Transcript Case of E.A.

Case of E.A.
General Data
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E.A.
51/ F
Married
Right -handed
Mandaluyong City
1year PTA:
• history of trauma, when she slipped while
walking, hitting her lower back
• no apparent difficulty in movement and
ambulation, no contusions or open wounds
• (-) loss of consciousness
• No consult
History of Present Illness
5 months PTA
• (+) intermittent, cramping, segmental/band-like,
non-radiating pain on the lower part of the costal
margin
• usual VAS of 1-2/10 and a worst VAS 4-5/10
• (+) weight loss of 20 lbs starting 4 months prior
• consult with a private physician  impression of
muscle strain
• was given Celecoxib 200 mg/cap, 1 cap once a day,
with slight relief of symptoms
• No labs were done
4 months PTA
• Persistence of similar symptoms
• shifted to Meloxicam with slight relief of pain
• Pt consulted in Mandaluyong Medical
▫ CXR: homogeneous ovoid density Left parahilar
area t/c TB, round pneumonia, or pulmonary
mass; and Cardiomegaly
▫ was given INH + Rifampicin + PZA + Ethambutol
(Fixcom4)  took for 2 weeks
3 months PTA
• (+) chest pain of same character  consult at
PGH-Family Medicine
▫ impression of PTB III, HPN Stage 2 uncontrolled
▫ Medications:
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Losartan + HCTZ 50/12.5 1 tab once a day
Amlodipine 10 mg 1 tab once a day
Meloxicam 15 mg/tab 1 tab PRN
Vitamin B complex OD
Metoprolol 50 mg/tab
• was asked to continue the TB Medications and
advised to follow-up.
2 months PTA
• Pt was walking with her husband when she suddenly
felt weakness of bilateral lower extremities which
caused her inability to ambulate
• (+)occasional paresthesia and shooting pain passing
through her legs
• No bowel and bladder dysfunction
• Pt consulted at UERMMC
▫ Impression of Spinal Cord Compression prob 2
extramedullary lesion r/o Potts T6 level
• Pt transferred to PGH-Orthopedics with complaints
of difficulty in ambulation and constipation
1 month PTA
• (+) worsening of lower extremity weakness
(with minimal movement)
▫ CBC revealed normal AST, elevated ALT, elevated
ESR
• was advised to continue medication and was
referred to Rehab for bracing
• At Rehab-OPD
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given Baclofen 10 mg/tab once a day
Pregabalin 50 mg/tab at HS
Lactulose at HS
was advised to follow-up after 2 weeks
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2 weeks PTA
(+) worsening of lower extremity weakness
MRI done
MST of 0/5 for both lower extremities
prompting admission
Review of Systems
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(-) fever
(+)weight loss
(-)anorexia
(-) headache
(-)dizziness
(-) seizure
(-)loss of consciousness
(-) cough, colds
(-)dyspnea
(-)hemoptysis
(-) orthopnea
(-) chest pain
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(-) palpitations
(-) nausea
(-) vomiting
(-)abdominal pain
(-)diarrhea
(-) constipation
(-) hematochezia
(-) rashes
(-) easy bruisability
Past Medical History
• (+)HPN – diagnosed 2006 with HBP 200/100
and usual BP 180/100 and maintained on
Amlodipine
• (-)BA, PTB, DM, CVD, CA, previous surgeries
Family Medical History
• (+)HPN – mother
• (+) BA- father and sister
• (-) DM/PTB/cancer
Personal and Social History
• Pt is the 2nd child among 5 siblings
• She is a secretarial graduate
• previously working at the Quality control section
of a garments factory
• (-) vices
Obstetrics-Gynecologic History
• Pt is a G2P2 (1-1-0-1)
• CS (1990-live birth and 1996-fetal demise due to
Placenta Previa)
• Menarche at 13 y/o
• Menopause at 50 y/o.
Physical Examination
• General Survey: awake, conscious, coherent,
cooperative, not in cardio-respiratory distress
• Vital Signs: BP 130/80 mmHg
HR 68 bpm
RR 20 cpm
T=35.9 C  38.0C
• HEENT: pink conjunctivae, anicteric sclerae, (-)
cervical lymphadenopathy, (-)
tonsillopharyngeal congestion, (-) neck vein
engorgement
• Chest and Lungs: symmetrical chest expansion,
(-) use of accessory muscles, (-) retractions, clear
breath sounds, (-) crackles/wheezes
• Heart: adynamic precordium, distinct heart
sounds, normal rate, regular rhythm, (-)
heaves/thrills/murmurs
• Abdomen: firm and globular abdomen,
normoactive bowel sounds, nontender, liver
edge non-palpable, intact Traube’s space, (+)
incision
• Skin: good turgor, moist, (-) jaundice, (-)
cyanosis, (-) pallor
• Extremities: pink nailbeds, full and equal pulses,
(-)edema, (-) cyanosis, (+) atrophy of disuse
both extremities
Mental Status Examination
• Awake, conscious, coherent, oriented to 3
spheres, can communicate via gestures, can
follow simple commands.
