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Case of E.A.

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.

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Case of E.A.

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  1. Case of E.A.

  2. General Data • E.A. • 51/ F • Married • Right -handed • Mandaluyong City

  3. 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

  4. 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

  5. 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

  6. 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 • Amlodipine10 mg 1 tab once a day • Meloxicam15 mg/tab 1 tab PRN • Vitamin B complex OD • Metoprolol50 mg/tab • was asked to continue the TB Medications and advised to follow-up.

  7. 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 paresthesiaand 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

  8. 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 • Pregabalin50 mg/tab at HS • Lactuloseat HS • was advised to follow-up after 2 weeks

  9. 2 weeks PTA • (+) worsening of lower extremity weakness • MRI done • MST of 0/5 for both lower extremities prompting admission

  10. Review of Systems • (-) fever • (+)weight loss • (-)anorexia • (-) headache • (-)dizziness • (-) seizure • (-)loss of consciousness • (-) cough, colds • (-)dyspnea • (-)hemoptysis • (-) orthopnea • (-) chest pain • (-) palpitations • (-) nausea • (-) vomiting • (-)abdominal pain • (-)diarrhea • (-) constipation • (-) hematochezia • (-) rashes • (-) easy bruisability

  11. 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

  12. Family Medical History • (+)HPN – mother • (+) BA- father and sister • (-) DM/PTB/cancer

  13. 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

  14. 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.

  15. 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

  16. 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

  17. 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

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

  19. 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

  20. Sensory Exam • C2-T5- 100% • T6-T8- 30% • T9-T12- 20% • L1-S3- 5%

  21. Motor Strength • C5-T1- 5/5 • L2-S1- 0/5 • No active motion on hips to toes, both right and left

  22. Normoreflexive • (+) Babinski bilateral, (+) clonus bilateral • Cerebellars: (-) nystagmus, dysdiadochokinesia, dysmetria • Meningeal Examination: (–) Brudzinski’s, (–) Kerning’s, (–) nuchal rigidity • Autonomics: (–) diaphoresis, (–) urinary incontinence, (–) bowel incontinence

  23. Pertinent Laboratory Findings • 6/22 • Albumin 29 • Alkaline Phosphatase 234 • Calcium 1.93 • 6/22 • FT4 22.2 • TSH IRMA 1.7

  24. 6/23 • E.coli 100,000 per ml urine • (-) polymorphonuclear cells • Gram (+) cocci • 6/25 • Fecalysis: rusty brown, soft, (-) RBC, (-) WBC

  25. 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

  26. 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.

  27. 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.

  28. 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

  29. 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

  30. 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

  31. 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

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