PID: 6174602
3/22/2026
SBAR: Kim Johnson
S: Kim Johnson is a 26-year-old female with paraplegia resulting from a complete thoracic spinal
cord injury. She was admitted to our facility this evening for continued care and rehabilitation.
B: The patient’s injury was sustained two weeks ago from a low-velocity gunshot wound to the
back at the T8 level during a work related-incident. The bullet impacted the spinal column;
notably, there was no associated injury to visceral organs.
A: The patient is currently alert and orientated to person, place, time, and situation. Vital signs
are stable with a respiratory rate of 18, heart rate of 78, blood pressure of 118/78, SpO2 of 96%,
and a temperature of 36.9℃. Upon assessment, the patient reported being pain-free. A sensory
exam revealed intact perception of pain and light touch throughout the upper extremities and
across the trunk above the T8 level, though the patient was unable to perceive pain in the lower
extremities. In the upper extremities, muscle tone remains normal; the patient is able to obey
motor commands and demonstrates equal bilateral grip strength rated 5/5. She successfully
resisted force with palms up and upper extremities extended, showing the ability to pronate and
supinate without drift. Conversely, the lower extremities exhibit decreased tone and flaccidity,
with a strength assessment revealing no volitional movement (rated 0/5) and an inability to raise
her legs or push against gentle pressure. Clinical education was provided regarding these
findings, emphasizing the necessity of maintain active range-of-motion exercises for the upper
extremities and passive range-of-motion exercises for the lower extremities.
R: Please continue to encourage the patient with her range-of-motion exercises. Additionally,
provide ongoing education regarding the roles of Physical and Occupational Therapy in her care
plan to help maximize her functional strength and future independence.