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General Data

General Data. RB 25M From Camarines Norte Roman Catholic Married, with 1 child R handed. Chief Complaint. Inability to walk. History of Present Illness. 10 mos PTA, (+) intermittent pain on R medial arm, described as “ parang binabanat ang ugat ”,

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General Data

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  1. General Data RB 25M From CamarinesNorte Roman Catholic Married, with 1 child R handed

  2. Chief Complaint Inability to walk

  3. History of Present Illness 10mos PTA, (+) intermittent pain on R medial arm, described as “parangbinabanatangugat”, NPS 10/10, occurring 3x/wk, aggravated by exertion (e.g. reaching out or lifting an object) relieved by an unrecalled analgesic 0/10 (-) numbness, tingling, skin lesion, hx of trauma 2 wks after, (+) similar symptoms on L armand both scapular areas (-) consult

  4. History of Present Illness 9 mos PTA, (+) weakness of R LE(-) pain, numbness, tingling (+) abdominal tightness sensation(+) dyspnea (-) hx of trauma (+) consult at BHC, given vitamins and analgesic

  5. History of Present Illness Few days later, (+) weakness of R LE (+) admitted to LH; CXR, holoab UTZ, cranial CT scan and labs done were allegedly normal (+) discharged and prescribed with unrecalled meds but stopped due to allergy (rashes on both thighs)

  6. History of Present Illness 8 mos PTA, (+) inability to walk/stand; assisted on ADLs (+) urinary/bowel incontinence (+) bedsore (1 cm, sacral) (-) fever

  7. History of Present Illness 5 mos PTA, (+) consult at V. Luna A> t/c Decompression sickness P> recompression x 10 session However, pt opted to discontinue after the third session due to fear of dyspnea inside the vessel

  8. History of Present Illness (+) consult at PGH OPD Ortho A> Pott’s disease P> workup and follow-upx 2 mos

  9. History of Present Illness 3 mos PTA, (+) admitted at Spine Unit, started on anti-TB meds co-managed by Rehab 1 mo PTA, s/p anterior decompression, debridement, fusion(C6-T2) with fibular strut graft (7/18/12) Day of admission, (+) admitted for further therapy

  10. Past Medical History (-) HPN, DM, BA, CA, previous hosp (-) PTB/Primary Complex (?) drug allergy

  11. Family Medical History (+) HPN, father (+) BA, 5 siblings (+) DM, uncle (-) PTB

  12. Personal and Social History (-) smoking, alcohol intake, illicit drug use Breadwinner of the family Works as fisherman(diver) Married, with 1 daughter Finished 2nd yr HS No food preference

  13. Functional History Previously independent on ADL Previously works as a fisherman (diving, swimming)

  14. Environmental History Lives in a 1-storey concrete house Safe from falls

  15. Review of Systems (present)

  16. Physical Exam (present) General: awake, NICRD BP 110/60 HR 90 RR 18 T afebrile HEENT: AS, pink PC, (-) CLAD/NVE (+) surgical scar on L neck to anterior chest Chest/Lungs: DHS, (-) murmur/thrills/heaves ECE, clear BS (-) rales/wheeze/rhonchi Abdomen: Flat, normoactive BS, (-) masses/tenderness Skin/Extremities: FEP, pink NB, (-) edema/cyanosis/jaundice (+) sacral ulcer, healed

  17. Physical Exam (present) MMT: 5/5 on all extremities (-) sensory deficit (-) Babinski/clonus (-) dysdiadochokinesia

  18. Assessment (of RIC) Tetraplegia secondary to multiple compression deformity secondary to Pott’s disease (Asia D) Neurogenic bowel and bladder Multiple decubitus ulcer

  19. Initial Meds Given by RIC Multivitamins 500 mg/tab 1 tab OD Vitamin C 500 mg/tab 1 tab OD Pregabalin 150 mg/tab 1 tab BID Losartan 100 mg/tab 1 tab OD Lactulose 30 CC OD HS FeSO4 OD

  20. Initial Labs CBC (8/14/13) Hgb 105 Hct 0.317 WBC 5.9 Plt 408 N 0.55 L 0.3 M 0.05 E 0.09 B 0.01

  21. Initial Labs Blood chem (8/19/13) BUN 5 mmol/L Crea 95.5 ummol/L Alb 33 g/L ↓ Na 141 mmol/L K 3.3 mmol/L ↓ Cl 108 mmol/L ↓

  22. Initial Labs UA (8/14/13) Yellow/sightly hazy SG 1.015/pH 7.5 (-) CHON/CHON RBC 15-20 WBC innumerable Cast: hyaline 0-1 EC: occ Bacteria: 2+ MT: rare Crystal: amorphous phosphate, few

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