InternDirected by Resident Dr. Directed by Attending Dr.

Patient InformationChart No.21301445NameOAge57 years oldGender: Male: Admission Date: 2009/10/02Chief Compliant:Difficulty of walking since one month before admission

Present illness on AdmissionLower back pain with both legs soreness , weakness since one year before admission. could not stand/bend/rest and intermittent claudication , lower legs weakness and nubness were noticed in recent one more monthHe went to Hospital for help , where lumbar spinal x ray showed spondylosis

2009/09/07 L-S Lat. View Degenerative spine disease with spur formation

2009/09/07 MRI of L-S spine

Spondylosis and mild scoliosis. posterior central disc protrusion Bulging discs Schmorl's nodes

General DataAdmission Date: 2009/10/02Transfer Date: 2009/10/22Hospitalization Days: 38 DaysPremorbid Functional status: wellPremorbid ADL: independent

Personal HistoryDiabetes Mellitus for 20 years - Under Novomix Chronic kidney disease, stage V, post renal transplantation on 2008/02/17HTN + for 4 yearsNo Smoking, Alcohol or Betel nutDrug Hx: No NSAID or Chinese herbAllergy: No Known Allergy

Pre-OP ConditionComa Scale: E 4 V 5 M 6 Muscle power:

PLANTAR FLEXION GRADE 4 ;DORSIFLEXION GRADE 3Deep tendon reflex:

Sensation: IntactANS: Urine- normal Stool- constipationGait: normal2+2+2+2+2+2+2+2+5555554433

Nerve decompression on 10/2Coma Scale: E 4 V 5 M 6 Muscle power:

Muscle power: right left Ankel dorsiflexion 0 2Plantar flexion 2 3

Deep tendon reflex:

Sensation: IntactANS: Urine- normal Stool- constipationGait: normal2+2+2+2+2+2+2+2+5552353220

2009/10/03 MRI of L-SpinePost-laminectomy at L2-3-4 with soft tissue swelling

2009/10/05 MRI of L-SpineA 2.1 x 0.6x 4.1cm seroma in posterior epidural space at L2-3 level cause effacement of the underlying thecal sac

Major Diagnosis L2-4 spinal stenosis post laminectomy on 2009/10/02Bilateral lower limbs weakness was noted after laminectomy, a 2.1 x 0.6 x 4.1cm seroma in posterior epidural space at L2-3 level was noted

Assessment10/08 NS WardMuscle power: R L L2 2 3 L3 1 2 L4 2 3 L5 2 3 S1 3 4ASIA Impairment Scale: C

After rehabilitation(11/10)Muscle power: R L L2 3 3 L3 3 3 L4 3 3 L5 3 3 S1 4 4Hip flexorsKnee extensorsAnkle DFEHLAnkle PF

Assessment10/08 NS WardFunctional status Rolling/ sitting: poorStanding/Ambulation: unableANS: BladderOn FoleyANS: BowelConstipationAfter rehabilitation(11/10)Functional status Rolling / sitting: fair Standing: poor Ambulation: unableANS: BladderOn FoleyANS: BowelContinence

Barthel index 40()10:() .,. ()5: , ()5: ,, ()5: ,()0: ()5: , (, ()0: ()5: , ()5: ,()()0:

Rehabilitation goalShort Term Trunk control and balance reaction Long Term ADL as independent as possible

Rehabilitation PlanPhysical Therapy:: bridge, SLR/: all four*10mins*2, creeping*2*2Occupational therapy:Balance trainingMoving trainingKT1-KT2 trainingL/E function training

Present medicationCyclosporin 100mg/cap 1PC BIDMycophenolate mofetil 250mg 3PC BID Calcitriol 0.25mcg/cap 1PC QDBio-cal 1PC QOD (Tricalcium phos.802mg+vit.D 3 1.56mcg) Prosultiamine 50mg+Vit B2 1PC TIDNovoMix (14U,30U,30U)

Present medicationNifedipine ex.release 30mg 1PC QDBisoprolol hemifumarate 5mg1PC QN Furosemide 40mg/tab 1PC QDFludiazepam 0.25mg/tab 1PC BIHSCiprofloxacin HCl 250mg Q12H

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