LLAUDERES, XIELO 12/M CN 1180336

January 26, 2021 Med Form No. 002-10

PHILIPPINE ORTHOPEDIC CENTER

Ma. Clara cor. Banawe St., Quezon City
SURNAME AGE HOSPITAL NO.
L L A U D E R E S 1 2 1 1 8 0 3 3 6
GIVEN NAME SEX WARD/ RM.
X I E L O V ■ M □ F C W

HISTORY AND PHYSICAL EXAMINATION

Chief Complaint: Inability to move both lower extremities

History of Present Illness/Injury
Seven months prior to admission, the patient complained of weakness both lower extremities described as
bucking of both knees with the need to hold on to furniture while walking. No numbness, fever, history of trauma, cough,
weight loss, nor night sweats were noted at this time. Patient had no reported no bed wetting episodes or bowel habit
changes. He was modified independent as to locomotion, needing support when negotiating stairs and independent as to
all other aspects of daily living. No consult nor intervention was done.
Five months prior to admission, there was progression of the weakness of both lower extremities, now described
as inability to ambulate. There was associated numbness up to the hip area. Patient also noted that he had lost weight
approximately 3kg. The patient consulted in our institution and was referred to TB-DOTS where he was then started on
Anti-Koch’s medication at four tablets per day. He was also referred to Rehabilitation Medicine for fabrication of a
Knight-Taylor brace. No bladder and bowel changes were noted and he was modified dependent with minimal assistance
as to eating, grooming and upper garment dressing while modified dependent with maximal assistance for other self-care
activities of daily living, locomotion, and transfers.
During the interim, the patient noted steady improvements in motor strength eventually becoming ambulatory
without an assistive device and completely independent as to all activities of daily living. This was associated with
gradual loss of numbness of both lower extremities. The patient continued to be complaint with his TB-DOTS
medication.
On the day of consult, due to the availability of his spinal implants, the patient followed up at our institution for
scheduling of posterior decompression and spinal fusion. He was then admitted and subsequently referred to
Rehabilitation Medicine as 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
GU: ■No Complaints □Dysuria □Hematuria □Urinary Retention □Urinary frequency
□Incontinence □Flank pain □Urgency

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January 26, 2021 Med Form No. 002-10

Past Medical History:

■ Unremarkable □ 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:
■ Unremarkable □ CAD □ CVD □ MI □ Hypertension □ PAD □ Diabetes Mellitus □Malignant Hyperthermia □ Cancer

Immunization:
The patient’s grandmother claimed complete childhood immunization acquired from the local health center but
no official records were available at the time of admission.

Nutritional History:
The patient was purely breastfed until he was 7 months old, after which mixed feedings with breastmilk and
formula was started. Breastfeeding was done until he was 1 year old. Solid food was introduced at 7 months old. The
patient’s usual diet is heavy on vegetables and fish such as sinigang and nilagang isda. He has no reported food allergies

Developmental History:
The patient was noted to be at par with age. The patient was able to have head control at 3 months, crawl at 6
months, sit with support at 7 months, sit without support at 9 months, stand at 10 months, walk at 14 months, and run at 2
years old. The patient started to babble at 1 month, say mama and papa at 4 months, count at 1 year old, and identify
colors at 2 years old. The patient scribbled at 1 year old, draw shapes at 3 years old, and write his name at 4 years old.
The patient started to smile at 1 month, took off his clothes at 1 year old, put on his clothes at 2 years old, potty trained at
3 years old, and tied his shoe laces at 4 years old.

HEADSS

Home: The patient lives together with his grandmother in a two-bedroom two-storey house made of cement materials.
The bathroom which has a toilet with a flush is 6 meters from the bedroom. There is adequate ventilation in their house.
Water supply is supplied by commercial water service, while drinking water is distilled. Electricity is provided by
commercial electrical company
Education: The patient is a grade 6 student. Accordingly is a very active student at school and is able to do well
academically.
Activities: The patient is fond of using his phone to pass the time.
Drugs/Vices: The patient does not smoke, drink alcoholic beverages, or use illicit drugs.
Sex/Relationship: The patient is described to be friendly and active with a lot of friends in his school. The patient has no
romantic relationship at the moment.

Personal & Social History:

Smoking: ■No □Yes
Alcohol: ■No □Yes
Substance Abuse: ■ No □ Yes

The patient is a single, right-handed, Roman Catholic, Filipino, Grade 6 student. He lives in a two storey house,
built from cement, that is reportedly wheelchair accessible. The patient has Philhealth. His primary caregiver will be his
grandmother.

