Client: Alexander Lacdao, 43 years old, Male Admitted: 08-13-13 Diagnosis: SCI Inc SL T8 secondary to Pathologic function T8-T9

Probably secondary to Pott's disease Client verbalized that he is from Cavite and he was residing with his brother here in Manila. Client had a history of Tuberculosis (2007) and was given several anti-tuberculosis medication ( Rifampicin, Isoniazid and Ethambutamol ) after which he had a history of slipping and sought medical help due to difficulty of standing up because of back pain. He was then diagnosed to have Pott's disease. No operation was done and continuous physical therapy was done every day at 8:00 to 8:30 am. Client was advised by his physician that he may be discharged before the week ends.

Physical Assessment
Integumentary : -Skin is dry and brown in color no lesions seen, capillary refill of 2 seconds on each finger and 3 seconds on each toe, Temperature of 36.0, Pulse rate of 96 and Blood pressure of 110/70 Head: -Oval in shape, symmetrical, no bleeding, masses or lesions Eyes : -White sclera, no bleeding or lesions Nose : -Nostrils are both patent, No NGT tube inserted or O2 inhalation Mouth : -Gums are pinkish in color, no lesions, most teeth on upper and lower gums aren't present, tongue is pinkish in color no lesions present Anterior Chest : -Breath sounds are clear, no crackles heard upon auscultation, no cough or colds, no using of accessory muscles when breathing, RR of 20 Posterior: -Kyphosis on RUQ, no lesions or sores. Palpable mass palpated at T8-T9

Abdomen : -Bowel sounds present on RLQ, RUQ, LUQ only, client verbalized that he defecates every other day, no bulging or protruding organs -PERINEAL AREA WAS NOT ASSESSED Lower extremities : -Muscle strength of 3/5 on left leg and 2/5 on right leg

NEUROLOGICAL ASSESSMENT:
Consciousness -Client is awake and responsive; client is also cooperative and follows most commands -GCS of 14/15 (4 for spontaneous eye opening, 5 for speech or voice and 5 for Sensory because he can only follow some instructions)

Cranial Nerve I - Olfactory - Client was able to identify the two scents we asked him to smell, perfume and alcohol

Cranial Nerve II - Optic - Client does not wear any eye glasses and was able to read the Jager's chart without difficulty -Confrontation test was not done -Client has a visual acuity of 20/40

Cranial Nerve III/IV/VI - Occulomotor/Trochlear/Abducens - Client was able to follow all six extra ocular movements -Pupillary reaction of 3 mm on both eyes Convergence test not done

Cranial Nerve V - Trigeminal - Client was able to contract his temporal and masseter muscles -Client was able to identify the sensations on his face -Corneal reflex not done

Cranial Nerve VII/IX/X/XII - Facial/glossopharyngeal/vagus/hypoglossal -Client is able to smile and has appropriate facial expressions during our interview -Client was able to protrude tongue move it upward,downward and side to side -Gag reflex not done

Cranial Nerve VIII - Vestibulocochlear -Client was able to hear well on both ears -Weber Test was done, client was able to hear sound equally on both ears -Rinne Test was also performed air conduction was longer than bone conduction on both ears

Cranial Nerve XI - Accessory - Client was able to shrug both shoulders equally -Client was able to elicit resistance on sternocleidomastoid muscle

REFLEXES : -Biceps reflex were not located -Triceps reflex present on Left arm only -Patellar reflex present on Left leg only -Plantar and Babinski reflex not done

MOTOR FUNCTION : -Client's mass on Right arm is not symmetrical to left arm ( it is crooked ) client verbalized that it is due to a fracture years back

-Muscle strength of 3/5 on both upper extremities and 3/5 on Lef leg and 2/5 on right leg -Client was able to perform alternate pronation and supination of hands - Rotation of ankles not done

CEREBELLAR FUNCTION : -Client was able to perform Finger to thumb on both hands - Finger to finger, Finger to nose, Heels down opposite shin not done -Walking gait not assessed ( client cannot sit or stand without the support of a Knight Taylor's Brace ) SENSORY FUNCTION : - Client was able to identify sensation on his Left Arm and Left leg only -Client wasn't able to feel or identify the sensation on his Right arm and right leg - Client was able to identify two items which we asked him to identify, a key and an eraser