Rehab Ward RADIOLOGIC EVALUATION CBC

RICAMARA, MARCO BLADDER: BOWEL:

22/M (+) PH Scout Film Abdomen (01/21/21) DATE Hgb Hct RBC MCV MCH WBC Neut Lym Mono Eos Baso Plt CRP ESR Blood On CIC q6h 2-3 days with
CN: 1190819 140- 0.37- 4.0-6.0 82- 28-32 4.8- 0.40- 0.19- 0.03- 0.00- 0-0.02 150- <0.6 <20 Type occ. Aid of
ADD: Antipolo - Ileus 180 0.57 92 10.8 0.74 0.48 0.09 0.07 450 mg/dl mm/h suppositories
r
DOA: 10/3/2020 - Fecal Stasis
SSU DIC: Dr. MARANION BED MOB Independent
AO DIC: Dr. J. PABER Chest X-ray AP, Initial read 10/3 80 0.24 3.10 76 26 20.09 0.91 0.05 004 0 0 329 >13.0 119 B+
CC: Non-healing wound, sacral (Philippine Orthopedic Center,
10/4 76 0.23 TRANSFER Modified
area October 3, 2020)
Independent
Occupation: Unemployed ● Trachea in midline
● Lung fields are clear 10/5 79 0.23
Admitting Diagnosis: ● Heart not enlarged SITTING TOL 30-40 mins
SCI, incomplete, SL T5, WORA, ● Both costophrenic sulci 10/6 98 0.29 3.58 81 27 34 13.69 0.11 0.06 0 0 412
probably secondary to IDEM, AIS- are intact SITTING BA good to normal
B 10.8 96 0.27 11.18
Unstageable Pressure Injury, Chest X-ray AP, Initial read STANDING TOL NA
Sacral Area; t/c Heterotrophic (Philippine Orthopedic Center, 11/24 65 0.20 2.48 80 26 13.47 0.85 0.09 0.06 0 0 364 6.98 >130
Ossification, Left Greater 01/19/21) STANDING BAL NA
Trochanter -compared previous examination 12/02 67 0.21 2.53 6.87 0.78 0.17 0.05 0 0 278 >13 100
last 11/26/20, shows no active
Present Diagnosis: parenchymal infiltrates seen 12/7 63 0.2 2.36 83 27 7.31 0.75 0.16 0.09 0 0 348 3.48 74
Brace Knight Taylor
SCC, incomplete, SL T5, - Heart is not enlarged Brace with
secondary to Compression - diaphragm and costophrenic Cervical
12/9 80 0.24 2.86 84 28 8.34 0.76 0.16 0.08 0 0 371
Deformity of T3 Vertebra, probably sulci are intact Extension at
secondary to Pott’s Disease, AIS-B bedside
12/13 83 0.26 3.04 86 27 8.25 0.72 0.18 0.09 0 0 408 >13 100

