RAMACULA, MARCELINO F.

61/M CN 1206587
June 14, 2021 Med Form No. 002-10

PHILIPPINE ORTHOPEDIC CENTER

Ma. Clara cor. Banawe St., Quezon City
SURNAME AGE HOSPITAL NO.
R AM A C U L A 6 1 1 2 0 6 5 8 7
GIVEN NAME SEX WARD/ RM.

M AR C E L I N O F ■ M □ F S W P R E O P

HISTORY AND PHYSICAL EXAMINATION

Chief Complaint: Weakness of both lower extremity

History of Present Illness/Injury:
Eight months prior to admission, the patient had a sudden onset of low back pain, dull in
character, intermittent, graded 4/10, non-radiating, aggravated by flexion of the spine and lifting
heavy objects, and relieved by rest. The pain is not relieved even during supine. This was not
accompanied by weakness, numbness, change in bowel or bladder habits, cough, fever, and weight
loss. The patient denies any trauma or fall. The patient self-medicated with Paracetamol 500mg/tab,
1 tablet every 6 hours as needed for pain which provided partial relief. He remained independent as
to all aspects of daily living.
Five months prior to admission, the patient reported persistence of pain of the same character
and severity but now accompanied with weakness of both lower extremities and numbness starting
from the anterior aspect of both knees downwards. He had difficulty of ambulation due to pain
described as taking more than reasonable time to cover short distances. No electric-like sensation or
changes in bowel or bladder habits were noted. The patient sought consultation with a local
physician who requested radiographs to be taken which revealed a compression deformity of L1. He
was referred to an orthopedic surgeon and was subsequently referred specifically to our institution
for a more specialized care. During this time, the patient was modified independent as to locomotion,
and was independent as to the remaining activities of daily living.
Three months prior to admission, he was seen by at the Spine Surgery Unit where an MRI
was requested which revealed a paraspinal mass at the thoracolumbar area with associated lytic
changes, pathologic compression fracture, and cord compression. Incidentally, the patient’s chest
radiograph showed hazy and reticular opacities on the right upper lung thus he was referred to TB-
DOTS. He was eventually started on anti-Koch’s regimen. During this time, the patient remained
functionally the same.
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Two months prior to admission, there was progression of the weakness of both lower
extremities, described as needing to hold objects for support, now associated with an electric-like
sensation on both of his feet. He was referred to the Rehabilitation Medicine Department for
conservative management of the pathologic fracture of the thoracolumbar vertebrae T12 and L1 and
was prescribed a Knight-Taylor brace and then underwent physical therapy. Range of motion
exercises of both hips, gentle passive stretching, strengthening exercises, postural re-education, and
proper body and back mechanics were taught as part of his physical therapy program which afforded
the patient partial relief of the pain. He was prescribed with Pregabalin 75mg/tab, 1 tablet twice a
day (1-0-1) and Methylcobalamin 500mcg/cap, 1 capsule three times a day. Upon follow-up with his
Orthopedic Surgeon, he was advised to undergo CT-guided fine needle aspiration biopsy, which
revealed negative for metastasis and tuberculosis. He was advised surgical management as definitive
treatment. During this time, the patient is modified independent as to transfers and locomotion and
needed minimal assistance as to toileting as well as lower body bathing and dressing, and completely
independent as to communication and social cognition.
Upon availability of logistics, the patient followed-up with the Spine Surgery Unit and was
admitted. He was then subsequently referred to the Rehabilitation Medicine department for co-
management.

Review of Systems:
CONSTITUTIONAL: ■ No Complaints □ Weight loss □ Night sweats □Fatigue □ Fever □ Chills
□ Other
EYES: ■ No Complaints □Visual Disturbance □Discharge □Itching □Pain □Redness
□ Photophobia □Other
ENT:
Ears: ■No Complaints □Pain □Bleeding □Drainage □Ringing □Hearing
Disturbances □Other
Nose: ■No Complaints □Bleeding □Congestion □Discharge □Other
Throat: ■No Complaints □Pain □Swelling □Voice Disturbance □Redness □Other
Mouth: ■No Complaints □Bleeding □Pain □Swelling Teeth □Other
RESPIRATORY: ■No Complaints □Cough □Hemoptysis □Wheeze □Pain with breathing
□Dyspnea on exertion / SOB / COPD
CARDIO: ■No Complaints □Chest pain □Left Arm pain □Diaphoresis □DOB
□Palpitations □Dizzy spells □Syncope / HTN / □ Poor Exercise Tolerance
□Other
GI: ■No Complaints □Abdominal pain □Nausea □Vomiting □Diarrhea □Melena
□Hematochezia
■Others: Last BM: June 14, 2021
GU: ■No Complaints □Dysuria □Hematuria □Urinary Retention □Urinary
frequency □Incontinence □Flank pain □Urgency

