Reg 25[1].2.09
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SA SPINAL CORD INJURY SERVICE 26 February 2009 Dr Ngo 216 Hanson Road WOODVILLE GARDENS SA 5012 Dear Dr Ngo, RE:
KIM THIEN NGUYEN RAH URN: 842076 – DOB: 18.10.1948
I reviewed Mr Nguyen in the Spinal Injury Rehabilitation Outpatient Clinic on the 25th of February 2009. He was accompanied by an interpreter. Mr Nguyen is a 60 year old gentleman living alone. He has a spinal cord injury secondary to a spinal cord canal stenosis at C6, C7 level. His main issues at present are lower limb spasticity, loss of bladder control and poor mobility. Currently he is independent with mobilizing using manual wheelchair. He can walk up to 5 to 10 minutes but then has to stop because of pain and fatigue. He uses a frame. He gets carers twice a day for showering and cleaning and receives prepared meals. There are no issues with his nutrition. There were no skin breakdown reported. He moves his bowels daily with the help of aperients. He denies any symptoms of neuropathic pain. On occasions he feels bloated in his abdomen. From a liver point of view he has stable chronic liver disease with normal levels of ALT. He stopped drinking five years ago. He has an indwelling catheter which is changed every six weeks. The last change was done almost two weeks ago. He reports having sensations in his bladder. He can feel the catheter being tucked in and out. It has been discussed in the past to try another trial of voiding. Catheter, although, gives him no discomfort. He has had no urinary infections in last one year. On examination he had good strength in both upper and lower limbs. Tone was mildly increased without any catch or release and limbs had full range of movements. There was no clonus. He was hyperreflexic on knee jerks and the planters were down going. He took baclofen dose in the morning approximately five hours prior to examination. Again the sensory examination was normal. He is on sodium valproate 200mg twice a day, baclofen 10mg in the morning and 40mg at night. He uses Bisalax, Coloxyl and Senna for bowels and Karvea 300mg for his blood pressure. I have not increased or changed the baclofen doses. If the spasms continue to interrupt his sleep he might benefit from other anti-spasticity medication such as diazepam in lower doses at night time.
Again I have discussed different options of completely emptying the bladder. Obviously there have been plans for having another trial of void. The problems would be his hand function. He has arthritic changes in his hands with swan neck deformities of middle and ring finger on the right hand and essential tremors in both hands. This might complicate his ability to manage self catheterisation. Mr Nguyen is also not happy to go for this option. He is more interested in avoiding catheterisation completely. I have reiterated that any trial of void is best done in a controlled environment. I will discuss this further with Dr Marshall to see if getting him into the Spinal Unit will be an option. If a trial of void fails then Mr Nguyen will be happy to continue with the indwelling catheter or a suprapubic catheter. He understands that this is important for his kidneys to function properly. We will review him in 6 months time. By that time he would have the routine ultrasound of kidney and bladder performed. I noticed his renal functions done in January are in the normal range. Thank you once again for your ongoing care. Yours sincerely
Dr Farooqi Rehabilitation Registrar Spinal Injury & Orthopaedic, Amputee Rehabilitation Unit Nguyen, kim
KIM THIEN NGUYEN RAH URN: 842076 – DOB: 18.10.1948
I reviewed Mr Nguyen in the Spinal Injury Rehabilitation Outpatient Clinic on the 25th of February 2009. He was accompanied by an interpreter. Mr Nguyen is a 60 year old gentleman living alone. He has a spinal cord injury secondary to a spinal cord canal stenosis at C6, C7 level. His main issues at present are lower limb spasticity, loss of bladder control and poor mobility. Currently he is independent with mobilizing using manual wheelchair. He can walk up to 5 to 10 minutes but then has to stop because of pain and fatigue. He uses a frame. He gets carers twice a day for showering and cleaning and receives prepared meals. There are no issues with his nutrition. There were no skin breakdown reported. He moves his bowels daily with the help of aperients. He denies any symptoms of neuropathic pain. On occasions he feels bloated in his abdomen. From a liver point of view he has stable chronic liver disease with normal levels of ALT. He stopped drinking five years ago. He has an indwelling catheter which is changed every six weeks. The last change was done almost two weeks ago. He reports having sensations in his bladder. He can feel the catheter being tucked in and out. It has been discussed in the past to try another trial of voiding. Catheter, although, gives him no discomfort. He has had no urinary infections in last one year. On examination he had good strength in both upper and lower limbs. Tone was mildly increased without any catch or release and limbs had full range of movements. There was no clonus. He was hyperreflexic on knee jerks and the planters were down going. He took baclofen dose in the morning approximately five hours prior to examination. Again the sensory examination was normal. He is on sodium valproate 200mg twice a day, baclofen 10mg in the morning and 40mg at night. He uses Bisalax, Coloxyl and Senna for bowels and Karvea 300mg for his blood pressure. I have not increased or changed the baclofen doses. If the spasms continue to interrupt his sleep he might benefit from other anti-spasticity medication such as diazepam in lower doses at night time.
Again I have discussed different options of completely emptying the bladder. Obviously there have been plans for having another trial of void. The problems would be his hand function. He has arthritic changes in his hands with swan neck deformities of middle and ring finger on the right hand and essential tremors in both hands. This might complicate his ability to manage self catheterisation. Mr Nguyen is also not happy to go for this option. He is more interested in avoiding catheterisation completely. I have reiterated that any trial of void is best done in a controlled environment. I will discuss this further with Dr Marshall to see if getting him into the Spinal Unit will be an option. If a trial of void fails then Mr Nguyen will be happy to continue with the indwelling catheter or a suprapubic catheter. He understands that this is important for his kidneys to function properly. We will review him in 6 months time. By that time he would have the routine ultrasound of kidney and bladder performed. I noticed his renal functions done in January are in the normal range. Thank you once again for your ongoing care. Yours sincerely
Dr Farooqi Rehabilitation Registrar Spinal Injury & Orthopaedic, Amputee Rehabilitation Unit Nguyen, kim