Heterotropic Ossification, Left Cervical X-ray, AP, Initial read 12/22 88 0.28 3.27 85 27 14.46 0.83 0.10 0.06 0.00 0.01 503 >13 82
Wheelchair NA
Greater Trochanter (Philippine Orthopedic Center,
October 3, 2020) 12/28 67 0.21 2.46 85 27 7.63 0.77 0.13 0.10 0.00 0.00 317 10.40 77
Septic Arthritis, Right Hip ● Cervical vertebrae are in Mobilizing with Knight-Taylor Brace with
normal alignment 12/30 76 0.23 2.72 84 28 7.89 0.71 0.18 0.11 0.00 0.00 296 >13.0 79 Cervical Extension
Admitting/Present MMT: ● Intact vertebral body Mobilization date: since Feb 08, 2021
heights DIET: High Protein, High Fiber, Low Fat,
01/03 77 0.24 2.81 86 27 7.56 0.74 0.16 0.08 0.02 0.00 428 7.09 91
Right Left ● Intact interpedicular Low Cholesterol
distances
1/06 91 0.29 3.28 87 28 7.86 0.73 0.18 0.05 0.03 0.01 417
C5-T1 5 5 ● Intact intervertebral disc Problem Lists:
spaces 1. Grade IV Pressure Injury - Healing
1/12 101 0.31 3.48 90 29 8.10 0.70 0.21 0.06 0.02 0.01 327 10.2 121
● No cortical breaks noted 2. Pott’s Disease
L2-S1 0 0
3. Scrotal Swelling
1/17 106 0.32 3.58 89 30 6.23 0.66 0.22 0.08 0.03 0.01 317
Cervical X-ray, Lateral, Initial 4. Weakness of Both Lower Extremities
MIS = 50/100 read (Philippine Orthopedic 5. Spasticity
Center, October 3, 2020) 1/27 103 0.32 3.57 90 29 6.21 0.57 0.28 0.07 0.08 0.00 386 1.51 94
6. Neurogenic Bladder
● Intact vertebral body 7. Neurogenic Bowel
Admitting / Present Sensory: heights 2/08 122 0.37 4.17 88 29 5.92 0.66 0.25 0.05 0.03 0.01 373 7.32 126
● Intact intervertebral disc PT: (Mobilizing with Knight Taylor Brace with
spaces 2/14 119 0.35 4.00 87 34 8.05 0.68 0.22 0.06 0.03 0.01 321 >13.0 119 Cervical Extension)
Right Left
● No cortical breaks noted 1. ES to B Quads, TA’s, Peroneals
● There is straightening of 3/01 129 0.39 4.45 89 29 8.31 0.61 0.26 0.06 0.06 0.01 278 5.75 91 2. PROMES to B Hips, Knees, Ankles
C2-T5 2 2
the cervical spine 3. GPS of B Hamstrings and Heelcords
4. PRES of B UE Major Muscle Groups
T6-S3 1 1 Thoracolumbar X-ray APL, 5. AROMES to B shoulders, elbows, wrists,
Initial read (Philippine DATE UIBC T. Fe binding Iron(Ferene) PROTHROMBIN TIME INR % APTT CLOTTING BLEEDING MCP’s, IPJ’s
S4-S5 1 1 Orthopedic Center, October 3, (Ferene) capacity (64.81- 11-15 seconds activit 22-45 seconds TIME TIME 6. Core activation exercises
2020) (69.28- (250.30-400.04 174.87) y 5-15 mins 1-7 mins 7. Transition skills: Supin-side lying-long
AP View 240.24) ug/dl)
SIS: 80/112 sitting-short sitting
● Intact vertebral body 8. Sitting Balance and Tolerance
heights 9. Mat Exercises as Tolerated
● Intact intervertebral disc 10/3 16 1.2 76 43.6 6 1 10. Transfer Skills: Bed-Wheelchair
spaces 11. Basic Wheelchair propulsion techniques
Normotonic (B) UE; Hypertonic (B)
● No cortical breaks noted 12/18 99.45 111.40 11.96 12. Pressure relief techniques
LE;
Intact interpedicular
(+) BCR, PAS (-) DAP, VAC
distances OT: (Mobilizing with Knight Taylor Brace with
(+) Babinski, B; (+) Clonus, B
● Distended bowel loops BLOOD CHEM Cervical Extension)
- Table top activities to improve trunk control
2x2x0.5cm Grade 4 sacral pressure Lateral View - for ADL retraining, grooming, eating,
injury with well-defined pink borders, ● No cortical breaks noted DATE HBA1C FBS BUN CREA CHOLES TRIGLY HDL LDL VLDL SGOT SGPT ALP SLDH garment dressing
and pink wound bed with 75% ● Intact interpedicular (4.8-5.9)

granulation, 25% slough formation, no distances To Psych/Soc/Voc: (Bed level)