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Past Medical History:

■ Hyperuricemia (2021), maintained on Febuxostat 80mg, ½ tab OD ■ Dyslipidemia (2021),
maintained on Rosuvastatin 20mg, ½ tab OD □ Hypertension □ Stroke □ Pulmonary Tuberculosis □
Coronary artery disease □ High Cholesterol □ Peripheral Vascular Disease □ Bleeding Tendencies □
DVT/Clots □ Claudication □ COPD
□ Chronic Bronchitis / Asthma □ Other Lung Disease □ Recurrent Infections □ Leg Ulcers □
Osteoarthritis □ Osteoporosis □ Anemia □ Hepatic Disease Renal Disease □ Urolithiasis □
Cholelithiasis □ Reflux/Colitis/Diverticulitis □ Peptic Ulcers □ Upper GI Bleed □ Lower GI Bleed □
Depression □ Cancer

Surgical/Anesthetic/Drug History:
■ Unremarkable No allergies to medicines nor food. No previous surgeries

Family History:
■ Hypertension (Paternal) □ MI □ Diabetes Mellitus □ CAD □ CVD □ PAD □Malignant
Hyperthermia □ Cancer

Personal & Social History:

Smoking: □No ■Yes – 5 pack year smoking history
Alcohol: □No ■Yes – Social drinker
Substance Abuse: ■ No □ Yes

The patient is a married, right-handed, Filipino, Roman Catholic, who is now a retired
fisherman from Surigao. He is a high school undergraduate. He is the youngest among the five
broods of his parents. He has 2 children from his first wife and none from his current common law
partner. He lives with his common law partner and youngest daughter in a one-storey house built
from mixed materials. All the rooms are reportedly wheelchair accessible. The distance between his
bed and the bathroom is about 5 feet. The patient has Philhealth and the primary caregiver during his
stay will be his daughter.

Functional History:

The patient is independent as to eating, grooming, upper body bathing, upper body garmenting,
bowel and bladder management, communication, and social cognition. The patient is modified
independent as to transfers and locomotion. He is modified dependent needing minimal assistance as
to lower body bathing, lower body garmenting and toileting.

Physical Examination:
General: Conscious, Coherent, Not in Distress
Anthropometrics:
Height 1.62 m Weight: 61 kg BMI: 23.2 kg/m2 (Normal)

Vital Signs:
Blood Pressure: 120/70 mmHg Respiratory Rate: 22 cpm
Pulse Rate: 93 bpm Temperature: 36.5 oC

O2sat: 98% at room air

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Physical Examination:
SHEENT: Normal Findings: No masses, no rashes
Neck: Normal Findings: Trachea is midline. No anterior neck mass. No
cervical and no axillary lymphadenopathies, bilateral
Respiration Normal Equal chest expansion, no retraction, clear breath sounds, no
wheezes, I:E ratio of 1:2; good diaphragmatic strength,
functional cough, (-) Litten’s sign
Cardiovascular: Normal Findings: Adynamic precordium, normal rate, and regular
rhythm, no murmur, no carotid bruit, PMI and Apex beat at 5 th
ICS LMCL
Gastro/abdomen: Normal Findings: soft, non-distended, normoactive bowel sounds, non-
tender abdomen, tympanitic, abdominal girth: 90 cm
No anal fissures, no skin tags, good sphincter tone, empty rectal
vault, no blood, with fecal material on examining finger
Genitourinary: Normal Findings: No hypogastric distention, absent suprapubic
tenderness, no urethral discharge
Neurological: Normal GCS:15 (E4, V5, M6)

