1.    Initial examination/evaluation:

1.1. Patient’s information and
demographics:

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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

15°

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.