tunneling no undermining, no ● No degenerative changes 4.1-5.9 2.1- 71-115 <5.17 <1.69 >1.5 0- 0-0.77 17-59 <50 <270 <248 Activities to allay anxiety
discharge seen 7.1 5 2.85
Medications:
1. Vitamin C 500mg/tab 1 tab TID
Lumbosacral X-ray, APL, Initial 10/5 5.50 4.36 50.24 2.71 1.79 0.23 1.67 0.81 28.27 25.66 275.2 138 2. Zinc tab OD
read (Philippine Orthopedic 3. Vitamin B complex/tab, 1 tab OD
Center, October 3, 2020) 10/22 238.2 184.50 4. Baclofen 10mg/tab TID (3-2-3)
AP View 3 5. HR 5 tabs ODAC
● Intact vertebral body 6. Sambong Forte tab, TID
heights
10/30 45.43 286.4 166.42
● Intact intervertebral
discs
● Intact interpedicular 11/4 7.50 4.13 48.14 3.66 1.10 0.67 2.49 0.5 14.13 14.5
distances
11/10 5.66
Lateral View
● No cortical breaks noted 11/25 2.54 40.02
● Intact interpedicular
distances 12/16 6.35 2.37 35.53 2.81 1.08 0.44 1.88 0.49 23.08 24.27
● No degenerative changes
seen
1/12 6.16 3.54 48.76 5.22 1.51 1.06 3.47 0.69 14.02 8.55
Pelvic X-ray AP, Initial read
(Philippine Orthopedic Center, 1/25 39.2
October 3, 2020)
● Intact hip joints
● Intact sacroiliac joints
● No fracture in visualized SERUM ELECTROLYTES. ETC
osseous fields
● There is a suspicious DATE Na K Cl Total Ca iCa T Protein Albumin Globulin A/G
osseous formation over 135-145 3.5-5.5 98-108 2.10-2.55 63-82 35-50 28-32 Ratio
the superior portion of the 1.5-3.1
greater trochanter, left
10/3 141.4 4.18 103.3
Both Knee X-ray (11/17/20)
- Osteochondroma, right proximal 10/5 131.4 97.4 64.55 21.57 42.98 0.5
tibia
- visualized bones are parotic 10/14 140.4 4.21 100.6
- Joint spaces are narrowed on
both sides 10/22 2.25 1.29

ULTRASOUND OF THE 10/30 29.81

KIDNEYS AND URINARY
BLADDER (1/14/21) 11/4 138.60 4.75 98.20 80.04 30.12 49.92 0.6
- Left Renal Cyst
- Unremarkable study of the right
kidney, urinary bladder and 11/24 129.2 3.61 94.6
prostate gland
11/27 133.60
12 LEAD ECG (12/23/2020),
POC 12/02 133.50 3.47 98.20
- Sinus Tachycardia
- Non-specific ST-Twave 12/7 132 3.95 100.9
changes
12/16 67.59 19.66 47.93 0.41
CT Scan Guided Biopsy
Paravertebral Mass T2, Left
1/03 140.10 2.96 103.00
(12/10/2020)
● Benign Skeletal Muscle,
Adipose Tissues, Blood 1/07 143.70 4.44 23.68

CT Scan Guided Biopsy 1/12 140.9 3.62 106.2 1.39 77.11 31.6 45.51 0.69
Paravertebral Mass T2, Left
(12/3/2020) 1/20 133.30 3.53 99.20
- t/c pott’s diease vs. neoplastic
process
URINALYSIS
MRI of the Thoracolumbar
Spine (11/1/2020)
DATE COLOR pH TRANSPARENCY SP. GRAV GLUC CHON RBC PUS EPITH BACT
● Compression Deformity, T3
Vertebral Body, Cortical 10/3 Y <5.5 HAZY >1.025 - - 0-2 2-5 2-5 FEW
Irregularities, Marrow Edema
● Paravertebral Mass, T3 11/02 Y 6.5 S. TURBID 1.025 - + +++ 50-100 FEW
extending to the anterior
epidural space, indenting to 11/13 Y 6.5 CLEAR 1.025 - + 2-5 0-2 FEW
the anterior epidural space ,
 anterior thecal sac, spinal 12/07 Y 7 S. TURBID >1.025 - + >50 10-25 0-2 2+
cord narrowing and
compression 1/04 Y 7.5 S. TURBID >1.025 - - 50-100 >100 0-2 3+
● Marrow Edema, T8 and T10
extending to the right pedicle
1/19 Dark Y. <5.5 Turbid >1.025 - + >100 >100 2-5 2+
and adjacent rib of T8; t/c
Pott’s Disease
● Multilevel Schmorl’s Nodes 2/12 Amber <5.5 Turbid >1.025 - ++ 25-50 >100 3+

