2 General DataE.A.51/ FMarriedRight -handedMandaluyong City
3 1year PTA:history of trauma, when she slipped while walking, hitting her lower backno apparent difficulty in movement and ambulation, no contusions or open wounds(-) loss of consciousnessNo consult
4 History of Present Illness 5 months PTA(+) intermittent, cramping, segmental/band-like, non-radiating pain on the lower part of the costal marginusual VAS of 1-2/10 and a worst VAS 4-5/10(+) weight loss of 20 lbs starting 4 months priorconsult with a private physician impression of muscle strainwas given Celecoxib 200 mg/cap, 1 cap once a day, with slight relief of symptomsNo labs were done
5 Persistence of similar symptoms 4 months PTAPersistence of similar symptomsshifted to Meloxicam with slight relief of painPt consulted in Mandaluyong MedicalCXR: homogeneous ovoid density Left parahilar area t/c TB, round pneumonia, or pulmonary mass; and Cardiomegalywas given INH + Rifampicin + PZA + Ethambutol (Fixcom4) took for 2 weeks
6 (+) chest pain of same character consult at PGH-Family Medicine 3 months PTA(+) chest pain of same character consult at PGH-Family Medicineimpression of PTB III, HPN Stage 2 uncontrolledMedications:Losartan + HCTZ 50/ tab once a dayAmlodipine 10 mg 1 tab once a dayMeloxicam 15 mg/tab 1 tab PRNVitamin B complex ODMetoprolol 50 mg/tabwas asked to continue the TB Medications and advised to follow-up.
7 (+)occasional paresthesia and shooting pain passing through her legs 2 months PTAPt 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 legsNo bowel and bladder dysfunctionPt consulted at UERMMCImpression of Spinal Cord Compression prob 2 extramedullary lesion r/o Potts T6 levelPt transferred to PGH-Orthopedics with complaints of difficulty in ambulation and constipation
8 (+) worsening of lower extremity weakness (with minimal movement) 1 month PTA(+) worsening of lower extremity weakness (with minimal movement)CBC revealed normal AST, elevated ALT, elevated ESRwas advised to continue medication and was referred to Rehab for bracingAt Rehab-OPDgiven Baclofen 10 mg/tab once a dayPregabalin 50 mg/tab at HSLactulose at HSwas advised to follow-up after 2 weeks
9 2 weeks PTA(+) worsening of lower extremity weaknessMRI doneMST of 0/5 for both lower extremities prompting admission
10 Review of Systems (-) fever (-) palpitations (+)weight loss (-) nausea (-)anorexia(-) vomiting(-) headache(-)abdominal pain(-)dizziness(-)diarrhea(-) seizure(-) constipation(-)loss of consciousness(-) hematochezia(-) cough, colds(-) rashes(-)dyspnea(-) easy bruisability(-)hemoptysis(-) orthopnea(-) chest pain
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 siblingsShe is a secretarial graduatepreviously working at the Quality control section of a garments factory(-) vices
14 Obstetrics-Gynecologic History Pt is a G2P2 ( )CS (1990-live birth and 1996-fetal demise due to Placenta Previa)Menarche at 13 y/oMenopause at 50 y/o.
15 Physical ExaminationGeneral Survey: awake, conscious, coherent, cooperative, not in cardio-respiratory distressVital Signs: BP 130/80 mmHg HR 68 bpm RR 20 cpm T=35.9 C 38.0CHEENT: 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/wheezesHeart: 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, (+) incisionSkin: good turgor, moist, (-) jaundice, (-) cyanosis, (-) pallorExtremities: 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 EOMsV- Intact V1-V3, intact corneal reflexVII- (-) facial asymmetryVIII- Intact gross hearingIX, X- Good phonation, gag and swallowXI- Good shoulder shrugXII- Tongue midline, (-) fasciculation, (-) atrophy
25 Pertinent Diagnostic findings X-ray:Pulmo mass L hilum probably malignant with bone metastasis r/o PTB and Pott’sMRI:minimal/ no significant changes vertebral body(+) spinal changes vertebral body(+) iliopsoas mass T5-T8Cord changes
26 Course in the ward6/14/09Admission 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 transferCBC, ESR, AST, and Urinalysis requestedPt was started on INH + Rifampicin + Ethambutol (Fixcom3) 3 tabs 30 minutes to 1 hour before breakfast.; Metoprolol 50 mg/tab 1 tab BIDNo bathroom privileges.
27 6/15Order 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 6/16Previous medication continue.Pt started on Losartan 50 mg + HCTZ 12.5 mg 1 tab OD in am, and Pregabalin 50 mg/tab ODLabs for ff-up
29 Patient was advised to have 6/19Medications Pregabalin mg/tab 1 tab OD at HS, referred to Pulmo was advised to continue Pregabalin and Fixcom3, Lactulose 30mg.Patient was advised to haveSputum AFB smears x 3daysUTZ of whole abdomenmammographyserum Ca, Albumin, TSH, FT4 and Alk Phosagree with chest w/ IV contrast
30 6/19Seen 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 6/23 6/29 increased OFI to 2L/day. Senna concentrate 374mg/tab 1 tab OD; discontinue Bisacodyl6/23for bone scan6/29for whole body bone scan, change VS monitoring to q shift; repeat SGOT, with slight icteresia