Spinal Cord Compression

GENERAL DATA

Marlyn Aguirre52/MMarriedUnemployed, formerly a factory workerfrom ManilaRoman CatholicRight-handed

CHIEF COMPLAINT

Left lower extremity weakness

HISTORY OF PRESENT ILLNESS

Patient was ambulatory, independent in all ADLs and apparently well until . . .2 yrs PTA – (+) gradual heaviness & weakness of the L leg, noticed while standing up & walking. Pt loses control of her gait, sometimes causing her to kneel down. (-) hx of trauma, (-) assoc. numbnesss, (-) paresthesia, (-) pain, (-) loss of consciousness, (-) headache, (-) nausea , (-) vomiting, (-) blurring of vision, (-) diplopia, (-) tinnitus, (-) slurring of speech, (-) bowel & bladder incontinence.

HISTORY OF PRESENT ILLNESS

Sought consult c/o private MD in Malaysia. Assessment was unrecalled, prescibed with unrecalled medications including Calcium supplements which provided minimal relief. Pt still able to ambulate independently, still able to do all ADLs independently. Until . . .

HISTORY OF PRESENT ILLNESS

1 yr PTA – Noted progression of weakness, same character. Pt had difficulty in ambulation. Sought consult c/o another MD in Malaysia. Assessment was also unrecalled, given unrecalled medication that was injected at the waist. (-) relief of symptoms. CT scan was done which revealed a spinal canal narrowing at L4-L5 level 20 to disc bulge & at L3-L4 20 to disc protrusion

HISTORY OF PRESENT ILLNESS

Pt eventually decided to come home. Sought consult @ Fatima Medical Center. Pt advised to undergo physical therapy x 2 months. Noted relief of symptoms after the program. Pt was again able to ambulate & perform all ADLS independently . Until . . .

HISTORY OF PRESENT ILLNESS

8 months PTA – Pt experienced progressive weakness of her Left lower extremity. Pt was still able to ambulate & perform all ADLs independently. (-) noted bowel/bladder incontinence.

HISTORY OF PRESENT ILLNESS

3 months PTA – Noted worsening of symtoms which now included numbness of her Left lower extremity. Pt consulted at St. Luke’s, lumbar MRI was done which showed unremarkable findings. Thoracic MRI was eventually done which showed a mass. A> Hemangioma. Pt was referred to NSS for evaluation. Pt was advised to undergo operation.

HISTORY OF PRESENT ILLNESS

Pt eventually decided to transfer to PGH due to financial constraints. This time, (+) beginning bowel incontinence, (-) urinary incontinence.1 ½ months PTA – Pt was seen @ NSS-OPD. Pt was admitted on May 24, 2009. Laminectomy w/ Excision of Mass done May 28, 2009. after 4 days, pt was discharged well. However, after 1 day @ home, pt developed DOB. Pt was readmitted @ NSSCU. A> HAP. Pt was intubated & stayed for 15 days.

HISTORY OF PRESENT ILLNESS

July 3, 2009 – Pt was extubated & stabilized. Pt was transferred from NSSCU to Rehab ward for further management.

REVIEW OF SYSTEMS

(-) fever, (-) anorexia, (-) malaise, (-) weight loss(-) BOV, (-) diplopia, (-) tinnitus, (-) hearing changes(-) cough, (-) colds, (-) dyspnea , (-) hemoptysis(-) chest pain, (-) orthopnea, (-) PND, (-) easy fatigability, (-) palpitations

(-) abdominal pain, (-) vomiting, (-) diarrhea, (-) constipation, (-) melena, (-) hematochezia, (-) ascites(-) dysuria, (-) nocturia, (-) hematuria, (-) oliguria, (-) frothy urine

REVIEW OF SYSTEMS

(-) heat/cold intolerance, (-) diaphoresis, (-) fine tremors, (-) polyuria, (-) polydipsia, (-) polyphagia

(-) paresthesia, (+) numbness (L lower ext), (+) weakness (L lower ext), (-) headache, (-) dysarthria, (-) dysphagia, (-) dysphonia, -) seizures, (-) dizziness (-) headache (-) loss of consciousness (-) insomnia (-) changes in sensorium(-) arthralgia, (-) myalgia(-) easy bruisability, (-) gum bleeding(-) jaundice, (-) edema, (-) palllor

PAST MEDICAL HISTORY

(+) HPN (Dx in 2005, HBP 140/90, UBP 110-120/70-80 maintained on Normatin? 50 mg OD)(-) DM(-) PTB, (-) Bronchial Asthma, (-) CA(-) heart/liver/kidney disease(-) history of seizures(-) previous hospitalizations/p Laminectomy (5/28/09)(-) allergy to food and drugs

FAMILY MEDICAL HISTORY

(+) DM – sister(-) CVD(-) HPN, PTB, bronchial asthma, CA(-) history of early cardiac death(-) liver disease(-) kidney disease(-) similar symptoms

OB-GYN HISTORY

Menarch @ 14 y/oLNMP = June 2009RMI until Jan 20093-4 days duration2-3 ppd, (-) dysmenorrheaG4 P4 (4004)All SVD c/o Midwife @ home & lying-in Clinic(-) Feto-Maternal Complications

PERSONAL/SOCIAL HISTORY

•(-) smoker•(-) alcoholic bev. drinker •(-) use of illegal drugs•Unemployed, previously worked in a garments factory x 15 years•Lives with family in 3-storey house made of concrete.

