ABPMR Part II sample vignette: spinal cord injury, walked through domains A to E

This vignette was written for practice. It is not an ABPMR vignette and is not taken from any book or course. The autonomic dysreflexia steps follow the Paralyzed Veterans of America (Consortium for Spinal Cord Medicine) clinical practice guideline; your institution's protocols and your own judgment govern real patients.

"History first. I want the details of his surgery and any spinal precautions or bracing; whether he had other injuries, including a head injury; his respiratory course and current cough strength; any episodes of low blood pressure on sitting up, or of headache with high blood pressure; his current bladder and bowel management; skin problems so far; pain and spasms; and his DVT prophylaxis. Functionally, what he can do now: feeding, grooming, transfers, wheelchair use. And psychosocially: his mood and sleep, who is supporting him, his girlfriend's role, the apartment's access, his insurance, and what he hopes for.

On examination I would repeat the full ISNCSCI examination myself, including the sacral exam for voluntary anal contraction and deep anal pressure, because the classification guides prognosis and goals. I'd check his skin from head to heels, his range of motion, tone and spasticity, respiratory function, and orthostatic vital signs."

"A complete injury: no sensory or motor function preserved in the lowest sacral segments, S4 to S5."

"This is autonomic dysreflexia until proven otherwise. He has an injury above T6, and his systolic pressure is about 80 above his baseline (the guideline uses a rise of more than 20 in adults), with headache, flushing and sweating above the level of injury and a relative bradycardia. It is a medical emergency because of the risk of stroke and seizure.

The question is the trigger. The most common cause is the bladder: a kinked, blocked or misplaced catheter, or an overfull drainage bag. Next is the bowel: constipation or impaction. Then skin (a pressure injury, an ingrown toenail, tight clothing or straps), and less commonly other causes such as a fracture below the level of injury, heterotopic ossification, or an abdominal process he cannot feel. I'd also ask whether he has had any vasopressor such as midodrine, which can add to the rise."

"Immediately sit him up and lower his legs, loosen his clothing, abdominal binder and any compression stockings, and check his blood pressure and pulse every one to two minutes. Then look for the trigger, starting with the bladder. His catheter is indwelling, so I'd check the whole length for kinks, the bag for overfilling and the catheter's position. If there is no obvious problem and the pressure is still up, I'd irrigate gently with 10 to 15 mL of saline at body temperature, without pressing on his bladder, and if the catheter is blocked, replace it, with lidocaine jelly first.

His systolic is well above 150, so while we deal with the catheter the guideline advises considering a rapid-onset, short-acting antihypertensive: for example 2% nitroglycerin ointment on the chest or back, which can be wiped off once he improves, after I confirm he has not recently taken a phosphodiesterase-5 inhibitor. Alternatives the guideline lists include immediate-release nifedipine swallowed, not given sublingually, or captopril if nitrates cannot be used.

If the bladder is not the cause, I check the rectum for stool with lidocaine jelly, with his systolic brought below 150 first, and then the skin and other triggers. After it resolves, I monitor him for at least two hours for recurrence or hypotension, document the episode, and look at why it happened."

"Prevention and education. A reliable bladder program, which we will review with urology including whether intermittent catheterization is realistic with his hand function and help at home; a scheduled bowel program; regular skin checks and pressure relief. I'd teach him and his girlfriend to recognize dysreflexia and start the first steps themselves, and give him a wallet card and a home blood pressure cuff.

For his overall rehabilitation: DVT prophylaxis to continue per guideline; spasticity managed with stretching and positioning first; tenodesis training and splints; adaptive equipment for feeding and grooming; wheelchair skills; and a seating evaluation for the right wheelchair and cushion. I would also screen for depression and pain."

"The team: physical and occupational therapy, rehabilitation nursing for bladder, bowel and skin teaching, psychology, social work and case management, and urology follow-up. He'll need a seating and mobility evaluation, and the documentation to justify the wheelchair and cushion to his insurer; durable medical equipment such as a tub bench and a hospital bed with a pressure-relieving mattress if needed; and a decision about home. A second-floor apartment without an elevator is not accessible, so social work should start on housing options or an interim plan now, not at discharge. Caregiver training for his girlfriend, and personal care assistance if she cannot or should not provide all of it.

After discharge: outpatient therapy, regular follow-up with a spinal cord injury program, vocational rehabilitation to look at return to work or retraining, peer mentoring, and driving evaluation when appropriate."

"I'll be straight with you, because you deserve that. Your injury is what we call complete, which means right now no signals are getting through below the level of the injury. With a complete injury at four weeks, most people do not regain the ability to walk. I wish I had different news. I also don't want that to be the only thing you hear today. You can move your shoulders, bend your elbows and lift your wrists, and that matters a lot: we'll work on using your wrists to grip, feeding yourself, getting around in a wheelchair, and getting back to as much of your life as we can, including work. We'll keep examining you, and if anything changes we'll tell you. What's on your mind most right now?"

"I'm glad you're looking for every option; that shows how much you care about him. Clinical trials are a reasonable thing to ask about, and I'm happy to help you look at legitimate ones registered on ClinicalTrials.gov and talk through whether he might qualify. I'd be cautious about clinics that charge for unproven treatments. Whatever you decide about trials, therapy now doesn't close any doors, and it's what gives him the most independence. Can we look at them together this week?"