Client: Michael Marshall Referring MD: Dr. William P Hitchcock
DOB: 11/10/1970 Diagnosis: Central Cord Syndrome Incomplete Spinal Cord Injury Age: 45 years Address: 130 Rancho Santa Fe, Oceanside -92069
Date of Evaluation: November 20, 2015 Date of Onset: 42 years
REASON FOR REFERRAL:
Michael Marshall was referred to Occupational Therapy secondary to developing neurological, motor, and sensory deficits in the upper extremities upon being diagnosed with Central cord syndrome. He is undergoing physical therapy since a period of two years and has been referred to Occupational therapy for additional treatment. The purpose of this evaluation …show more content…
Michael Marshall's primary care physician is Dr. Ryan Dominguz and consulting Orthopedic Surgeon is Dr. William P Hitchcock. Mr. Michael Marshall served in combat in Iraq for 3 years before returning to San Diego, California, with sustained cervical cord Injuries. He survived a long fall that induced hyperextension injuries to his neck. Upon a comprehensive neurological examination by the doctor, three-dimensional MRI reports explicitly confirmed hematoma-mediated spinal cord impingement. Since then, Mr. Michael has received physical therapy at the outpatient clinic to preserve his Range of Motion (ROM) and for improvement of mobility skills pertaining to trunk balance and stabilization. While there has been some improvement in the range of motion, the patient is still unable to meet his activities of daily living (ADL) such as preparing food, transferring from a wheelchair, exercising, and dressing up, for which he has been referred to Occupational Therapy.
A. HISTORY DESCRIPTION OF CENTRAL CORD SYNDROME: Central Cord syndrome is an incomplete type of Spinal cord injury. It occurs when there is damage to the nerve fibers that bring messages from the brain to the body also known as the descending tracts. This can happen due to trauma, or any kind of injury to the central part of the cord that leads to a collection of signs and symptoms, and mostly all these appear together in no particular order. Mr. Michael contracted this post war.
B. SYMPTOM …show more content…
Michael is seen for an initial evaluation to obtain current level of function and to develop a treatment plan as required. Initial findings, according to the ASIA Motor Index and the Jebsen Hand Function Test, indicate Michael presents decreased upper extremities functioning and has decreased functioning in fine motor skills and fractionation. He is unable to meet his ADLs without help and is unable to perform his IADLs such as cooking and cutting vegetables. Michael uses wheelchair assistance for moving around and he will be able to independently meet his occupational needs with some additional adaptive equipment and gait