Name: Judy Anne Gubatanga Lasprilla

Address: Basak, PakPakan, Lapu-lapu City, Cebu

Date of Birth: 7/15/1974 (35y11m18d)
Gender: F
Nationality: Filipino
Religion: Catholic
Occupation: Housewife
Adm date: Sept. 14 2010

CC: Pt. complains of inability to move her LE after a vehicular accident

Prior level of fxn: Pt. does the household chores like cooking, washing the clothes
Social Hx: Pt. is admitted in VCME and is visited by her husband after work
Employment status: Pt. states that she is a housewife
General health status: Pt. states that her health is good except for her complains of her LE
Family Health Hx: Pt. denies any heredito-familial diseases
Medical and Surgical Hx: Pt. states that she had a surgery on her head after the accident.
She also states that she will have a surgery for her low back (Lumbar). Pt. is in an in-
patient bases rehab.
Functional status and Activity level: Pt. states that she can perform any activities
involving the UE while in supine or sidelying.
Medications: Pt. states that she is taking a multivitamins once/day and ferrousulfate.
Goals: Pt. wants to be effective in any activities involving any household chores after
surgery and completing the rehab.

OI:
Physique: Ectomorph
Pt. is confined in bed
Pt has no IV or any other attachments except for catheter

Systems Review:
Cardiovascular and Pulmunary System
PR: 78 bpm, R radial artery, sidelying
BP: 100/70, R arm, sidelying

Musculoskeletal:
Gross ROM: impaired
ROM strength: impaired

Integumentary:
Continuity: unimpaired
Pliability: unimpaired
Color: Unimpaired
Healed pressure ulcer on the L distal fibula due to limited movements of a limb.

Cognition:
LOC: alert
 Judgement: unimpaired
Orientation: x3 (to time, person, place)

Communication: Pt. talks in an age appropriate manner

Affect: Pt. stops in the middle of her story and show signs of hesitations

Learning Style: Demonstration, verbal cues, visual cues

Learning Barrier: None

Educational Needs: Pt. needs to reminded in moving her LE on another position after 15-
20 mins.

Test and Measures:

Sensory:
L LE R LE
pinprick 1 1
Light touch 2 2

(note: pt only localizes the sensation felt esp. during deep sensory testing pinprick)

Reflexes:

MMT:

L R
C5 5 5
C6 5 5
C7 5 5
C8 5 5
T1 5 5
L4 3 3
L5 2 2
S1 3 3
Gross ROM:
ROM in the UE are all normal
ROM in the LE are normal except for hip flexion, knee flexion hip abduction and
Adduction, hip IR and ER
(note: Pt. is afraid and hesitant in moving limb LE)

MBT:
Area L R Difference
3.5 “ ↓ medial 10.5” 10.5” 0
femoral condyle

A:
PT impression: Incomplete SCI @ the level of lumbar

Dx: Paraplegia on both LE with AROM and AAROM on the ankles, LE and the
use of orthotic device after surgery. Practice Pattern 1°: Neuromuscular Practice Pattern
H: impaired motor function, Peripheral integrity and Sensory Integrity assoc. with non-
progressive disorders of the spinal cord. 2° Integumentary Practice Pattern A: Primary
Prevention/Risk Reduction for Integumentary Disorders.
Prognosis: Pt. has good rehab potential. Pt. is young and motivated.

Plan of Care
EO: Attain pt’s normal ROM on the LE in 4-6 mos after surgery
I: PROM of the LE while waiting for surgery and on the 1st 3 wks after
surgery
II: AAROM of the LE while for surgery and on the 4rth wk and for
1month
III: AROM and RROM of pt LE for 2 mos after surgery
IV: Improve pts posture and gait for 2mos of rehab after surgery.

Intervention Plan: Pt. will seen in rehab once/day:

Wait for the wounds to heal before performing hip and knee exercise
Use FES for 15-20 mins.
Use weights in performing AAROM/Arom exercises with 10 reps for
5 mins. PWB exercises for 10 reps in 10 mins in the parallel bars.