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    Binder 1

    Uploaded by

    marclyndoncafino

    Copyright:

    © All Rights Reserved
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    Binder 1

    Uploaded by

    marclyndoncafino
    2 views2 pages

    Original Title

    Binder1

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    © All Rights Reserved
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    2 views2 pages

    Binder 1

    Uploaded by

    marclyndoncafino

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
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    Trigger 1

    A case of a 38-year-old male, farmer, from Bayawan, Neg. Oriental presented to the ER due to 5-month
    history of upper back
    Trigger 2
    6 months prior to admission, patient complained of upper back associated with chest pain, dull in
    character, non-radiating with PS of 2-3/10, with no aggravating factor thus relieved by analgesics. No
    consult was done.
    Until 3 days PTA, onset of weakness and inability to move both lower limbs were noted. Upper back pain
    progressively worsening with PS of 10/10, making him difficulty to turn his neck. Pain was still relieved
    by analgesics which he routinely purchased. Patient also noticed pricking sensation in both lower limbs
    which he attributed to drug side effects. Morning PTA, patient was unable to stand without support and
    has difficulty walking. No history of trauma, chronic cough, fever or weight loss.
    Trigger 3
    No previous history of hospitalization and surgery
    No known FAD allergy
    Hypertension and DM are the only known heredofamilial disease
    Works as a farmer and a tobacco smoker for 8 years

    Trigger 4
    General Survery: awake, alert, unable to ambulate, not pale, afebrile,
    HEENT: AIS, PPC, no alar flaring, no cervical LAD
    C/L: ECE, CBS, no retractions
    CVS: AP, DHS with normal heart rate and rhythm
    Abd: soft, nontender, with no organomegaly
    Ext: CRT <2s, weakness of both lower limbs with MS of 2/5 with reduction of tone. Tenderness upon
    passive and active ROM of his back
    Neuro Exam: MSE: intact
    CN: intact
    Motor: 5/5 upper extremities
    2/5 lower exremities
    DTR: patellar and Achilles tendon 4+
    Babinski: positive on the left
    Sensory: pricking sensation on lower extremities, intact vibration and position senses
    TRIGGER 5
    Diagnostics
    CBC: Hgb 12g/dL
    WBC 6000
    Mantuox test: negative
    Serum electrolyte, Urea, and Creatinine as well as fasting blood glucose levels were within normal limits
    Thoracic Xray: normal dorsal curvature and vertebral alignment with vertebral bodies normal in height
    Posterior elements and disc spaces were also normal.
    CXR and abdominal UTZ : within normal limits
    MRI: lumbar and lower dorsal- NORMAL
    But signal abnormalities were noticed in upper thoracic vertebra and the examination extended superiorly
    to include the entire cervical spine. The cervical spine was straightened and showed destruction of C7 to T4
    vertebrae worse at T1 and T2 with retropulsion and spinal compression. An epidural collection hyperintense
    on T2W with peripheral contrast enhancement extending from C7 to T3 further compressed the cord causing
    signal changes and mild expansion at this level. There were extensive para-vertebral and pre-vertebral
    collections of similar signal characteristics elevating the anterior longitudinal ligament from C5 to T3 which
    extended into the apex of the chest on the right. A diagnosis of multiple contiguous vertebral destruction
    with extra-spinal and intra-spinal collections and spinal cord compression was made.

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