Case of E.A.

General Data

•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 Illness5 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:

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

▫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

•2 weeks PTA •(+) worsening of lower extremity

weakness•MRI done•MST of 0/5 for both lower extremities

prompting admission

Review of Systems

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

Mental Status Examination

•Awake, conscious, coherent, oriented to 3 spheres, can communicate via gestures, can follow simple commands.

Cranial Nerves• 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

•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,

(–) Kerning’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:

▫minimal/ no significant changes vertebral body

▫(+) spinal changes vertebral body▫(+) iliopsoas mass T5-T8 ▫Cord changes

Course in the ward6/14/09 • 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 ▫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