: 2/12/2016 Diagnosis: SCI (cauda equina) Height: 164cm Admission date: 13/8/2017 Treating doctor: Dr. amin nassralla BMI: 27.
9 (overweight) Date of birth: 1942 PT before: Yes-central military hospital Address: bourj hammoud Age: 74years old 1.2. Reason for referral:1.2.1. Current Condition: A 74 years old patient is an outpatientat central military hospital, in august 2016 he did low back pain surgery atthe level of L3-L4 after he wakeup from the surgery there wasn’t any movementof the upper and lower extremities .so, the doctor decided to refer himdirectly to physical therapist in the same hospital.
The patient was referredby Dr.Amin Nasrallah due to cauda equine lesion . Ahmads chief complaint that hecan’t do his ADL and IADL activities neither walking.1.2.2.
PMH:gall bladder. 1.2.3.
MEDS: Medication Indication Side effects aspicot (Acetylsalicylic) Anticoagulant Gastrointestinal disorders, nausea, vomiting, headache. zocor (semvastatine) STATINS Difficult breathing ,swelling of face lips tongue. Atacand (candesartan) High blood pressure Headaches, dizziness, back pain.
Zoloft (sertraline) Neuropathic pain` Dizziness ,diarrhea , insomnia, , tremor, headache, paresthesia, anorexia, decreased libido. 1.2.4. Socialhistory and participation: 1.2.4.
1. Thepatient is married and have 3 boys they are married he lives with his wife in the third floorbuilding with a elevator. 1.
2.4.2. Heis left handed 1.2.4.3. Heis heavy smoker but he is trying toquit.
1.2.5. Familyhistory: hypertension , diabetes , livercirrhosis..1.
2.6. Generalhealth status: 1.2.
6.1. Patienthealth is not good, he is overweight 1.2.6.2. he hascholesterol and hypertension 1.
3. Activities: 1.3.1. Personalactivity: As we perform Lawton(IADL) and katz(ADL) we concluded that the patient is dependent. He cannot perform anyactivity during walking or standing position.
1.3.1.1. Katz(ADL) score 3/6 1.3.
1.2. Lawton(IADL) score 2/8 1.3.1.3.
Functionalindependence measure (FIM) score 48/126à The patient is dependent1.3.2. Occupationaland work activity: Before he had SCI he used to sitwith his son in shoe shop and help him in selling.1.3.3.
Leisureactivities: listening quran and reading books.1.3.4.
Assistiveor adaptive devices: wheelchair 1.4. Impairments: 1.4.1. Inspection: 1.4.
1.1. There is nodiscoloration1.4.1.2. Overweight1.4.
1.3. Roundedshoulder1.4.
1.4. Forward headposture1.4.
1.5. Scar on L3-L4muscles1.4.
1.6. Atrophied UE(biceps and triceps)1.4.1.7. Atrophy in theLE1.4.
2. Posture: 1.4.2.1. Roundedshoulders1.4.
2.2. Forward headposture1.4.2.3.
wheelchair 1.4.3.
Pain Assessment: Thepatient doesn’t feels pain at restAggravatingfactors:during exercise the pain is during muscle contractures Relieving factors: taking analgesic,rest 1.4.4. ROM: 1.4.4.
1. Shoulder joint: Right left Active passive Active Passive Flexion 71° 92° 73° 97° Extension 20° 31° 26 36° Abduction 44° 66° 47° 65° External Rotation 30° 35° 33° 37° Internal Rotation 42° 50° 45° 56° 1.4.
4.2. Elbow joint: Right left Active passive Active Passive Flexion 150° 160 155 160 Extension -8 -5 -8 -5 Pronation 91 95 89 90 Supination 79 85 83 87 1.4.4.3. Hip joint: Right left Active passive Active Passive Flexion (side lying) 91° 115° 95° 115° Extension 7° 15° 5° 15° Abduction 18° 30° 20° 32° Adduction 24° 30° 27° 30° External Rotation – 23 – 23 Internal Rotation – 10 – 10 1.
4.4.4. Knee joint: Right Left Active passive Active Passive Flexion side lying 133 150 137 160 Extension side lying 12 15 12 15 1.4.4.5. Ankle joint Right left Active passive Active Passive Dorsiflexion – 10 – 10 Plantar flexion – 20 – 20 Inversion – 22 – 22 Eversion – 10 – 10 1.
4.5. Anthropometric characteristics: 1.4.5.1.
He is overweight his BMI:27.9 1.4.6. Cognitive function: 1.4.