MRI of the Pelvis (12/23/2020) 2/14 Dark Y. 6.0 Turbid 1.025 - ++ 0-2 >100 3+

● Findings consistent with 2/28 Dark Y. <5.5 Turbid >1.025 - - 25-50 >100 3+
Septic Arthritis of the right
hip with moderate joint 3/11 Dark Y. 5.5 Turbid >1.025 - Trace 25-50 10-25 1+
effusion with synovitis,
osteomyelitis, and eorisve
changes, further described
above. Abnormal signal /
GS/CS
osteomyelitis involving the
body of the left ilium and
left anterior acetabulum DATE SPECIMEN GS/CS Antibiotic susceptibility
● Accompanying moderate
to large soft tissue 10/03 Wound E. Coli Ceftriaxone – sensitive
abscesses in the right hip Gentamycin – Intermediate
and right proximal thigh, Resistant – Ampicillin
left anterior thigh
compartment and a 11/03 URINE KLEBSIELLA PNEUMONIAE Gentamycin, Amoxicillin/Clavulanic Acid – Sensitive
smaller one in the left Ampicillin – Resistant
posterior sacral region
11/30 WOUND MRSA Erythromycin, Clindamycin, TMP-SMX – sensitive
● Mild abnormal signal
oxacillin – Resistant
involving the left sacroiliac
joint 12/01 BLOOD MRSA Erythromycin, Clindamycin, TMP-SMX – sensitive
● Extensive myositis oxacillin – Resistant
diffusely involving the 12/05 BLOOD MRSA Erythromycin, Clindamycin, TMP/SMX – Sensitive
muscles of the proximal Oxacillin – Resistant
thighs and hips bilaterally, 12/07 URINE KLEBSIELLA PNEUMONIAE Gentamycin, Co-Amox, PipTaz – Sensitive
involving the iliopsoas and Ampicillin, Ceftri, TMP-SMX - Resistant
gluteus medius 01/04 BLOOD No Growth after 5 Days of
● Findings suggestive of Incubation
preexsiting hip dysplasia
of the right hip, hypoplastic
right femoral head and a 1/21 BLOOD E. Coli Gentamycin, Ceftriaxone - Sensitive
shallow right acetabulum Ampicillin - Resistant

Ultrasound, Right Gluteal Area 1/23 SPUTUM Klebsiella Pneumonia Amikacin - Sensitive
(12/23/2020) Ampicillin, Amoxicillin/Clavulanic Acid, Ceftriaxone, Piperacillin-
Tazobactam, Gentamycin - RESISTANT
2/02 BLOOD No Growth after 7 Days of
● Consider Lymphocele vs.
Incubation
Serome, Antero-lateral
aspect of the right hip
2/14 PENILE Klebsiella Pneumoniae Sensitive: Gentamycin, Amoxicillin/Clavulanic Acid, Pip-Tazo
DISCHARGE Resistant: Ampicillin, Ceftriaxone
NON-CONTRAST MRI OF THE
PELVIS (2/18/2021), POC 2/14 URINE No Growth after 48 Hours of
- Interval regression of the soft Incubation
tissue abscess in the right hip,
right proximal thigh, left anterior 3/02 URINE Klebsiella Pneumonia Sensitive- Gentamycin, Meropenem
thigh compartment and left Resistant- Ampicillin
posterior sacral region 3/10 URINE No Growth After 48 Hours of
- heterogenous T2 hyperintense Incuation
mass, region of the right Hip
extending to th anterior aspect of
the right proximal thigh may be
GRAM STAIN
due to an infectious/inflammatory
process such as septic arthritis
with synovitis cannot rule out a 10/04 BLOOD No growth after 7 days of incubation
neoplastic process. Suggest
Tissue and microbiological 12/31 WOUND No growth after 72 hours of incubation
correlation
- stable finding of resorption of 10/03 WOUND WBC - Few
the femoral head with Gram + cocci in singly and in clusters = +2
superolateral displacement of the Gram negative bacilli = Few
proximal femur, erosion of the Gram positive bacilli = +1
right acetabulum and abnormal
 marrow signal of the right No spore forming bacilli seen on microscopic
proximal femur and right examination
acetabulum, and left anterior
acetabulum may be due to 10/14 WOUND WBC - +2
osteomyelitis Gram + cocci in singly = +2
- consider sacroilitis, Left Gram + cocci in pairs = Few
-Pyomyositis versus muscle No spore forming bacilli seen on microscopic
edema, both iliopsoas, right examination
gluteal muscle, and proxiomal
thigh and hips
10/17 DEEP SITE No growth after 48 hours of incubation
- subcutaneous edema, right Hip
OF SOFT
TISSUE
CT-GUIDED BIOPSY -
PARAVERTEBRAL MASS T2,
LEFT (12/03, POC) 01/04 BLOOD No growth after 5 days of incubation
Pathologic Diagnosis: Benign
Skeletal Muscle, Adipose 1/21 BLOOD Heavy Growth
Tissues, and Blood

