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Comprehensive Medical Case Analysis of a 51-Year-Old Female with Complex Health Issues

This case study details the medical history and examination of a 51-year-old married female from Mandaluyong City, who presents with a longstanding history of trauma and multifaceted health complications. The patient has experienced progressive lower extremity weakness, intermittent pain, weight loss, and previous diagnoses of hypertension and pulmonary tuberculosis. Findings from physical and neurological examinations, imaging studies, and management strategies are discussed to provide a holistic understanding of her medical condition and treatment approach.

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Comprehensive Medical Case Analysis of a 51-Year-Old Female with Complex Health Issues

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  1. Case of E.A.

  2. General Data • E.A. • 51/ F • Married • Right -handed • Mandaluyong City

  3. 1year PTA: • history of trauma, when she slipped while walking, hitting her lower back • no apparent difficulty in movement and ambulation, no contusions or open wounds • (-) loss of consciousness • No consult

  4. History of Present Illness 5 months PTA • (+) intermittent, cramping, segmental/band-like, non-radiating pain on the lower part of the costal margin • usual VAS of 1-2/10 and a worst VAS 4-5/10 • (+) weight loss of 20 lbs starting 4 months prior • consult with a private physician  impression of muscle strain • was given Celecoxib 200 mg/cap, 1 cap once a day, with slight relief of symptoms • No labs were done

  5. 4 months PTA • Persistence of similar symptoms • shifted to Meloxicam with slight relief of pain • Pt consulted in Mandaluyong Medical • CXR: homogeneous ovoid density Left parahilar area t/c TB, round pneumonia, or pulmonary mass; and Cardiomegaly • was given INH + Rifampicin + PZA + Ethambutol (Fixcom4)  took for 2 weeks

  6. 3 months PTA • (+) chest pain of same character  consult at PGH-Family Medicine • impression of PTB III, HPN Stage 2 uncontrolled • Medications: • Losartan+ HCTZ 50/12.5 1 tab once a day • Amlodipine10 mg 1 tab once a day • Meloxicam15 mg/tab 1 tab PRN • Vitamin B complex OD • Metoprolol50 mg/tab • was asked to continue the TB Medications and advised to follow-up.

  7. 2 months PTA • Pt was walking with her husband when she suddenly felt weakness of bilateral lower extremities which caused her inability to ambulate • (+)occasional paresthesiaand shooting pain passing through her legs • No bowel and bladder dysfunction • Pt consulted at UERMMC • Impression of Spinal Cord Compression prob 2extramedullary lesion r/o Potts T6 level • Pt transferred to PGH-Orthopedics with complaints of difficulty in ambulation and constipation

  8. 1 month PTA • (+) worsening of lower extremity weakness (with minimal movement) • CBC revealed normal AST, elevated ALT, elevated ESR • was advised to continue medication and was referred to Rehab for bracing • At Rehab-OPD • given Baclofen 10 mg/tab once a day • Pregabalin50 mg/tab at HS • Lactuloseat HS • was advised to follow-up after 2 weeks

  9. 2 weeks PTA • (+) worsening of lower extremity weakness • MRI done • MST of 0/5 for both lower extremities prompting admission

  10. Review of Systems • (-) fever • (+)weight loss • (-)anorexia • (-) headache • (-)dizziness • (-) seizure • (-)loss of consciousness • (-) cough, colds • (-)dyspnea • (-)hemoptysis • (-) orthopnea • (-) chest pain • (-) palpitations • (-) nausea • (-) vomiting • (-)abdominal pain • (-)diarrhea • (-) constipation • (-) hematochezia • (-) rashes • (-) easy bruisability

  11. Past Medical History • (+)HPN – diagnosed 2006 with HBP 200/100 and usual BP 180/100 and maintained on Amlodipine • (-)BA, PTB, DM, CVD, CA, previous surgeries

  12. Family Medical History • (+)HPN – mother • (+) BA- father and sister • (-) DM/PTB/cancer

  13. Personal and Social History • Pt is the 2nd child among 5 siblings • She is a secretarial graduate • previously working at the Quality control section of a garments factory • (-) vices

  14. Obstetrics-Gynecologic History • Pt is a G2P2 (1-1-0-1) • CS (1990-live birth and 1996-fetal demise due to Placenta Previa) • Menarche at 13 y/o • Menopause at 50 y/o.