–13 steps from the ground, 4 rooms in the 2nd floor–Patient lives at the sala on the 1st floorBathroom located on the 1st floor, 9 meters from sala–Main door opens to a concrete pavement which can accommodate one wheelchair–House is 50 meters away from main road

FUNCTIONAL HISTORYPre-Morbid Post-Morbid

SELF-CAREA. Eating 7 7B. Grooming 7 7C. Bathing 7 7D. Dressing – Upper Body 7 7E. Dressing – Lower Body 7 7

F. Toileting 7 4SPHINCTER CONTROLG. Bladder Management 7 3H. Bowel Management 7 4TRANSFERSI. Bed, Chair, Wheelchair 7 7J. Toilet 7 7K. Tub, Shower 7 7

FUNCTIONAL HISTORYPre-Morbid Post-Morbid

LOCOMOTIONL. Walk/Wheelchair 7 6M. Stairs 7 6COMMUNICATIONN. Comprehension 7 7O. Expression 7 7

MOTOR SUB-TOTAL 105 93SOCIAL COGNITION

P. Social Interaction 7 7Q. Problem Solving 7 7R. Memory 7 7

COGNITIVE SUB-TOTAL 21 21TOTAL SCORE 126 114

PHYSICAL EXAMINATION

•Awake, conscious, coherent, NICRD•BP 120/70, HR 96, RR 20, Temp 36.9oC•Pink conjunctivae, anicteric sclerae, (-) neck vein engorgement, (-) anterior neck mass, (-) cervical lymphadenopathy, (-) tonsillopharyngeal congestion•Equal chest expansion, clear breath sounds,(-) rales, (-) wheezes•(-) heaves, (-) thrills, distinct heart sounds, normal rate, regular rhythm, (-) murmurs, (-)S3, (-) S4, PMI at 5th ICS LMCL

PHYSICAL EXAMINATION

•Flabby, normoactive bowel sounds, (-) bruits, soft, nontender, (-) masses, (-) hepatosplenomegaly, (-) CVA tenderness• Spine midline, (+) 5 x 1 cm hyperpigmented, flat surgical scar, midline @ Level T3-T4, (-) discharge, (-) swelling, (-) erythema•Pink nailbeds, full and equal pulses, (-) cyanosis, (-) edema, (-) jaundice

PHYSICAL EXAMINATION

Thigh Circumference

Distance from patella R L 6 cm 34 cm 34 cm 8 cm 35.5 cm 34 cm 10 cm 36 34 cm

Leg Circumference R L widest circumference 29 cm 27.5 cm

PHYSICAL EXAMINATION

PULSES

R L Popliteal ++ ++ Dorsalis Pedis ++ ++ Posterior Tibialis ++ ++

NEUROLOGIC EXAM

Patient is awake, cooperative, conversant, and follows commands . GCS 15 (E4V5M6)Patient is oriented to person, place and time. He has pleasant mood and appropriate affect, good immediate, recent & remote memory, good calculation ability, good insight and good judgment.(-) right and left confusion, (-) hemineglect, (-) visual field cuts, (-) dysarthria(-) aphasia, (-) apraxia

NEUROLOGIC EXAM

Cranial Nerves

•I Grossly intact•II Pupils 2-3mm EBRTL, (+) consensual reflexes•III, IV, VI Full and equal EOMs•V Intact sensation at V1, V2, V3•V, VII Brisk corneal reflexes, OU•VII (-) facial palsy•VIII Intact gross hearing•IX, X Intact gag reflex, uvula in midline

• XI Weak shoulder shrug on the L•XII Tongue in midline

NEUROLOGIC EXAM

MOTOR

Manual Muscle Testing

UPPER EXTREMITIES

MUSCLE R L

C5 Elbow flexors 5 5C6 Wrist extensors 5 5C7 Elbow extensors 5 5C8 Finger flexors 5 5T1 Small finger abductor 5 5