MMT Right Left

C5-T1 5 5
L2 2 2
L3 4 4
L4 2 2
L5 3 3
S1 4 4
MIS = 80/100

SENSORY Right Left

C2-L1 2 2
L2-S1 1 1
S2-S5 2 2
SIS= 102/112

Muscle Tone: Normotonic muscle tone on bilateral upper and lower extremities
Deep Tendon Reflexes:
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Biceps reflex: Right: Normoreflexive Left: Normoreflexive

Brachioradialis reflex: Right: Normoreflexive Left: Normoreflexive
Triceps reflex: Right: Normoreflexive Left: Normoreflexive
Patellar reflex: Right: Hyperreflexive Left: Hyperreflexive
Achilles reflex: Right: Hyperreflexive Left: Hyperreflexive

Sacral Reflexes: (+) BCR, (+) DAP, (+) VAC (+) PAS
Other Reflexes: (+) Babinski, bilateral; (+) Clonus, bilateral, fatigable; (-) Hoffman’s sign, bilateral

Musculoskeletal findings:
Inspection: (-) atrophy noted on all upper and lower major muscle groups
Spasticity: No noted spasticity
Limitation of Range of Motion:
Full range of motion of both upper extremity actively done, pain-free
Full range of motion both hips (within precautionary range), actively done, pain-free
Full range of motion both knees and ankles, actively done, pain-free

Initial Impression/Diagnosis:
● Spinal Cord Compression, incomplete, SL L1 secondary to Paraspinal Mass at T10 to L1
with lytic destruction of T11-L1 secondary to Metastatic Bone Disease vs Pott’s Disease,
AIS-C
● Pulmonary Tuberculosis, right upper lung

Drs. Espinosa / Dacanay / Bionat / Abello / Nacion / Cordova / Rabara

Primary SOAP:

S> CC: Weakness of both lower extremity

O>
Physical Examination:
General: Conscious, Coherent, Not in Distress
Anthropometrics:

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Height 1.62 m Weight: 61 kg BMI: 23.2 kg/m2 (Normal)

Vital Signs:
Blood Pressure: 120/70 mmHg Respiratory Rate: 22 cpm
Pulse Rate: 93 bpm Temperature: 36.5 oC

O2sat: 98% at room air

Physical Examination:
SHEENT: Normal Findings: No masses, no rashes
Neck: Normal Findings: Trachea is midline. No anterior neck mass. No
cervical and no axillary lymphadenopathies, bilateral
Respiration Normal Equal chest expansion, no retraction, clear breath sounds, no
wheezes, I:E ratio of 1:2; good diaphragmatic strength,
functional cough, (-) Litten’s sign
Cardiovascular: Normal Findings: Adynamic precordium, normal rate, and regular
rhythm, no murmur, no carotid bruit, PMI and Apex beat at 5 th
ICS LMCL
Gastro/abdomen: Normal Findings: soft, non-distended, normoactive bowel sounds, non-
tender abdomen, tympanitic, abdominal girth: 90 cm
No anal fissures, no skin tags, good sphincter tone, empty rectal
vault, no blood, with fecal material on examining finger
Genitourinary: Normal Findings: No hypogastric distention, absent suprapubic
tenderness, no urethral discharge
Neurological: Normal GCS:15 (E4, V5, M6)

MMT Right Left

C5-T1 5 5
L2 2 2
L3 4 4
L4 2 2
L5 3 3
S1 4 4
MIS = 80/100

SENSORY Right Left

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C2-L1 2 2
L2-S1 1 1
S2-S5 2 2
SIS= 102/112

Muscle Tone: Normotonic muscle tone on bilateral upper and lower extremities
Deep Tendon Reflexes:
Biceps reflex: Right: Normoreflexive Left: Normoreflexive
Brachioradialis reflex: Right: Normoreflexive Left: Normoreflexive
Triceps reflex: Right: Normoreflexive Left: Normoreflexive
Patellar reflex: Right: Hyperreflexive Left: Hyperreflexive
Achilles reflex: Right: Hyperreflexive Left: Hyperreflexive

Sacral Reflexes: (+) BCR, (+) DAP, (+) VAC (+) PAS
Other Reflexes: (+) Babinski, bilateral; (+) Clonus, bilateral, fatigable; (-) Hoffman’s sign, bilateral