6.1. Memory:- Short and long term memory: normal – BOMC Test : score 0à no signs for impaired cognition 1.4.6.
2. Attention: Normal 1.4.
7. Speech & Communication:1.4.7.1. Patient doesn’t have any impairments inspeech & communication1.4.
7.2. Comprehension; social interaction ;problemsolving and expression are normal. 1.4.8. Cranial Nerves CN I -Smell Normal CN II -Visual acuity Normal CN III, IV, VI -Ptosis -Eye movement -Pupillary light reflex None Normal Normal CN VI – Sensory function (forehead, cheeks, chin) Normal CN VII – Facial expressions Normal CN VIII -Auditory acuity: -Weber test -Eye-head coordination and orientation Normal CN IX -Sense of taste Normal CN X -Phonation, swallowing Normal CN XI – Tone, strength (Trapezius, SCM) Normal CN XII -Motor function (tongue) Normal 1.4.
9. Vital Signs:1.4.9.
1. Temperature: 37 C°1.4.9.
2. RespiratoryRate: 17cycle/min1.4.9.3. BloodPressure: 100/70 mm/Hg1.4.9.
4. PulseRate: 90 beats/min 1.4.10. Circulation:1.4.10.
1. Peripheral pulses: normal 1.4.11. Integumentary integration:1.
4.11.1. Scar onlow back (lumbar region) due to the operation length 5 cm.
1.4.12. Motor Integrity:1.4.12.1.
Musclebulk, Firmness: – Atrophy in the UE right and left side.- Atrophy in the LE right and left side.1.4.12.2.
Muscle tone: – hyporeflexia1.4.12.3. Reflexes:- Deep tendon Reflexes: Reflex Right Left Biceps tendon reflex Normal Normal Triceps tendon reflex Normal Normal Patellar tendon reflex Hyporeflexia hyporeflexia Achilles tendon reflex Hyporeflexia Hyporeflexia – Babinski response: negative no movement ofthe toes. 1.4.13.
Strength:- Manual Muscle Test (MMT): 1.4.13.
1. shoulder joint: Right Left Flexors 2+ 2+ Extensors 3 3 Abductors 3 3 Adductors 3 3 External Rotators 2+ 2+ Internal Rotators 2+ 2+ 1.4.13.2. Elbow joint: Right Left Flexors 3 3 Extensors 3 3 Pronators 3+ 3+ Supinators 3+ 3+ 1.
4.13.3. Hip joint: Right left Flexors 2 2 Extensors 2 2 Abductors 1 1 Adductors 1 1 External Rotators 0 0 Internal Rotators 0 0 1.4.13.
4. Knee joint: Right Left Flexors 3 3 Extensors 3 3 1.4.
13.5. Ankle joint Right Left Dorsiflexors 0 0 Plantar flexors 0 0 1.
4.14. Coordination:1.4.
15. Gross motor neuron UE: patient couldn’t perform all ofthem on both sides .1.4.16.
Fine motor neuron UE: normal on both sides.1.4.
17. Gross motor neuronLE: couldn’t be perform all in theleft side but its normal in the right.1.4.18. Fine motor neuron: couldn’t be perform in the leftside but its normal in the right. 1.4.
19. Aerobic capacity:1.4.19.
1. Modified Fatigue Impact – Physical subscale: 22/36- Cognitive subscale: 1/40 moderate impact of fatigue.- Psychological subscale: 6/8- Total score = 29 /84 1.4.20. Bowel and Bladder: 1.4.
20.1. normal 1.4.21.
Psychological status:1.4.21.1. Hamilton Rating Scale for Depression itscores 12 the patient is going in slight depression.
1.4.22. Scales: 1.4.
22.1. Asia scale : light touch both sides totalscore: 51 Pin prick both sides total score:51 Motor Incomplete, since asstated above more than the half of the key muscles are below the single NLIless than or equal to grade 3 muscle.1.5. Assessment:Ahmadhamed is 74 years old outpatient at Lebanese military hosptail.
he was referredby Dr. nasralla due to incomplete SCI. after low back pain (disk heriniation)surgery he woke up with no motor movements in the upper and lower extremeties, he couldn’t walk . Hischief complaint that he couldn’t walk and cant perform the ADL and IADLactivities. he has been doingphysiotherapy 8 months ago with progression in moving upper limbs,communication skills, and slight improvement in lower limb muscle performance.
The patient feels sensation all over his body except at the operated region(l3, l4). he has lower motor neuron; cauda equine with hyporeflexia.he haslimitation in elbow and shoulder ROM . he has generally muscle weakness andatrophied muscles in UE &LE.
The patient comes 4days per week 2-3 hours asession. he will benefit from physical therapy sessions to improve his impairments.