NEUROLOGIC EXAM

Manual Muscle Testing

LOWER EXTREMITIES

MUSCLE R L

L2 Hip flexors 5 3L3 Knee extensors 5 3L4 Ankle dorsiflexors 5 3L5 Long toe

extensors5 3

S1 Plantar flexor 5 3

RANGE OF MOTIONShoulder Normal Right Active Right

PassiveLeft Active Left Passive

Flexion 0-180 0-180 0-180 0-180 0-180

Extension 180-0 180-0 180-0 180-0 180-0

Abduction 0-180 0-180 0-180 0-180 0-180

Adduction 0-45 0-45 0-45 0-45 0-45

Internal rotation

0-90 0-90 0-90 0-90 0-90

External rotation

0-90 0-90 0-90 0-90 0-90

Elbow

Flexion 0-150 0-150 0-150 0-150 0-150

Extension 0-150 0-150 0-150 0-150 0-150

Pronation 0-90 0-90 0-90 0-90 0-90

Supination 0-90 0-90 0-90 0-90 0-90

RANGE OF MOTIONWrist Normal Right Active Right

PassiveLeft Active Left Passive

Flexion 0-90 0-90 0-90 0-90 0-90

Extension 0-80 0-80 0-80 0-80 0-80

Radial Deviation

0-20 0-20 0-20 0-20 0-20

Ulnar Deviation

0-30 0-30 0-30 0-30 0-30

MCPs

Flexion 0-90 0-90 0-90 0-90 0-90

Extension 0-40 0-40 0-40 0-40 0-40

Abduction 0-20 0-20 0-20 0-20 0-20

Adduction 20-0 20-0 20-0 20-0 20-0

RANGE OF MOTIONHip Normal Right Active Right

PassiveLeft Active Left Passive

Flexion–knee flexed

0-120 120 120 80 120

Flexion–knee extended

0-90 90 90 50 90

Extension– knee flexed

0-30 30 30 20 30

Extension–knee extended

0-40 40 30 20 40

Abduction 0-45 45 45 20 45

Adduction 0-30 30 30 15 30

Internal rotation

0-35 35 35 20 35

External rotation

0-45 45 45 25 45

RANGE OF MOTIONKnee Normal Right Active Right

PassiveLeft Active Left Passive

Flexion 0-135 0-135 0-135 0-135 0-135

Extension 0 0 0 0 0

Ankle

Dorsiflexion 0-20 0-20 0-20 0-20 0-20

Plantar flexion 0-50 0-50 0-50 0-50 0-50

Eversion 0-5 0-5 0-5 0-5 0-5

Inversion 0-5 0-5 0-5 0-5 0-5

MTPs

Flexion 0-40 0-40 0-40 0-40 0-40

Extension 0-70 0-70 0-70 0-70 0-70

Abduction 0-15 0-15 0-15 0-15 0-15

Adduction 0-10 0-10 0-10 0-10 0-10

NEUROLOGIC EXAM

DTRs: +2 R upper & lower extremities, +2 L upper & lower extremities, (+) Babinski, bilateral(-) clonus

NEUROLOGIC EXAM

Sensory

Level Pain Light Touch

R L R L

C2 100% 100% 100% 100%

C3 100% 100% 100% 100%

C4 100% 100% 100% 100%

C5 100% 100% 100% 100%

C6 100% 100% 100% 100%

C7 100% 100% 100% 100%

C8 100% 100% 100% 100%

T1 100% 100% 100% 100%

T2 100% 100% 100% 100%

T3 100% 100% 100% 100%

NEUROLOGIC EXAM

Sensory

Level Pain Light Touch

R L R L

T4 100% 100% 100% 100%

T5 100% 100% 100% 100%

T6 100% 100% 100% 100%

T7 100% 100% 100% 100%

T8 100% 100% 100% 100%

T9 100% 100% 100% 65%

T10 100% 65% 100% 70%

T11 100% 60% 100% 50%

T12 100% 80% 100% 90%

L1 100% 60& 100% 75%

NEUROLOGIC EXAM

Sensory

Level Pain Light Touch

R L R L

L2 100% 75% 100% 65%

L3 100& 60% 100% 90%

L4 100% 80% 100% 65%

L5 100% 65% 100% 65%

S1 100% 70% 100% 50%

S2 100% 60% 100% 75%

S3 100% 70% 100% 70%

NEUROLOGIC EXAM

CEREBELLARS(-) dysmetria (-) dysdiadochokinesia, (-) nystagmus

MENINGEALS(-) nuchal rigidity, (-) Kernig’s, (-) Brudzinski

Labs

• 7/3 Hgb 133, Hct 0.425, Plt Ct 462, WBC 8.33• 7/3 U/A yellow, clear, 1.015, pH 6.0, sugar (-), protein (-), RBC (-), WBC 0-1• 7/3 BUN 1.54, Crea 50, Na 138, K 3.9

Present Working Impression

• Spinal Cord Compression, Incomplete, ASIA C, Motor Level T8, Sensory Level T8, 20 to Hemangioma T5-T6

• s/p Laminectomy (5/28/09)• HPN St I, Good Control• t/c HHD in SR, NIF• Neurogenic bowel & bladder• HAP, resolved

Present Meds

• Citicoline 500 mg/cap 2 caps Q6H• Amlodipine 5 mg/tab 1 tab OD• Omeprazole 40 mg/tab 1 tab OD @ HS• Paracetamol 500 mg/tab PRN for T > 37.8

Course in the Wards

• 7/3 Admitted to Rehab Ward Bed 15, CBC, BUN, Crea, Na, K, urinalysis• 7/6 Pt started on physical therapy, on-going intermittent urinary catheterization Q6• 7/14 Pt still on physical therapy, still w/ on-going intermittent urinary catheterization Q6