ABG

DATE pH pCO2 pO2 HCO3 B.E. O2 sat RR FI02 Interpretation

1/19 7.34 36.5 92.4 19.3 -5.6 96.7% 30bpm 8 L/min Uncompensated
Metabolic Acidosis

FECALYSIS

12/1 Occult Negative

Blood

SWA2 Thoracolumbar Plain MRI CBC BLADDER: BOWEL:

CAMIA, JOE NEIL (Divine Grade Medical Center, Freely Voiding Daily without use
27/M (+) PH 3/4/2021) DATE Hgb Hct RBC MCV MCH WBC Neut Lym Mono Eos Baso Plt CRP ESR Blood of suppositories
CN: 1212613 140- 0.37- 4.0-6.0 82- 28-32 4.8- 0.40- 0.19- 0.03- 0.00- 0-0.02 150- <0.6 <20 Type
ADD: 419, Tanib St., Tabon 1, There is a sizeable hyperintense 180 0.57 92 10.8 0.74 0.48 0.09 0.07 450 mg/dl mm/h
r BED MOB N/A
Kawit, Cavite T2/STIR paraspinal mass noted
DOA: 04/17/21 at the level of T11 to L4
4/16 81 0.24 3.23 74 25 25.19 0.88 0.07 0.05 0.00 0.00 385 >13 121 TRANSFER N/A
DOB: 01/31/94 vertebra extending posteriorly to
Contact #: 09484025125 envelope the vertebra; bodies
and posterior elements of the 4/18 87 0.27 3.5 77 25 14.97 0.84 0.10 0.06 0.00 0.00 322 SITTING TOL N/A
SSU DIC: Dr. DIMACALI T11 to L2 vertebrae. The lesion
AO DIC: Dr. Cruz extends laterally to the left 4/19 81 0.24 3.11 77 26 14.13 0.81 0.11 0.08 0..00 0.00 275 8.23 88 SITTING BA N/A
CC: Pain on both hips and mid psoas muscle forming a large
back pain loculated fluid collection with 4/20 100 0.30 3.75 79 27 9.41 0.78 0.16 0.05 0.01 0.00 294 >13 97
STANDING TOL NA
thick walls and minimal
septations, measuring 05/04 119 0.37 4.43 84 27 12.78 0.73 0.20 0.06 0.01 0.00 397 >13 >130
STANDING BAL NA
Admitting Diagnosis: 6.4x6.4x16.4cm.
 ASCI, Incomplete, The lesion extends from the level 05/10 119 0.37 4.45 83 27 12.55 0.74 0.18 0.07 0.01 0.00 323 >13 21
Neurologic level L1 of T12 down to the psoas pelvic Brace For fabrication of
secondary to lytic insertion. A similar but smaller KT Brace
destruction of T12, L1, L2 lesion is seen in the right psoas
probably secondary to Pott’s muscle, measuring 0.65x1.28cm For
DATE UIBC T. Fe binding Iron(Ferene) PROTHROMBIN TIME INR % APTT CLOTTING BLEEDING
disease, AIS-D and extends from the level of L2 (Ferene) capacity (64.81- 11-15 seconds activit 22-45 seconds TIME TIME
 Pulmonary Tuberculosis, down to the pelvic insertion. T2 (69.28- (250.30-400.04 174.87) y 5-15 mins 1-7 mins Wheelchair NA
bilateral bright signal changes are seen in 240.24) ug/dl)
 T/C Pyomyositis, left gluteal both psoas muscles suggestive
area of muscle edema or DIET: High Protein Diet with Strict
 T/C Septic arthritis, both inflammation. 4/16 15.1 1.14 82 27.8 8’ 2’
Aspiration Precaution
hips probably secondary to A similar loculated fluid lesion is
extra-pulmonary TB also noted in the posterior sacral Problem Lists:
 Psoas abscess, left region, level of S5 to coccygeal BLOOD CHEM 1. Pott’s Disease & PTB, bilateral
region, measuring 3.3x2.0cm.
Anti-Koch’s medications
There is also extension of the
Intensive phase (04/17/21) 3 HRZE tabs OD
Admitting MMT: lesions into the posterior DATE HBA1C FBS BUN CREA CHOLES TRIGLY HDL LDL VLDL SGOT SGPT ALP SLDH
