INITIAL EVALUATION

General Information

Pt’s Name: R.G.S

Age: 30 y/o
Sex: M
Address: 68 B Sta. Maria St., Brgy. Commonwealth, Quezon City
Status: Married
Handedness: (L)
Occupation: Motor Technician
Referring Unit: FEU-DNRMF
Referring Doctor: Dr. Brown G. Williams MD in Nuerology
Rehab Doctor: Dr. Mary Anne Santos
Date of Admission: September 15, 2015
Date of Referral: August 20, 2015
Date of Initial Evaluation: September 22, 2018
Diagnosis: Posterior Cord Syndrome
S:
C/C: Pt. c/o difficulty in walking and uncontrolled movement on (B) LE, pt has also a history of
fall due to muscle imbalance and weakness.
Pt Goals:
Pt will be able to walk and transfer with intact balance and pt will be able to go back to work.
HPI
This is a case of Pt. R.GS, 30 y/o, M, a Motor Technician, Mesomorph, (+) HTN Uncontrolled,
(-) DM (+) Smoker (+) Alcoholic beverage drinker.
2 years ago, when pt experienced sudden, brief, and severe stabbing pain spreading in the back
and upper limbs PS (6/10). Pt decided to rest, and pain subsides after a minute. The following
week while he is fixing an engine, he suddenly experiences tingling sensation on his (R) arm. Pt
stated that he also experiences nausea. After a year, pt presented with difficulty in ambulating
resulting for him to loss his balance. Pt stated that he experienced incident of fall as he is
walking outside their house. Pt also experience muscle weakness on (B) of the lower extremities
and bladder incontinence.
 Upon physical examination, pt presented with decreased DTR on (B) LE and positive Argyll
Robertson pupil. Pt also presented with absence of sense of proprioception. Dr. Brown advised
the pt to undergo for a CSF examination and MRI scan to further understand the condition.
Cerebrospinal fluid (CSF) examination revealed 303 Χ 10 6 cells/L (84% were lymphocytes),
917 mg/L protein, normal glucose and chloride and positive rapid plasma regain test (RPR). The
MRI revealed that the pt. has swelling and high signal intensity of the spinal cord parenchyma at
level of T7 on T2-weighted images and focal gadolinium enhancement. Pt is diagnosed with
Posterior Cord Injury T7. At present the pt presents with impaired sense of vibration and
proprioception resulting difficulty in ambulation. Pt also presented with wide-based gait
characterized by slapping gait and presence of photophobia.

Current Medications:

Medication Dosage Frequency Indication

CELECON 17.54 mg 1qd Stool softener

Past Medical History:

(-/+)
UTI (2020) (+)
Kidney Stone (2020) (+)
HTN (+)
Stroke (-)
DM (-)

Family Medical History:

Maternal (-/+) Paternal (-/+)
HTN (+) (-)
Stroke (-) (-)
DM (-) (-)
CVA (-) (+)
Trauma (-) (-)
Personal/Social Hx:
Personality type: Optimistic type of person with highly competitive spirit
Diet: The patient consumes carbs, vegetable and fish/meat
Cigarette Use: Non-smoker
Alcohol beverage Consumption: 3 times per week
o Type of alcoholic beverage: Beer
o Frequency: 355 ml per bottle
Lifestyle: Tries to keep himself active by performing exercises at home
Financial Stability: Stable health care insurance

Home Situation:
lives in a 2-storey house
lives with wife and son
Pt sleeps on a medical bed with an overhead trapeze
Bedroom ↔ Front door (200.36 cm)
Bedroom ↔ CR (115.92 cm)
Bedroom ↔ Kitchen (172.88 cm)
Bed ↔ Wheelchair and Walker (37 cm)
Work Situation:
Pt works as a motor technician in a company sometimes patient also needs to travel with the truck
drivers in case there is engine problems while trying to deliver goods. Pt also do deliveries when
there are no drivers available. Pt drives a motorcycle in going to work.
 Ancillary Date Findings
Procedure
Posterior Cord Syndrome
Magnetic January 1, Axial T2-weighted MR image shows a hyper intense signal,
Resonance 2020 with the classic inverted V configuration (arrow), in the dorsal
Imaging columns.

Significance: According to (Freund et al., 2018) MRI is the gold standard to evaluate any damage
spinal cord induced by trauma and it also provide information on what neurodegenerative changes might
occur adjacent to the injury. (Talbott et al., 2019) also indicate that MRI is still the establish gold
standard imaging modality to evaluate spinal cord injury.

O:
Vital Signs Normal Values a During p
Blood Pressure (BP) 120/80 mmHg 125/90 mmHg 130/90 mmHg 120/80 mmHg
Pulse Rate (PR) 60-100 bpm 65 bpm 90 bpm 80 bpm
Respiratory Rate (RR) 12-20 cpm 17 cpm 25 cpm 15 cpm
Temperature 37.5ºC 36.5 ºC 37 ºC 36.5 ºC

OI:
MOA: Minimal assist c wheelchair
Mesomorph
Alert, coherent, cooperative
(+) Postural deviation
(+) Ataxic Gait
(+) Muscle Weakness on (B) LE
(+) Minimal atrophy at his (L) LE
(+) Swelling on ® LE
(-) Erythema on all exposed body parts
(-) Deformities on (B) UE and LE
(-) Pressure sores on exposed body parts

Neurologic Evaluation:
ASIA Classification: Incomplete SCI C c motor level T2 below spinal cord injury and sensory
level for pin prick and light touch (B) LE.

MMT:
All muscle of (B) UE/LE and Trunk are grossly graded 5/5, except
Lower Trunk = 3+/5
(R) Quads = 3/5
(L) Quads = 2+/5
(B) Gastrocnemius = 2/5

Deep Tendon Reflex

+ Hyporeflexia

++ Normoreflexia

+++ Hyperreflexia
++++ Clonus

Findings: Normoreflexive on (B) UE & LE except Areflexia on (L) ankle reflex. Hyporeflexia on (B)
Knee reflex and ® ankle.
ICF Domain: Body Structure/ Function
Motor and Sensory Function
Revised ASIA Impairment Scale
Motor Score: ® = 41/50 ; (L) = 41
UE =50/50
LE = 28/50
Sensory Score:
® = Light Touch: 48/112 (L) = Light Touch: 48/112
® = Pin Prick: 53/112 (L) = Pin Prick: 51/112
Level of Affectation: T7 = Posterior Cord Injury