Chief Complaint: 19-year-old man with broken back.
History: Allen Dexter, a 19-year-old college student, was rock climbing when he fell 30 feet to the ground. Paramedics arriving at the scene found him lying in the supine position, unable to move any extremities and complaining of neck pain. He was awake, alert, and oriented to his current location, the date and day of the week, and the details of his fall. His responses to questioning were appropriate. He complained that he could not feel his arms and legs. His pupils were equal and reactive to light. He showed no other signs of injury except for several scrapes on his arms. His vital signs revealed a blood pressure of 110 / 72, heart rate of 82 beats per minute, respirations of 18 per minute. The paramedics applied a cervical collar, placed him on a back board, immobilized his head, and transported him to the trauma center by helicopter.
Upon examination at the hospital, Allen had minimal biceps brachii stretch reflexes, but no triceps or wrist extensor reflexes. All other muscle stretch reflexes in the upper and lower extremities were absent. His perception of sensory stimuli ended bilaterally at an imaginary line drawn across his chest about 3 inches above the nipples (i.e. everything below felt numb). He had some sensation in his arms, but could not localize touch or describe texture with any consistency there. He was able to raise his shoulders and tighten his biceps brachii slightly in each arm, but could not raise either arm against gravity. His lower extremities were flaccid, despite attempts to move them.
X-rays taken upon arrival revealed a fractured vertebra at a particular location. A chest X-ray showed a decreased lung expansion upon inhalation. The neurosurgeons immobilized his neck by inserting tongs into the skull above the ears to hold his neck in a position so that no further injury could occur. A physical examination four days later revealed normal vital signs and no change in his arm strength or sensation, but also marked spasms and exaggerated stretch reflexes of the lower extremities. He also had urinary incontinence which required the placement of a Foley catheter connected to a urine collection bag.
Explain the above clinical assessment in a report comprehensible to an average 10-year old. Explain the normal/healthy function of the vertebral column and spinal cord, how the various tests (cognition, reflexes, sensations, voluntary actions) indicated which areas/functions were normal and which were not, why Allen needed a catheter and what his long-term outcome would be.
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One (or more) appropriate diagram/image should be included but remember to cite the source from which the image was obtained. Note: the labels and figure title will not count in the total word count, but if a figure description is included – it will count toward to overall word count.
*500 word count max
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