paraspinal muscle groups at the
2. Psoas Abscess (Resolved)
 Right Left level of T11 to L2. (4.8-5.9) - For MSK UTZ, left lower back (Lumbar area, left
There is subligamentous spread hip, left gluteal area)
C5-T1 5 5 tracking laterally and posteriorly 4.1-5.9 2.1- 71-115 <5.17 <1.69 >1.5 0- 0-0.77 17-59 <50 <270 <248 - I&D done (2L bloody purulent foul smelling
to form an epidural mass at the 7.1 5 2.85 discharge)
posterior aspect of the spinal -Wound discharge/Abscess GSCS awaiting result
L2 3 2
canal at the level of L2 to L4. 4/16 51.0 + GeneXpert
This causes displaced and -Ceftriaxone 2gm/IV q24H ()ANST
L3 3 1 bunching of the caudal roots
4/19 3.24 3.34 1.13 1.14 0.29 0.32 0.52 19.29 17.-3
anteriorly and to the left. 3. T/C Septic Arthritis, B Hips
L4 5 5 There is associated mild - Scheduling of MRI hips, Bilateral
vertebral destruction involving the 05/04 64.95 11.47 10.40
L5 1 5 T12 and L1 vertebral bodies with 4. Anemia
bone marrow inflammatory signal - s/p transfusion of 2u pRBC & 2u FWB
changes seen at the T12 to S1
S1 5 5 - Fluid resuscitation + FeSO4, 1 tab TID
vertebrae. There is mild anterior SERUM ELECTROLYTES. ETC
displacement of the T12 vertebra
MIS = 85/100 in relation to L1. The rest of the 5. Underweight
DATE Na K Cl Total Ca iCa T Protein Albumin Globulin A/G
lumbar para spinal muscles show DAT W/ SAP – High protein diet; Referred to
135-145 3.5-5.5 98-108 2.10-2.55 63-82 35-50 28-32 Ratio nutrition service
inflammatory signal changes. 1.5-3.1
Admitting Sensory: High T2/STIR signals are seen in
the L1-L2, L2-L3 and L3-4 disc 7. Electric like sensation, B hips
4/16 131.6 4.11 97.9 Gabapentin 300mg/tab, 1 tab TID
Right Left spaces.
There is mild dilation of the upper
4/19 17.31 50.01 0.35 PT: (Bed level)
C2-S3 2 2 collecting system of the left
1. GBCE, DBCE
kidney. No renal lesions noted.
2. AROMES to B shoulders, elbows,
The T1 to T10 and intervening 05/04 141.8 4.39 102.8 94.36 34.06 60.3 0.56
S4-S5 2 2 wrist, mcp and ip joints; to B hips,
disc spaces are relatively
knees and ankles (please observe
preserved.
SIS: 112/112 precaution)
No evidence of disc herniations. URINALYSIS 3. GPS to B pecs, hamstrings and heel
No evidence of spinal canal
cords
stenosis at the thoracic region. DATE COLOR pH TRANSPARENCY SP. GRAV GLUC CHON RBC PUS EPITH BACT 4. PRES to B UE and LE major muscle
No spinal cord signal changes
groups
Normotonic (B) UE; Hypertonic (B) noted.
4/18 O 7.0 Turbid >1.025 - - 0-2 2-5 FEW 5. Chest expansion exercises
LE; Minimal T2 signals seen in the
6. Core activation exercises
(+) BCR, PAS, DAP, VAC paraspinal muscles at the level of
7. Pressure relief techniques
(+) Babinski, B; (+) Clonus, B T3-T4 down to the lumbar region
Culture and Sensitivity 8. Bed mobility skills
likely inflammatory changed.
Incidental findings of a low
2x0.5cm sinus draining tract on R T2/intermediate T1 right 04/24 Blood No growth after 5 days of incubation
inguinal area with purulent, foul mediastinal soft tissue mass
