OSPITAL NG MAYNILA MEDICAL CENTER DEPARTMENT OF INTERNAL MEDICINE
Name: SANTOS, ROSITA Age/sex: 65/F Address: Tondo, Manila Date of Admission: June 29, 2007 Admitting Diagnosis: Spinal cord compression level T10-L1, prob Pott’s disease Residents-in-charge: Dr. delos Reyes-Gonzales/Dr. Filio/Dr. Indon Clerks-in-charge: Villanueva/Villarama/Ybañez CLINICAL ABSTRACT GENERAL DATA This is a case of a 65-year-old female from Tondo, Manila who came in due to inability to pass out urine.
Hospital Number: 1703704
HISTORY OF PRESENT ILLNESS: One month prior to admission, patient experienced lower back pain which occurred during movement and l ying down. There was no abdominal pain, no change in urine or bowel habits. No consult was done and no medications were taken. Two weeks prior to admission, there was persistence of lower back pain now associated with weakness and numbness of the lower extremities. There was no muscle or joint pain, no tremors, no seizures. Still no consult was done and no medications taken. Six days prior to admission, patient was unable to pass out urine and was still with weakness and numbness of the lower extre mities. There was no fever, no dysuria, no loss of consciousness, and no seizure. Consult was done with a private physician where patient was catheterized and given unrecalled medications which offered temporary relief. Patient was then sent home with request for MRI. Diagnosis unrecalled. Three days prior to admission, patient followed up with the same physician with MRI results. Patient was then advised to tra nsfer to our institution, hence consult.
PAST MEDICAL HISTORY: (+) hypertension of 10 years maintained on Nifedipine HBP: 150/90 UBP: 130/80 (-) DM (-) CVD (-) Bronchial asthma (-) PTB (-) allergies s/p craniotomy March 2007 due to TB granuloma FAMILY MEDICAL HISTORY: (-) heredofamilial diseases PERSONAL and SOCIAL HISTORY: Non-smoker, not an alcoholic beverage drinker REVIEW OF SYSTEMS: Constitutional: no fever, no weight loss, no chills, no loss of appetite Skin: no pallor, no rashes, no jaundice HEENT: no tinnitus, no diplopia, no blurring of vision, no epistaxis, no dysphagia, no hoarseness Respiratory: no cough, no difficulty of breathing Cardio: no chest pain, no palpitations, no PND, no orthopnea, no easy fatigability GIT: no changes in bowel movement, no melena, no hematochezia GUT: with urinary retention, no pain upon urination, no hematuria Endo: no polyuria, polydipsia, polyphagia, Hema: no easy bruisability, no poor wound healing, no gum bleeding Musculoskeletal: no weakness, no myalgia, no athralgia PHYSICAL EXAMINATION: Conscious, coherent, in respiratory distress Vital signs: BP: 120/80 mmHg HR: 81 beats / minute RR : 20 cycles / minute Temp: 36.7 º C (axillary) Skin: No jaundice, good skin turgor HEENT: anicteric sclera, pink palpebral conjunctiva, no naso-aural discharge, no cervical lymphadenopathy, no tonsillopharyngeal congestion, no mass, no neck vein engorgement Chest: Symmetric chest expansion, no lagging, no retractions, bibasal crackles th Heart: Adynamic precordium, PMI at 6 ICS LMCL, normal rate, regular rhythm, no murmurs Abdomen: flabby, normoactive bowel sounds, no tenderness, no mass Extremities: Grossly normal, no cyanosis, no jaundice, full and equal pulses Neuro: Patient oriented to three spheres CN I – Intact MOTOR SENSORY DTR (-) Babinski, CN II – Pupils equally reactive to light and accommodation 2-3mm (-) clonus CN III, IV, VI – EOM’s intact (-) nuchal rigidity CN V – (+) corneal reflex CN VII – No facial asymmetry CN VIII – intact CN IX, X – good gag CN XI – Good shoulder shrug CN XII – tongue at midline
ASSESSMENT: Spinal cord compression level T10-L1, prob Pott’s disease
