1. Initial examination/evaluation:
1.1. Patient’s information and
demographics:
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 outpatient
at central military hospital, in august 2016 he did low back pain surgery at
the level of L3-L4 after he wakeup from the surgery there wasn’t any movement
of the upper and lower extremities .so, the doctor decided to refer him
directly to physical therapist in the same hospital. The patient was referred
by Dr.Amin Nasrallah due to cauda equine lesion . Ahmads chief complaint that he
can’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.
Social
history and participation:
1.2.4.1.
The
patient is married and have 3 boys they are married he lives with his wife in the third floor
building with a elevator.
1.2.4.2.
He
is left handed
1.2.4.3.
He
is heavy smoker but he is trying to
quit.
1.2.5.
Family
history: hypertension , diabetes , liver
cirrhosis..
1.2.6.
General
health status:
1.2.6.1.
Patient
health is not good, he is overweight
1.2.6.2.
he has
cholesterol and hypertension
1.3. Activities:
1.3.1.
Personal
activity: As we perform Lawton(IADL) and katz
(ADL) we concluded that the patient is dependent. He cannot perform any
activity 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.
Functional
independence measure (FIM) score 48/126à The patient is dependent
1.3.2.
Occupational
and work activity: Before he had SCI he used to sit
with his son in shoe shop and help him in selling.
1.3.3.
Leisure
activities: listening quran and reading books.
1.3.4.
Assistive
or adaptive devices: wheelchair
1.4. Impairments:
1.4.1.
Inspection:
1.4.1.1.
There is no
discoloration
1.4.1.2.
Overweight
1.4.1.3.
Rounded
shoulder
1.4.1.4.
Forward head
posture
1.4.1.5.
Scar on L3-L4
muscles
1.4.1.6.
Atrophied UE
(biceps and triceps)
1.4.1.7.
Atrophy in the
LE
1.4.2.
Posture:
1.4.2.1.
Rounded
shoulders
1.4.2.2.
Forward head
posture
1.4.2.3.
wheelchair
1.4.3.
Pain Assessment:
The
patient doesn’t feels pain at rest
Aggravating
factors:
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 in
speech & communication
1.4.7.2.
Comprehension; social interaction ;problem
solving 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.
Respiratory
Rate: 17cycle/min
1.4.9.3.
Blood
Pressure: 100/70 mm/Hg
1.4.9.4.
Pulse
Rate: 90 beats/min
1.4.10.
Circulation:
1.4.10.1.
Peripheral pulses: normal
1.4.11.
Integumentary integration:
1.4.11.1.
Scar on
low back (lumbar region) due to the operation length 5 cm.
1.4.12.
Motor Integrity:
1.4.12.1.
Muscle
bulk, Firmness:
–
Atrophy in the UE right and left side.
–
Atrophy in the LE right and left side.
1.4.12.2.
Muscle tone:
–
hyporeflexia
1.4.12.3.
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 of
the 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 of
them 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 the
left side but its normal in the right.
1.4.18.
Fine motor neuron: couldn’t be perform in the left
side 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 it
scores 12 the patient is going in slight depression.
1.4.22.
Scales:
1.4.22.1.
Asia scale : light touch both sides total
score: 51
Pin prick both sides total score:51
Motor Incomplete, since as
stated above more than the half of the key muscles are below the single NLI
less than or equal to grade 3 muscle.
1.5. Assessment:
Ahmad
hamed is 74 years old outpatient at Lebanese military hosptail. he was referred
by 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 . His
chief complaint that he couldn’t walk and cant perform the ADL and IADLactivities. he has been doing
physiotherapy 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 has
limitation in elbow and shoulder ROM . he has generally muscle weakness and
atrophied muscles in UE &LE. The patient comes 4days per week 2-3 hours a
session. he will benefit from physical therapy sessions to improve his impairments.