  15. Physical Examination • General Survey: awake, conscious, coherent, cooperative, not in cardio-respiratory distress • Vital Signs: BP 130/80 mmHg HR 68 bpm RR 20 cpm T=35.9 C  38.0C • HEENT: pink conjunctivae, anicteric sclerae, (-) cervical lymphadenopathy, (-) tonsillopharyngeal congestion, (-) neck vein engorgement

  16. Chest and Lungs: symmetrical chest expansion, (-) use of accessory muscles, (-) retractions, clear breath sounds, (-) crackles/wheezes • Heart: adynamic precordium, distinct heart sounds, normal rate, regular rhythm, (-) heaves/thrills/murmurs

  17. Abdomen: firm and globular abdomen, normoactive bowel sounds, nontender, liver edge non-palpable, intact Traube’s space, (+) incision • Skin: good turgor, moist, (-) jaundice, (-) cyanosis, (-) pallor • Extremities: pink nailbeds, full and equal pulses, (-)edema, (-) cyanosis

  18. Mental Status Examination • Awake, conscious, coherent, oriented to 3 spheres, can communicate via gestures, can follow simple commands.

  19. Cranial Nerves • I- Intact • II- Pupils 2-3mm EBRTL, (-) visual field cuts • III, IV, VI- Full EOMs • V- Intact V1-V3, intact corneal reflex • VII- (-) facial asymmetry • VIII- Intact gross hearing • IX, X- Good phonation, gag and swallow • XI- Good shoulder shrug • XII- Tongue midline, (-) fasciculation, (-) atrophy

  20. Sensory Exam • C2-T5- 100% • T6-T8- 30% • T9-T12- 20% • L1-S3- 5%

  21. Motor Strength • C5-T1- 5/5 • L2-S1- 0/5 • No active motion on hips to toes, both right and left

  22. Normoreflexive • (+) Babinski bilateral, (+) clonus bilateral • Cerebellars: (-) nystagmus, dysdiadochokinesia, dysmetria • Meningeal Examination: (–) Brudzinski’s, (–) Kerning’s, (–) nuchal rigidity • Autonomics: (–) diaphoresis, (–) urinary incontinence, (–) bowel incontinence

  23. Pertinent Laboratory Findings • 6/22 • Albumin 29 • Alkaline Phosphatase 234 • Calcium 1.93 • 6/22 • FT4 22.2 • TSH IRMA 1.7

  24. 6/23 • E.coli 100,000 per ml urine • (-) polymorphonuclear cells • Gram (+) cocci • 6/25 • Fecalysis: rusty brown, soft, (-) RBC, (-) WBC

  25. Pertinent Diagnostic findings • X-ray: • Pulmo mass L hilum probably malignant with bone metastasis r/o PTB and Pott’s • MRI: • minimal/ no significant changes vertebral body • (+) spinal changes vertebral body • (+) iliopsoas mass T5-T8 • Cord changes

  26. Course in the ward 6/14/09 • Admission at Rehab Ward with plan to attain acceptable bowel and bladder function, ambulatory rehabilitation on gait retraining, lower extremity strengthening, and facilitation of ADL independence especially transfer • CBC, ESR, AST, and Urinalysis requested • Pt was started on INH + Rifampicin + Ethambutol (Fixcom3) 3 tabs 30 minutes to 1 hour before breakfast.; Metoprolol 50 mg/tab 1 tab BID • No bathroom privileges.

  27. 6/15 • Order postvoiding catheterization. • 3 consecutive postvoiding catheterization (550 to 50 cc; 350 to 40 cc; 300 to 40 cc). • Diet shifted to low salt, low fat, high fiber. Order for 12-Lead ECG. • Labs ordered for BUN, Crea, Na, K, Cl, Lipid profile, FBS, CXR-PA. • BP measured at 180/100 with verbal order for Captopril 25 mg/tab ½ tab now then PRN for BP > 170/90; Metoprolol 100 mg 1 tab/BID. BP monitoring from 180/100 to 170/100.

  28. 6/16 • Previous medication continue. • Pt started on Losartan 50 mg + HCTZ 12.5 mg 1 tab OD in am, and Pregabalin 50 mg/tab OD • Labs for ff-up

  29. 6/19 • Medications Pregabalin mg/tab 1 tab OD at HS, referred to Pulmo was advised to continue Pregabalin and Fixcom3, Lactulose 30mg. • Patient was advised to have • Sputum AFB smears x 3days • UTZ of whole abdomen • mammography • serum Ca, Albumin, TSH, FT4 and Alk Phos • agree with chest w/ IV contrast

  30. 6/19 • Seen by Ortho-Spine. • Advised to have repeat ESR, CRP and X-ray Cervical, TL/LS/APL. • Addendum: Bisacodyl tab 2 tabs before bedtime, Hold Senna concentrate

  31. 6/21 • increased OFI to 2L/day. • Senna concentrate 374mg/tab 1 tab OD; discontinue Bisacodyl • 6/23 • for bone scan • 6/29 • for whole body bone scan, change VS monitoring to q shift; repeat SGOT, with slight icteresia

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