NEUROLOGY MINI-Grandrounds

PGI Batch 2010 – Group 526-July 2009

GENERAL DATA• D.C.• 32 year old• Female• Married• R handed• Filipino• Inglesia Ni Cristo• Housewife• Graduate• Cabalucan, Castillejos Zambales• Date of Admission: 19-June 2009

CHIEF COMPLAINT

Low Back Pain

History of Present Illness

• Jan 2009 – (+) low back pain – Lumbar area– non-radiating– 3/10 in severity– aggravated by lifting heavy objects– relieved by lying still.– No bowel/bladder incontinence

History of Present Illness

• Feb 2009 – pain radiating to both lower extremities

• Mar 2009 – progression of symptoms– 6/10 in severity(+) Consult – Dx: UTI / Ureterolithiasis

- given unrecalled antibiotics• June 17, 2009 – (+) severe low back pain– Accompanied by progressive difficulty in

ambulation

Past Medical History

(-) HPN(-) DM(-) PTB(-) CA(-) allergy(-) previous hospitalization(-) previous blood transfusion

Personal and Social History

• Occasional smoker• Occasional alcoholic beverage drinker• Denies illicit drug use• Mixed diet

Family History

(+) DM - grandparents(+) Cancer – mother (blood) brother (liver)(-) PTB(-) heart disease(-) allergy(-) asthma

Review of Systems

• No weight loss, night sweats• No dyspnea, orthopnea, PND, no easy fatigability• No palpitations, no chest pain• No nausea or vomiting, no abdominal pain, no

diarrhea or constipation• No dysuria, urgency, frequency, hesitancy• No diarrhea, no constipation• No tremors• No pallor, no easy fatigability

Physical Examination on Admission

• Conscious, coherent, not in cardiorespiratory distress• BP: 130/90 HR: 88,reg RR: 19 T. 36.8°C• Warm moist skin, no active dermatoses• Pink palpebral conjunctiva, anicteric sclera, no

nasoaural discharge, moist buccal mucosa, tonsils not enlarged, non hyperemic PPW,

• Supple neck, thyroid not enlarged, no palpable cervical lymph nodes, no carotid bruit

• Symmetrical chest expansion, no retractions, clear breath sounds

• Adynamic precordium, no heaves or thrills, AB 5th LICS MCL, S2> S1 at the base, S1 > S2 at the apex, no murmurs

• Breast: (-) masses, (-)discharge, (-)palpable lymph nodes, (-) skin changes

• Flabby abdomen, normoactive bowel sounds, soft, nontender, no masses palpated

• (+) paravertebral tenderness (L4-L5)• Pulses full and equal, no edema, no cyanosis

Neurologic Examination

• Awake, not oriented to time and place, follows commands, recent and remote memory not intact, can write and read, cannot count

• Pupils 2-3 mm ERTL, (+) direct and consensual light reflex; no visual field cuts

• Fundoscopy: (+) ROR (-) papilledema (-) hemorrhage• EOMs full and equal, no ptosis

• V1-V3 intact, can clench teeth• Able raise eyebrows, frown, close eyes tightly, able to puff cheeks• No lateralization on Weber’s; AC>BC on Rinnes• Uvula midline on phonation• Can shrug shoulders, rotate head against resistance • Tongue midline on protrusion• (-) atrophy, (-) spasticity , (-) rigidity, MMT 5/5 on both upper

extremities and 3-4/5 on lower extremities; • Can do APST, FTNT and heel to shin with ease• DTR’s ++ on all extremities• (-) Babinski• (-) nuchal rigidity (-) Brudzinski (-) Kernigs

Initial Assessment

• Is there a neurologic problem?• Where is the lesion?• What is the lesion?

Is there a neurologic problem?

• Focal Neurologic Deficits– Radicular pain, bilateral lower extremities

(sciatica)

Where is the lesion?

• Levelization: Nerve Root• Lateralization: Bilateral• Localization: L4-L5

What is the lesion?

• Onset: Chronic• Course: Progressive• Type: Focal• Etiology: Infectious vs Mass

Admitting Impression

•

Plans

• Diagnostic

Plans

• Therapeutic

DIAGNOSTIC WORK-UPS

AFB Stain

• 1st day: negative• 2nd day: negative• 3rd day:

X-ray StudiesChest Xray: June 17, 2009 Fibrosis, both upper lobes Incidentally, Dextroscoliosis, Thoracic Spine

Lumbosacral spine xray: June 24, 2009Apposing vertebral end plates of L4 and L5 are indistinctDisc space between L4 and L5 are obliteratedLumbar lordosis is maintainedDisc spaces are intact

Thoracic spine xray: June 22, 2009 Expansile and infiltrative lesion at the paravertebral region at the L4 and L5 level with extension to the anterior aspect of S1 vertebral bodies with multi septated abscess formation and bone changes, as described, consistent with Pott’s disease

Magnetic Resonance ImagingMRI Thoracic Spine: June 17, 2009 Posterior compression deformity, T9 vertebral body with discs changes as described. A beginning Pott’s disease is considered.

MRI Lumbar Spine: June 17, 2009 Expansile and infiltrative lesion at the paravertebral region at the L4 and L5 level with extension to the anterior aspect of S1 vertebral bodies with multi septated abscess formation and bone changes, as described, consistent with Pott’s disease

CBC18-June 2009

COMPLETE BLOOD COUNT RESULT REFERENCE RANGE

HGB 110 120-170 g/L

RBC 3.89 4.0-6.0 x10^12/L

HCT 0.33 0.37-0.54

Platelet 406 150-450 x10^9/L

WBC 5.7 4.5-10.0 x10^9/L

Differential Count

Neutrophils 0.84 0.50-0.70

Lymphocytes 0.16 0.20-0.40

ESR 0.00-0.07

Modified Westergren 59.0 0-20 mm after 1 hr

Blood Chemistry 18-June 2009

RESULT REFERENCE RANGE

Urea Nitrogen 16.0 9-23 mg/dL

Fasting Blood Sugar 128 70.9-110 mg/dL

Creatinine 0.58 0.5-1.2 mg/dL

SGOT – AST 18 U/L

HBA1C 6.01 4.8-6 %

Urinalysis 18-June 2009

ROUTINE RESULTColor Yellow Transparency Clear

Reaction 6.5Specific Gravity 1.010

Sugar ++++Protein Negative

Microscopic Pus cells 0-3/hpf RBC 10-15/hpf

Bacteria Few Epithelial cells Few

Surgical Pathology Report

July 11, 2009

Spinal Epidural mass, spine surgery: Chronic Granulomatous Inflammation with suppuration