Cranial Nerves
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I- Intact
II- Pupils 2-3mm EBRTL, (-) visual field cuts
III, IV, VI- Full EOMs
V- Intact V1-V3, intact corneal reflex
VII- (-) facial asymmetry
VIII- Intact gross hearing
IX, X- Good phonation, gag and swallow
XI- Good shoulder shrug
XII- Tongue midline, (-) fasciculation, (-)
atrophy
Sensory Exam
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C2-T5- 100%
T6-T8- 30%
T9-T12- 20%
L1-S3- 5%
Motor Strength
• C5-T1- 5/5
• L2-S1- 0/5
• No active motion on hips to toes, both right and
left
• Normoreflexive
• (+) Babinski bilateral, (+) clonus bilateral
• Cerebellars: (-) nystagmus, dysdiadochokinesia,
dysmetria
• Meningeal Examination: (–) Brudzinski’s, (–)
Kernig’s, (–) nuchal rigidity
• Autonomics: (–) diaphoresis, (–) urinary
incontinence, (–) bowel incontinence
Pertinent Laboratory Findings
• 6/22
▫ Albumin 29
▫ Alkaline Phosphatase 234
▫ Calcium 1.93
• 6/22
▫ FT4 22.2
▫ TSH IRMA 1.7
• 6/23
▫ E.coli 100,000 per ml urine
▫ (-) polymorphonuclear cells
▫ Gram (+) cocci
• 6/25
▫ Fecalysis: rusty brown, soft, (-) RBC, (-) WBC
Pertinent Diagnostic findings
• X-ray:
▫ Pulmo mass L hilum probably malignant with
bone metastasis r/o PTB and Pott’s
• MRI:
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minimal/ no significant changes vertebral body
(+) spinal changes vertebral body
(+) iliopsoas mass T5-T8
Cord changes
Course in the ward
6/14/09
• Admission at Rehab Ward with plan to attain
acceptable bowel and bladder function, ambulatory
rehabilitation on gait retraining, lower extremity
strengthening, and facilitation of ADL independence
especially transfer
• CBC, ESR, AST, and Urinalysis requested
• Pt was started on INH + Rifampicin + Ethambutol
(Fixcom3) 3 tabs 30 minutes to 1 hour before
breakfast.; Metoprolol 50 mg/tab 1 tab BID
• No bathroom privileges.
6/15
• Order postvoiding catheterization.
• 3 consecutive postvoiding catheterization (550
to 50 cc; 350 to 40 cc; 300 to 40 cc).
• Diet shifted to low salt, low fat, high fiber. Order
for 12-Lead ECG.
• Labs ordered for BUN, Crea, Na, K, Cl, Lipid
profile, FBS, CXR-PA.
• BP measured at 180/100 with verbal order for
Captopril 25 mg/tab ½ tab now then PRN for
BP > 170/90; Metoprolol 100 mg 1 tab/BID. BP
monitoring from 180/100 to 170/100.
6/16
• Previous medication continue.
• Pt started on Losartan 50 mg + HCTZ 12.5 mg 1
tab OD in am, and Pregabalin 50 mg/tab OD
• Labs for ff-up
6/19
• Medications Pregabalin mg/tab 1 tab OD at HS,
referred to Pulmo was advised to continue
Pregabalin and Fixcom3, Lactulose 30mg.
• Patient was advised to have
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Sputum AFB smears x 3days
UTZ of whole abdomen
mammography
serum Ca, Albumin, TSH, FT4 and Alk Phos
agree with chest w/ IV contrast
6/19
• Seen by Ortho-Spine.
• Advised to have repeat ESR, CRP and X-ray
Cervical, TL/LS/APL.
• Addendum: Bisacodyl tab 2 tabs before bedtime,
Hold Senna concentrate
• 6/21
▫ increased OFI to 2L/day.
▫ Senna concentrate 374mg/tab 1 tab OD;
discontinue Bisacodyl
• 6/23
▫ for bone scan
• 6/29
▫ for whole body bone scan, change VS monitoring
to q shift; repeat SGOT, with slight icteresia
Working Impression:
• Spinal Cord Compression Incomplete, ASIA B
Prob. 2° to Pott’s Disease
Pott’s Disease
• most common site of bone infection in TB
• haematogenous spread of tuberculosis from
other sites, often pulmonary, greater than 1
vertebra affected with disc involvement
• Progress slowly and may have systemic signs
and symptoms of TB
• Abscess may compress on the cordneuro signs
Diagnostics
• AFB and culture of M. tuberculosis
• X-ray AP of Thoracic Spine
▫ Wedge-shaped/collapsed vertebra
▫ Fusiform shadows beside the spine/loss of psoas
shadow in lumbar spine
• MRI Lateral View
▫ Extent of compression
▫ Bone elements visible within swelling/abscess
Management
• Non-operative
▫ Anti-TB drugs
• Spine immobilization
• Operative
▫ if there is spinal deformity or neurologic signs of
SCC
▫ Prevent kyphosis progression
▫ Unacceptable complications such as paraplegia
and deformities