case of e.a.. general data e.a. 51/ f married right -handed mandaluyong city
TRANSCRIPT
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