Case Presentation Son Eui Young 2007313075 Sungkyunkwan University

Case Presentation Son Eui Young 2007313075 Sungkyunkwan University School of Medicine

Chief Complaint n n 20/F Rehabilitation for quadriplegia – Quadriplegia onset : 15 weeks ago

Present illness n 2012. 02. 20 – Anterior corpectomy C 5, 6 anterior fusion C 4 -7, dural sealing 시행 n 2012. 02. 27 – – – n Desaturation 지속되어 SMART contact Chest-X ray 에서 관찰되는 LLL 의 dense opacity 있어서 Atelectasis 의심되어 tazocin + levoloxacin 투여 2012. 03. 05 – Spinal cord injury 에 대한 포괄적 management 및 재활치료 위해 REH 전과함

Chest X-ray n 2012. 02. 27

Past Medical History n HTN / DM / Dyslipidemia ( - / - ) Hepatitis / Allergy ( - / - ) n Medication n – – – – Levosulpiride 25 mg Azelastine 1 mg Cetamadol® 325 mg Gabapentin 300 mg Tazocin® 4. 5 g Ambroxol 15 mg Levofloxacin 750 mg Ipratropium nebulizer 500 mc

Personal History n Family history – No family history of HTN / DM / hepatitis / Tb / allergy / Cancer n Social history – – Never-smoker Never-drinker Occupation : 대학생 Residence : 강원도 정선 아파트 5층, 엘리베이터 있음

Review of system n General appearance – General weakness / Fatigue / Weight change ( + / - ) – Fever / Chill / Sweating ( - / - ) n Head and neck – Headache / dizziness / vertigo ( - / - ) – Cough / sputum / dyspnea ( - / - ) n Cardiopulmonary – n Gastrointestinal – – – n Chest pain / palpitation ( - / - ) Anorexia / nausea / vomiting ( - / - ) Abdominal pain / discomfort ( - / - ) Constipation / diarrhea ( - / - ) Skin – Rash / easy bruisability ( - / - ) – Tingling sensation : both arms and legs, 특히 팔쪽이 심함

Physical examination n n 2012. 03. 08 시행 Vital sign, body measurement n – – – 103/63 -63 -20 -36. 4, 49. 3 kg, 153 cm n General appearance – Alert, Good orientation to Person/Time/Place n Head & neck n Chest – – – symmetric chest expansion regular heart beat s murmur vesicular breath sound s crackle, wheezing soft bowel sound – hypoactive (1회/5분) no tenderness/rebound tenderness no palpable mass no shifting dullness Back and Extremity – no other site tenderness – Leg edema (-/-) – Neck vein engorgement (-) – Cervical LN enlargement (-/-) n Abdomen n Skin – rash/purpura/erythema (-/-/-) – Pressure sore : sacral sore, grade II, 0. 5 cm x 0. 5 cm

Neurologic Examination n n 2012. 03. 08 시행 Functional mobility – – – n Rolling : Totally dependent Come to sit : Totally dependent Sit to stand : ( - ) Wheel chair transfer : Totally dependent Sitting balance : ( - ) Standing balance : ( - ) Manual Motor Test – – – n n Shoulder abduction Elbow flexor(C 5) Wrist extensor(C 6) Elbow extensor(C 7) Finger flexor(C 8) Finger abduction(T 1) Sensory – – – – n Pin Prick : Hypesthesia below T 3 Light Touch : Symmetrically intact Vibration : Hypesthesia below ASIS s/p Foley insertion Defecation – – n Hip, knee : 0 Ankle : 1 / 1. 5 Voiding – n Biceps / Triceps / Knee / Ankle jerk : - / Hoffmann’s Sign : - / Babinski Sign : - / Ankle clonus : - / - Spasticity – – n (I/I) ( II / II ) (0/0) DTR Diaper defecation Anal sense : ( - ), but decreased Anal tone : normal Voluntary anal contracture : ( - ) Neuropathic pain – Both arms and legs 에 저린 느낌.

Problem List

Assessment

Plan

Hospital Course

Case Review n Spinal Cord Injury – Epidemiology – Classification – ASIA scale – Types – Management of spinal cord injury