Spinal Cord Compression

1. Spinal Cord Compression

2. Marlyn Aguirre 52/M Married Unemployed, formerly a factory worker from Manila Roman Catholic Right-handed General Data

3. Left lower extremity weakness Chief Complaint

4. Patient was ambulatory, independent in all ADLs and apparently well until . . . 2 yrs PTA – (+) gradual heaviness & weakness of the L leg, noticed while standing up & walking. Pt loses control of her gait, sometimes causing her to kneel down. (-) hx of trauma, (-) assoc. numbnesss, (-) paresthesia, (-) pain, (-) loss of consciousness, (-) headache, (-) nausea , (-) vomiting, (-) blurring of vision, (-) diplopia, (-) tinnitus, (-) slurring of speech, (-) bowel & bladder incontinence. History of Present Illness

5. Sought consult c/o private MD in Malaysia. Assessment was unrecalled, prescibed with unrecalled medications including Calcium supplements which provided minimal relief. Pt still able to ambulate independently, still able to do all ADLs independently. Until . . . History of Present Illness

6. 1 yr PTA – Noted progression of weakness, same character. Pt had difficulty in ambulation. Sought consult c/o another MD in Malaysia. Assessment was also unrecalled, given unrecalled medication that was injected at the waist. (-) relief of symptoms. CT scan was done which revealed a spinal canal narrowing at L4-L5 level 20 to disc bulge & at L3-L4 20 to disc protrusion History of Present Illness

7. Pt eventually decided to come home. Sought consult @ Fatima Medical Center. Pt advised to undergo physical therapy x 2 months. Noted relief of symptoms after the program. Pt was again able to ambulate & perform all ADLS independently . Until . . . History of Present Illness

8. 8 months PTA – Pt experienced progressive weakness of her Left lower extremity. Pt was still able to ambulate & perform all ADLs independently. (-) noted bowel/bladder incontinence. History of Present Illness

9. 3 months PTA – Noted worsening of symtoms which now included numbness of her Left lower extremity. Pt consulted at St. Luke’s, lumbar MRI was done which showed unremarkable findings. Thoracic MRI was eventually done which showed a mass. A> Hemangioma. Pt was referred to NSS for evaluation. Pt was advised to undergo operation. History of Present Illness

10. Pt eventually decided to transfer to PGH due to financial constraints. This time, (+) beginning bowel incontinence, (-) urinary incontinence. 1 ½ months PTA – Pt was seen @ NSS-OPD. Pt was admitted on May 24, 2009. Laminectomy w/ Excision of Mass done May 28, 2009. after 4 days, pt was discharged well. However, after 1 day @ home, pt developed DOB. Pt was readmitted @ NSSCU. A> HAP. Pt was intubated & stayed for 15 days. History of Present Illness

11. July 3, 2009 – Pt was extubated & stabilized. Pt was transferred from NSSCU to Rehab ward for further management. History of Present Illness

12. (-) fever, (-) anorexia, (-) malaise, (-) weight loss (-) BOV, (-) diplopia, (-) tinnitus, (-) hearing changes (-) cough, (-) colds, (-) dyspnea , (-) hemoptysis (-) chest pain, (-) orthopnea, (-) PND, (-) easy fatigability, (-) palpitations (-) abdominal pain, (-) vomiting, (-) diarrhea, (-) constipation, (-) melena, (-) hematochezia, (-) ascites (-) dysuria, (-) nocturia, (-) hematuria, (-) oliguria, (-) frothy urine Review of Systems

13. (-) heat/cold intolerance, (-) diaphoresis, (-) fine tremors, (-) polyuria, (-) polydipsia, (-) polyphagia (-) paresthesia, (+) numbness (L lower ext), (+) weakness (L lower ext), (-) headache, (-) dysarthria, (-) dysphagia, (-) dysphonia, -) seizures, (-) dizziness (-) headache (-) loss of consciousness (-) insomnia (-) changes in sensorium (-) arthralgia, (-) myalgia (-) easy bruisability, (-) gum bleeding (-) jaundice, (-) edema, (-) palllor Review of Systems

14. (+) HPN (Dx in 2005, HBP 140/90, UBP 110-120/70-80 maintained on Normatin? 50 mg OD) (-) DM (-) PTB, (-) Bronchial Asthma, (-) CA (-) heart/liver/kidney disease (-) history of seizures (-) previous hospitalization s/p Laminectomy (5/28/09) (-) allergy to food and drugs Past Medical History

15. (+) DM – sister (-) CVD (-) HPN, PTB, bronchial asthma, CA (-) history of early cardiac death (-) liver disease (-) kidney disease (-) similar symptoms Family Medical History

