NEUROLOGY MINI- Grandrounds

1. NEUROLOGY MINI-Grandrounds PGI Batch 2010 – Group 5 26-July 2009

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

3. CHIEF COMPLAINT Low Back Pain

4. 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

5. 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

6. Past Medical History (-) HPN (-) DM (-) PTB (-) CA (-) allergy (-) previous hospitalization (-) previous blood transfusion

7. Personal and Social History • Occasional smoker • Occasional alcoholic beverage drinker • Denies illicit drug use • Mixed diet

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

9. 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

10. 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

11. Adynamicprecordium, 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

12. 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

13. 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

14. Initial Assessment • Is there a neurologic problem? • Where is the lesion? • What is the lesion?

15. Is there a neurologic problem? • Focal Neurologic Deficits • Radicular pain, bilateral lower extremities (sciatica)

16. Where is the lesion? • Levelization: Nerve Root • Lateralization: Bilateral • Localization: L4-L5

17. What is the lesion? • Onset: Chronic • Course: Progressive • Type: Focal • Etiology: Infectious vs Mass

18. Admitting Impression

19. Plans • Diagnostic

20. Plans • Therapeutic

21. DIAGNOSTIC WORK-UPS

22. AFB Stain • 1st day: negative • 2nd day: negative • 3rd day:

25. CBC18-June 2009

26. Blood Chemistry18-June 2009

27. Urinalysis18-June 2009