Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with a C4 incomplete spinal cord injury following [Mechanism of Injury]. Patient reports [partial/preserved] sensation and motor function below the level of injury. Current status includes [e.g., diaphragm function preserved/impaired, upper extremity weakness, lower extremity paralysis]. No signs of autonomic dysreflexia or acute respiratory distress at this time.
Clinical Examination Findings
Neurological exam: Cranial nerves II-XII intact. Motor: C4 myotome shows [e.g., 3/5] strength; distal upper and lower extremities demonstrate [e.g., 0/5] strength. Sensory: Dermatomes C4 and above intact; patchy sensation noted below C4 level. Reflexes: Hyperreflexia noted in lower extremities with positive Babinski sign. Tone: Increased spasticity in lower extremities. Skin: Intact, no pressure ulcers noted.
Treatment Protocol
Plan: 1. Multidisciplinary rehabilitation (PT/OT) to maximize functional independence. 2. Respiratory monitoring and pulmonary hygiene. 3. Spasticity management with [e.g., Baclofen]. 4. Bowel and bladder management program. 5. DVT prophylaxis. 6. Regular skin integrity checks and pressure relief protocols.