General Information of the Patient

Patient : Check-in Date :

Institution : Check-out Date :
Birthplace : Service :
Birth Date : Doctor :
Tr No : Protocol No :
Father’s Name : GSS Tracking No :
Provision : Telephon :
Type
Adress : Registry Prt No :

Passaport No : Yupass No :
Treatment : Inpatient Treatment Type : Physical treatment and rehabilitation
Type
EPICRISIS REPORT

Patient's Complaints and History

THE PATIENT, WHO COMPLAINED OF WEAKNESS IN BOTH LEGS AND FEET, INABILITY TO WALK, URINARY INCONTINENCE, WAS OPERATED ON
06/07/2021 AT DIYARBAKIR DICLE UNIVERSITY HOSPITAL AT THE LEVEL OF L1 L2.PARAPLEGIA OCCURRED AFTER THE SURGERY.THE PATIENT
WAS GIVEN NEUROLOGICAL REHABILITATION TO THE PATIENT DIAGNOSED WITH PARAPLEGIA IN THE DEPARTMENT OF BRAIN SURGERY. THE
PATIENT WAS BROUGHT TO US BY WHEELCHAIR.

Examination Findings
ENGINE EXAMINATION:
RIGHT LOWER EXTREMITY:
HIP FLEXORS: 2/5
KNEE EXTENSOR: 2/5
ANKLE DF: 2/5
ANKLE PF: 3/5
LEFT LOWER EXTREMITY:
HIP FLEXORS: 1/5
KNEE EXTENSOR: 1/5
ANKLE DF: 0/5
ANKLE PF:1/5
ANKLE PF:1/5
SENSORY EXAMINATION: LEFT L1-S1 DERMATOME HYPOAESTHETIC
RIGHT L4-5 DERMATOME
HYPOAESTHETIC BABINSKI:+/+
URINARY INCONTINENCE:+

Notes
PATIENT ; WITH THE DIAGNOSIS OF PARAPLEGIA: BETWEEN 09.07/2021--24/07/2021, TOTAL: 10 SESSIONS OF INSIDERING PHYSICAL THERAPY
AND REHABILITATION PROGRAM WAS APPLIED.PHYSICAL THERAPY AND REHABILITATION PROGRAM WAS APPLIED TO THE PATIENT DAILY
FOR 1 HOUR AND 1 SESSION IN THE PATIENT'S TREATMENT:ELECTROTHERAPY: ACTIVE ROM, PASSIVE ROM, STRENGTHENING, STRETCHING,
BALANCE COORDINATION, WALKING TRAINING AND PNF EXERCISES WERE APPLIED TO THE ENTIRE BODY REGION AFTER THE PATIENT SAW
THE SESSION ON 24/07/2021, THE OUTPATIENT PHYSICAL THERAPY AND REHABILITATION PROGRAM SESSIONS WERE TERMINATED BECAUSE
HE DID NOT WANT TO CONTINUE TREATMENT ON OTHER DAYS

ICD-10 Diagnosis
Primary Diagnosis Type of Diagnosis Diagnosis
Yes Definitive Diagnosis G82.2 - Paraplegia, unspecified
No Preliminary Diagnosis G82.2 - Paraplegia, unspecified