Course in the wards: Patient was admitted into the Infirmary ward under the service of Dr. delos Reyes-Gonzales/Dr. Filio/Dr. Indon. Patient was hooked to plain NSS. Laboratory exams requested were: CBC, urinalysis, SGPT, SGOT, Na, K, Cl, CXR, BUN, Creatinine, ECG, RBS, FBS, cholesterol, TG , HDL, LDL, BUA. Medications given were Myrin P (Rifampicin, Isoniazid, Pyrazinamide, Ethambutol), Vitamin B complex, Paracetamol 300 mg/amp 1 ½ amp for fever, Tramadol 50 m g TIV for pain, Dexamethasone 4 mg TIV q6, Clonidine 75 mcg for BP ≥140/90, and Imidapril 10 mg OD. Foley catheter was inserted and urine output monitored. Patient’s vital signs were monitored hourly and patient was watched for progression of neuro deficit. On the first hospital day, patient had BP of 140/80, other vital signs stable. Repeat potassium, ABG’s serum Cl, repeat urinalysis, and urine Na, K, Cl were requested. Present management was continued. On the second hospital day, patient was febrile and still unable to move lower extremities. Medications were continue d. On the second hospital day, patient had BP 140/90, HR 88, RR 20. Temp 36.5. IV fluids were discontinued and shifted to heploc k. Imidapril was shifted to Candesartan 16mg + HCTZ 12.5 mg 1 tab OD. Ofloxacin 200 mg/tab OD was started. Other medications we re continued. On the third hospital day, patient had stable vital signs. Dexamethasone IV was shifted to oral 4mg tab q6. Patient was monit ored hourly for severe back pain, hypotension, dyspnea, and chest pain. Medications were continued. On the fourth hospital day, patient was still unable to move lower extremities. Gabapentin 100 mg TID was started. Referral to surgery for e valuation was done. Present management was continued and bedboard was applied to feet to avoid contractures. On the fifth hospital day, patient had stable vital signs. Present management was continued. On the sixth hospital day, repeat referral to surgery was done and patient was advised elective four-level laminectomy T10-L1.
Summary of Laboratory exams:
Complete Blood Count WBC RBC Hgb Hct MCV MCH MCHC Platelet Neutrophils Lymphocytes Monocytes Eosinophils Basophils Hypochromia: Urinalysis Color Transparency Epithelial Cells Mucus Threads Amorphus Urates Pus Cells Erythrocytes Cast Albumin Sugar Sp gravity pH Bacteria Urine Na Urine K Urine Cl June 29, 2007 Yellow Turbid Few Few Few 18-20 0-2 Neg Neg 1.010 7.0 many Jun 30, 2007 Yellow Turbid Occasional Few Many Many 9-11 Neg Neg 1.020 7.0 198.50 36.50 187.50 Normal Values June 29, 2007 4.8-10.8 x 109 /L 9.9 12 4.0-6.20 x 10 /L 3.2 12-16g/dl 9.9 37-47 % 29.2 80-90 fL 92.7 27-31 31.5 32-36 34 150-400 x 10^9/L 212 55-57 76.7 20-30% 15.6 0-7% 6 0-3% 1.7 0-1% 0 (+); Anisocytosis: (+++); Poikilocytosis (+); TG (-)
Blood Chemistry Normal Values BUN 2.5 - 7.10 mmol/L Creatinine 53 – 115 umol/L Uric acid Sodium 140-148 mmol/L Potassium 3.6 – 5.2 Chloride 100-108 mmol/L
6/29/07 5.56 110.52 133 2.88
Arterial Blood Gas 6/30/07 pH pCO2 pO2 HCO3 TCO2 BEb O2 Sat 7.493 31.70 85 24 25 1.9 97.20%
MRI Lumbosacral with contrast Findings: T12 vertebral body and posterior elements are diffusely abnormal in signal. Homogenously enhancing epidural soft tissue masses noted from T10-L1. It encases and compresses the cord but without gross hyperintense edema and/or myelomalacia. At these levels, it also extends asymmetrically to the neural foramina on the right. Minimal prevertebral component is also seen at T12. The adjacent discs are unremarkable. At L5-S1 and L4-L5 there is disc dessication. Incidental fatty filum. Impression: The above changes may be secondary to Pott’s disease with intraspinal extension and cord compression.