16. Menarch @ 14 y/o LNMP = June 2009 RMI until Jan 2009 3-4 days duration 2-3 ppd, (-) dysmenorrhea G4 P4 (4004) All SVD c/o Midwife @ home & lying-in Clinic (-) Feto-Maternal Complications OB-Gyn History

17. (-) smoker (-) alcoholic bev. drinker (-) use of illegal drugs Unemployed, previously worked in a garments factory x 15 years Lives with family in 3-storey house made of concrete. 13 steps from the ground, 4 rooms in the 2nd floor Patient lives at the sala on the 1st floor Bathroom located on the 1st floor, 9 meters from sala Main door opens to a concrete pavement which can accommodate one wheelchair House is 50 meters away from main road Personal/Social History

18. Functional History

19. Functional History

20. Awake, conscious, coherent, NICRD BP 120/70, HR 96, RR 20, Temp 36.9oC Pink conjunctivae, anictericsclerae, (-) neck vein engorgement, (-) anterior neck mass, (-) cervical lymphadenopathy, (-) tonsillopharyngeal congestion Equal chest expansion, clear breath sounds,(-) rales, (-) wheezes (-) heaves, (-) thrills, distinct heart sounds, normal rate, regular rhythm, (-) murmurs, (-)S3, (-) S4, PMI at 5th ICS LMCL Physical Examination

21. Flabby, normoactive bowel sounds, (-) bruits, soft, nontender, (-) masses, (-) hepatosplenomegaly, (-) CVA tenderness Spine midline, (+) 5 x 1 cm hyperpigmented, flat surgical scar, midline @ Level T3-T4, (-) discharge, (-) swelling, (-) erythema Pink nailbeds, full and equal pulses, (-) cyanosis, (-) edema, (-) jaundice Physical Examination

22. Thigh Circumference Distance from patella R L 6 cm 34 cm 34 cm 8 cm 35.5 cm 34 cm 10 cm 36 34 cm Leg Circumference R L widest circumference 29 cm 27.5 cm Physical Examination

23. PULSES R L Popliteal ++ ++ Dorsalis Pedis ++ ++ Posterior Tibialis ++ ++ Physical Examination

24. Patient is awake, cooperative, conversant, and follows commands . GCS 15 (E4V5M6) Patient is oriented to person, place and time. He has pleasant mood and appropriate affect, good immediate, recent & remote memory, good calculation ability, good insight and good judgment. (-) right and left confusion, (-) hemineglect, (-) visual field cuts, (-) dysarthria (-) aphasia, (-) apraxia Neurologic Exam

25. Cranial Nerves I Grossly intact II Pupils 2-3mm EBRTL, (+) consensual reflexes III, IV, VI Full and equal EOMs V Intact sensation at V1, V2, V3 V, VIIBrisk corneal reflexes, OU VII(-) facial palsy VIII Intact gross hearing IX, X Intact gag reflex, uvula in midline XI Weak shoulder shrug on the L XII Tongue in midline Neurologic Exam

26. MOTOR Manual Muscle Testing Neurologic Exam

27. Manual Muscle Testing Neurologic Exam

28. Range of Motion

29. Range of Motion

30. Range of Motion

31. Range of Motion

32. DTRs: +2 R upper & lower extremities, +2 L upper & lower extremities, (+) Babinski, bilateral (-) clonus Neurologic Exam

33. Sensory Neurologic Exam

34. Sensory Neurologic Exam

35. Sensory Neurologic Exam

36. CEREBELLARS (-) dysmetria (-) dysdiadochokinesia, (-) nystagmus MENINGEALS (-) nuchal rigidity, (-) Kernig’s, (-) Brudzinski Neurologic Exam

37. Labs • 7/3 Hgb 133, Hct 0.425, Plt Ct 462, WBC 8.33 • 7/3 U/A yellow, clear, 1.015, pH 6.0, sugar (-), protein (-), RBC (-), WBC 0-1 • 7/3 BUN 1.54, Crea 50, Na 138, K 3.9

38. Present Working Impression • Spinal Cord Compression, Incomplete, ASIA C, Motor Level T8, Sensory Level T8, 20 to Hemangioma T5-T6 • s/p Laminectomy (5/28/09) • HPN St I, Good Control • t/c HHD in SR, NIF • Neurogenic bowel & bladder • HAP, resolved

39. Present Meds • Citicoline 500 mg/cap 2 caps Q6H • Amlodipine 5 mg/tab 1 tab OD • Omeprazole 40 mg/tab 1 tab OD @ HS • Paracetamol 500 mg/tab PRN for T > 37.8

40. Course in the Wards • 7/3 Admitted to Rehab Ward Bed 15, CBC, BUN, Crea, Na, K, urinalysis • 7/6 Pt started on physical therapy, on-going intermittent urinary catheterization Q6 • 7/14 Pt still on physical therapy, still w/ on-going intermittent urinary catheterization Q6