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 Amlodipine 10 mg 1 tab once a day Meloxicam 15 mg/tab 1 tab PRN Vitamin B complex OD Metoprolol 50 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 paresthesia and 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 Pregabalin 50 mg/tab at HS Lactulose at 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 2 nd 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 Traubes space, (+) incision Skin: good turgor, moist, (-) jaundice, (-) cyanosis, (-) pallor Extremities: pink nailbeds, full and equal pulses, (-)edema, (-) cyanosis, (+) atrophy of disuse both extremities

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: (–) Brudzinskis, (–) Kernigs, (–) 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 Potts 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

32. Working Impression: Spinal Cord Compression Incomplete, ASIA B Prob. 2° to Potts Disease

33. Potts Disease most common site of bone infection in TB haematogenous spread of tuberculosis from other sites, often pulmonary, greater than 1 vertebra affected with disc involvement Progress slowly and may have systemic signs and symptoms of TB Abscess may compress on the cord neuro signs

34. Diagnostics AFB and culture of M. tuberculosis X-ray AP of Thoracic Spine Wedge-shaped/collapsed vertebra Fusiform shadows beside the spine/loss of psoas shadow in lumbar spine MRI Lateral View Extent of compression Bone elements visible within swelling/abscess

35. Management Non-operative Anti-TB drugs Spine immobilization Operative if there is spinal deformity or neurologic signs of SCC Prevent kyphosis progression Unacceptable complications such as paraplegia and deformities