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【Stroke (腦中風)】
This 65 y/o woman has an acute infarction with Rt hemiparesis that occurred on 99-
11-30. Her past history includes HTN, DM, and dyslipidemia.
Present Illness:
This 50 years-old man suffered from four-limb weakness and numbness after falling
during work from 5 meters high this morning. He was brought to our ER by EMT
within 15 minutes after injury. At the ER, he showed clear consciousness, but limb
weakness was noted with a fair grade in manual muscle testing. A PE revealed intact
anal reflex and tone. A Cervical MRI ordered by the ER doctor showed cord
contusion at C5-6with edema. Conservative treatment including high-dose steroid and
neck collar protection was given at ER. Under the impression of SCI(ASIA scale C),
he was admitted to rehab unit for further management.
PE
Conscious : clear, GCS: E4V5M6,
Chest : smooth respiratory pattern, breathing sound: clear
Abdomen: soft without distension, no tenderness,
MMT C5-T1: R/L 44443/44444; L2-S1: 44333/44343.
ASIA impairment scale : C
Anal tone:intact, Anal contraction:(+), Anal sensation(+).
anal reflex:(+), bulbocavernosus reflex:(+)
Paresthesia and pain over four limbs.
Current functional status is as followed:
ASIA impairment scale : C, incomplete injury
MMT C5-T1: R/L 55555/44444; L2-S1: 55555/32143.
MAS: 1/1
Gross motor:
Rolling to R/L:+/+
Sitting up: (+), with minimal/moderate/maximal assist
sitting balance Static/Dynamic:G/F
Standing up: (+),with minimal/moderate/maximal assist
standing balance Static/Dynamic:G/F
Transfer: with rotation/ rolling board
Locomotion:W/C bound/ transfer bed
Ambulation:(+/-), walking with quadricane, spastic gait, moderate assist for 20
meters/ without device under supervision for 100M, balance fair
Device: regular cane, quadricane, walker
Gait: spastic gait, circumductive gait, limping gait
Assist: +, minimal, moderate, maximal, -
Distance: 100M
Up stair/down stair : +/+, with support, fair balance
without device and assist, with non-alternative gait
Device: regular cane, quadricane,
Gait: alternative, non-alternative
Assist: minimal, moderate, maximal
Right/Left hand function:
Finger flexion /extension: +-/+-, Grasp:+-, Lateral prehension:+-,
Opposition:+-, Pinch:+-, Writing:+-
ADL function:
Eating/dressing/Light hygiene/Heavy hygiene: ID/PD/ID/PD
Speech and swallowing evaluation:
Speech: fluency:(-+), repetition:(-+), comprehension:(-+) partial impaired, can
obey
simple order. expression:paraphasia
Swallowing: removed NG with improved oral motor function,
Impression: spinal cord injury, level C6, incomplete injury (ASIA scale C)
Plan and management: Arrange aggressive rehab program to improve the patient's
gross motor and fine motor function. Physical therapy with facilitation training,
strengthening, posture, PROM-> AAROM, balance training, tilting table training and
occupational therapy with posture, PROM-> AAROM, balance training, hand
function, moving and ADL training.
Physical modality with IFC, TENS, SSP for focal S/S relief.