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SPINE Small Group Discussion

SPINE Small Group Discussion. Patient Information. S.B. 52 M Married Roman Catholic Quezon Farmer Right-handed. Chief Complaint. Fall. History of Present Illness. DOI : Dec. 23, 2009 TOI: 9 am POI: Quezon. History of Present Illness. Mechanism Of Injury:

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SPINE Small Group Discussion

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  1. SPINE Small Group Discussion

  2. Patient Information • S.B. • 52 M • Married • Roman Catholic • Quezon • Farmer • Right-handed

  3. Chief Complaint • Fall

  4. History of Present Illness • DOI: Dec. 23, 2009 • TOI: 9 am • POI: Quezon

  5. History of Present Illness • Mechanism Of Injury: • Getting a coconut from the tree, 20 feet high • he lost his footing and fell • he hit his back first when he landed • (-) move his lower extremities. • (-) head trauma • (-) vomitting, (-) blurring of vision

  6. He was then brought to a nearby local hospital, and immediately advised to transfer to PGH.

  7. Course in the ER • The patient arrived at the PGH ER in the evening. • Physical exam on admission showed • (+) lax sphincter tone • (+) bulbocavernosusreflex • 0/5 muscle strength on his lower extremities • last intact sensory level was T11.

  8. Diagnostic tests done are as follows: • Blood chemistry, CBC, urinalysis, electrolytes, Chest Bucky, CT scan • Assessment: • Spinal Cord Injury complete ASIA A secondary to fall, fracture dislocation of T12 vertebra

  9. Course in the Wards • Orthopedic Plan • Patient is scheduled for Operation: Posterior Instrumentation using pedicels screws C5-C6 level with cross-linking under General Anesthesia • Awaiting for funds • January 6, 2010: • tightening headache • from the frontal area radiating to the back • VAS score of 5/10 • nausea and minimal non-projectile vomiting • Laboratory results • 4-9 WBCs on urinalysis

  10. Review of Systems • (-) Loss of consciousness • (+) nausea • (-) weight loss • (+) headache • (-) BOV • (-) seizure • (-) fever • (-) anorexia • (-) vomiting, • (-) chest pain • (-) abdominal pain • (+) constipation • (+) urinary incontinence, • (+) paralysis of lower extremities • (+) loss of sensation of trunk immediately after umbilicus and lower extremities

  11. Past Medical History • (-) hypertension, DM, CA, goiter, BA, heart disease • No food/drug allergy • No previous hospitalization or previous surgery

  12. Family Medical History • (-) Hypertension, DM, PTB, BA, CA, stroke, other systemic illness

  13. Personal-Social History • (+) 30 pack year smoking history • (+) occasional alcoholic drinker • farmer since 1978 • primary caregiver of his bed-ridden wife. • five children [31 eldest, 19 youngest] • Financial support: • patient’s relatives • government agencies

  14. Functional History

  15. Living Conditions • flat one-storey concrete house • 15x20 square feet along the highway. • bed 10 steps towards the toilet area.

  16. Physical Exam • Awake, conscious, coherent, not in cardiorespiratory distress, bed-ridden • Vital signs: BP-90/60 mmHg • HR-64 bpm • RR-18 cpm • T-37oC • Pink palpebral conjunctivae, anictericsclerae, (-) CLAD/ANM/TPC

  17. Equal chest expansion, (+) kyphosis with prominent thoracic spine, clear breath sounds

  18. Adynamicprecordium, distinct heart sounds, (-) murmurs • Flat abdomen, normoactive bowel sounds, (-) masses/tenderness, (-) bladder distention • (+) lax sphincter tone, (+) fecal material per examining finger • Full and equal pulses, (-) cyanosis/edema, (+) atrophied lower extremities

  19. Neuro Exam • GCS 15, conscious, coherent, oriented to three spheres, conversant, able to follow commands • Cranial nerves are intact

  20. Sensory Examination

  21. Motor ExaminationMuscle Strength Testing

  22. Range of Motion: • Upper extremities: full range of motion on active and passive motion • Lower extremities • with full range of motion on passive motion • no active movement of the lower extremities.

  23. Reflexes

  24. Laboratory Examinations • Blood Chemistry BUN 4.66 Crea 66 Na 136 K 4.5 Cl 99 • Urinalysis Clear, yellow, sp. Gravity 1.010, (-) sugar/protein/RBC, (+) 4-9 WBC, (-) bacteria, rare epithelial cells, (-) casts/crystals • ECG Regular sinus rhythm, normal axis, non-specific STT wave changes

  25. Assessment • Spinal cord injury complete ASIA A secondary to fall • Fracture dislocation of T12 vertebra • UTI, complicated, resolving • CSAP, CCS II

  26. Problem list

  27. Medical and Surgical Problems • Spinal cord injury complete ASIA A secondary to Fracture dislocation of T12 vertebra • UTI, complicated • CSAP, CCII • Tension Headache

  28. PROBLEM LIST

  29. PROBLEM LIST

  30. Goals

  31. Goals

  32. Goals

  33. Thank you!

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