Musculoskeletal findings:
Inspection: (-) atrophy noted on all upper and lower major muscle groups
Spasticity: No noted spasticity
Limitation of Range of Motion:
Full range of motion of both upper extremity actively done, pain-free
Full range of motion both hips (within precautionary range), actively done, pain-free
Full range of motion both knees and ankles, actively done, pain-free

A>
 Spinal Cord Compression, incomplete, SL L1 secondary to Paraspinal Mass at T10 to L1
with lytic destruction of T11-L1 secondary to Metastatic Bone Disease vs Pott’s Disease,
AIS-C
● Pulmonary Tuberculosis, right upper lung

P>
Goal Setting:
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Short term goals:

1. For posterior decompression and spinal fusion with instrumentation and rapid frozen
section (by Spine Surgery Unit)
2. Pain control
3. Stabilization of thoracolumbar spine
Long term goals:
1. Independent bipedal ambulation

RADIOLOGICS:

Plain MRI of the Thoracolumbar Spine (i.Scan, March 17, 2021)

● T10 to L1 paraspinal mass with lytic marrow changes at T11, T12 and L1 & T12 pathologic
compression fracture, with epidural mass component at T11-T12 causing cord compression
● Right psoas muscle mass likely abscess
● Above findings likely relate to Pott’s Disease. Recommend clinical correlation.
● Degenerative osseous changes in the thoracolumbar spine
● Degenerative disc disease and annular fissures at the lumbar level.
● Straightened spinal curvatures

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Pelvis AP/Lumbosacral Spine (Philippine Orthopedic Center, March 23, 2021)

● Suggestive lytic changes are seen at T11 and T12 vertebral bodies, best noted in lateral view
● Lumbar curvature is straightened with hypertrophic changes along the lumbar vertebral
bodies
● Lumbar spine is in the midline

Chest X-ray (Mediscan, March 24, 2021)

AP View
● A patch of reticulonodular opacities is seen in the right upper lung field associated with
superior traction of the hilar structures.
● Short, horizontally oriented linear opacities are noted in the left lower lung field.
● The heart is not enlarged.
● Trachea is midline
● Both hemidiaphragm and right costophrenic angles are intact
● The osseous structures and soft tissues are unremarkable

Impression: Findings suggestive of pulmonary tuberculosis with cicatricial changes.

Subsegmental atelectasis vs nonspecific pulmonary parenchymal fibrosis, left

CT-guided fine needle aspiration biopsy (NKTI, April 7, 2021)

● Negative for atypical cells
● MTB not detected

Chest X-ray (Philippine Orthopedic Center, June 7, 2021)

AP View
● Hazy and reticular opacities are seen in the right upper lung.
● Heart is not enlarged.
● Diaphragm, sulci are intact.

Impression: Right upper lung PTB. Suggest clinical and laboratory correlation.

Thoracolumbar Spine (Philippine Orthopedic Center, June 10, 2021)

● Severe anterior compression deformity is noted at the L1 vertebral body with adjacent soft
tissue density. Consider an infectious process such as Pott’s disease; cannot rule out
neoplastic process

Cervical X-ray, Initial Read (Dr Co, Philippine Orthopedic Center, June 14, 2021)
AP view
● Intact vertebral body height of all vertebrae
● Intact intervertebral disc space between all vertebrae
● Intact interpedicular distances between all vertebra

Lateral view
● Straightening of the cervical lordosis
● Intact vertebral body height of all vertebrae
● Intact intervertebral disc space between all vertebrae

Swimmers View

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● Straightening of cervical lordosis

● Intact vertebral body heights
● Intact intervertebral disc spaces

Open Mouth
● No noted fracture of odontoid process
● Intact atlantoaxial joint space

Thoracolumbar X-ray APL, Initial read (Dr. Co, Philippine Orthopedic Center, June 9, 2021)
AP View
·      Intact interpedicular distances
·      Decreased vertebral body height of L1 vertebrae by 75%
·      Decreased intervertebral disc space of T12-L1 by 50%

Lateral view
● Decreased vertebral body height of L1 vertebrae by 75%
● Decreased intervertebral disc space of T12-L1 by 50%
● Lytic destruction of the anterior portion of T12 vertebrae
● Decreased lucency of the inferior end plate of the T11 vertebrae
● Other vertebrae have intact vertebral body heights
● Other vertebrae have intact intervertebral disc spaces
● Other vertebrae have intact interpedicular distances

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