Functional History:
The patient was modified independent as to eating, grooming, upper and lower garment dressing, bathing,
toileting, transfers, and locomotion. Independent as to communication and social cognition.

Physical Examination:
General: Awake, alert, coherent, not in respiratory distress
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Anthropometrics:
Height 1.52 m (63.2% Weight: 44 kg (57.5% BMI: 19 kg/m2 (Normal)
percentile) percentile)
Vital Signs:
Blood Pressure: 100/70 mmHg Respiratory Rate: 19 cpm
Pulse Rate: 91 bpm Temperature: 36.6 oC

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 5th ICS LMCL
Gastro/abdomen: Normal Findings: soft, non-distended, normoactive bowel sounds, non-tender
abdomen, tympanitic, abdominal girth: 85 cm
No anal fissures, no skin tags, good sphincter tone, empty rectal vault, no
blood, with fecal material on examining finger;
Last BM: January 26, 2021
Genitourinary: Normal Findings: No hypogastric distention, absent suprapubic tenderness, no
urethral discharge
Neurological: Normal GCS:15 (E4, V5, M6)

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MMT Right Left

C5-T1 5 5
L2-S1 5 5
MIS = 100/100

SENSORY Right Left

C2-S3 2 2
S4-S5 2 2
SIS= 112/112
Muscle Tone: Normotonic muscle tone on bilateral upper extremities 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: Normoreflexive Left: Normoreflexive
Achilles reflex: Right: Normoreflexive Left: Normoreflexive
Sacral Reflexes: (+) BCR, (+) DAP, (+) VAC (+) PAS
Other Reflexes: (-) Babinski, bilateral; (-) Clonus, bilateral; (-) 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 left upper extremity actively done, pain-free
Full range of motion both lower extremities actively done, pain-free

Initial Impression/Diagnosis:
● Spinal Cord Injury, Incomplete, Sensory level L1 secondary to Pott’s Disease of T11, AIS-E

Dr. Cembrano / Senolos / Carpio / Tan / Jumawan / Barba / Rabara

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Primary SOAP:

S> No new subjective complaints

O>
General: Awake, alert, coherent, not in respiratory distress
Vital Signs:
Blood Pressure: 100/70 mmHg Respiratory Rate: 19 cpm
Pulse Rate: 91 bpm Temperature: 36.6 oC

MMT Right Left

C5-T1 5 5
L2-S1 5 5
MIS = 100/100

SENSORY Right Left

C2-S3 2 2
S4-S5 2 2
SIS= 112/112
Muscle Tone: Normotonic muscle tone on bilateral upper extremities 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: Normoreflexive Left: Normoreflexive
Achilles reflex: Right: Normoreflexive Left: Normoreflexive

Sacral Reflexes: (+) BCR, (+) DAP, (+) VAC (+) PAS
Other Reflexes: (-) Babinski, bilateral; (-) Clonus, bilateral; (-) 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 left upper extremity actively done, pain-free
Full range of motion both lower extremities actively done, pain-free
A>
● Spinal Cord Injury, Incomplete, Sensory level L1 secondary to Pott’s Disease of T11, AIS-E

P>
Goal Setting:
Short term goals:
1. Continuation of Anti-Koch’s medication
2. Surgical Intervention
Long term goals:
1. Independent bipedal ambulation

RADIOLOGICS:

Chest X-ray, Initial reading (Philippine Orthopedic Center, January 27, 2020)
AP View
 Heart is not enlarged
 No tracheal deviation
 Bony structures are unremarkable
 No blunting of costophrenic angle
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 Aorta is unremarkable

Thoracic X-ray APL, Initial read (Philippine Orthopedic Center, January 27, 2020)
AP View
 Decreased vertebral body height of T11 by 75%
 Decreased intervertebral disc space of T10 to T11
 Intact vertebral body height of all other vertebrae
 Intact interpedicular distances of all other vertebrae
 Intact intervertebral disc space of all other vertebrae
Lateral view
 Decreased vertebral body height of T11 by 75%
 Decreased intervertebral disc space of T10 to T11
 Kyphotic deformity noted at the level of T11
 Intact vertebral body height of all other vertebrae
 Intact interpedicular distances of all other vertebrae
 Intact intervertebral disc space of all other vertebrae

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