OT/PSYCH/SOC/VOC: (Bed level)
smelling discharge seen adjacent to the trachea and 04/21 Hip, lateral Consistent with a suppurative inflammatory - IE
right mainstem bronchus aspect, process. - OT supportive activities
Gibbus deformity at the level of T12 measuring 3.9x3.9cm along its incision
& L1 widest diameters. and Negative for malignant cells.
There is also a similar lesion draining Medications:
Fluctuant, non-tender, non- seen in the right posterior
1. Zinc Sulfate 1 tab PO OD
erythematous, movable mass on left mediastinal region abutting the
05/05 SPUTUM No growth after 48 hours of incubation 2. Ascorbic Acid 500mg, 1 tab PO BID
medial thigh right posterior chest wall
3. Ferrous Sulfate, 1 tab PO TID
measuring 5.5x3cm.
4. HRZE, 3 tabs ODAC (4/17)
Present Diagnosis: Several enlarged mediastinal
5. Gabapentin 300mg, 1 tab PO TID
 ASCI, Incomplete, lymph nodes are also noted.
6. Salbutamol neb, 1 neb TID
Neurologic level S5 The conus medullaris terminates
7. N-acetylcysteine 600mg, 1 sachet BID
secondary to lytic at the level of L1.
destruction of T12, L1, L2 Mild splenomegaly is incidentally
probably secondary to Pott’s noted.
disease, AIS-E
 T/C Pyomyositis, left gluteal Impression
area Above findings are compatible
 T/C Septic arthritis, both with Pott’s disease with multiple
hips probably secondary to paraspinal abscess formation
extra-pulmonary TB and extensions to the epidural
 Psoas abscess, left space, psoas muscles, pelvic and
coccygeal region, as described.
Fairly large mediastinal masses,
Admitting MMT: as described, likely TB in
etiology, contrast enhanced chest
CT scan and tissue correlation is
Right Left suggested.
Enlarged mediastinal lymph
C5-T1 5 5 nodes
Mild splenomegaly
L2-S1 5 5 Mild ureteropelvocaliectasia, left,
likely due to ureteral compression
MIS = 100/100 effects by the large left psoas
abscess.
Admitting Sensory: CT Scan of the thorax with
Contrast (Divine Grade Medical
Right Left Center, 3/4/2021)

A coarsely calcified mass

C2-S3 2 2
(.6x5.2x2.7cm) is noted in the
apica;/posterior segments of the
S4-S5 2 2 right upper lobe, as well as ill-
defined nodular densities with
SIS: 112/112 variable calcifications scattered in
the bilateral upper lobes.
Cluster of calcified masses
probably lymph nodes are seen
in the mediastinum
predominantly paratracheal in
location, but few smalled
calcifications are also noted in
the pericarinal, right hilar,
prevascular and lower
paraesophageal spaces.
Further calcified nodules/lymph
nodes are noted along the right
lower jugular chain.
Trace fluid is present in the
bilateral posterior pleural spaces,
with minimal subpleural of the
bilateral lower lobe posterior
segments.
Tracheobronchial tree normal.
Heart is normal in size and
configuration.
Aorta and pulmonary arteries are
normal.
Thoracic spine is straightenend.
Chest wall soft tissues are intact.
Visualized upper abdomen
shows more calcifications in the
enlarged liver (mainly left lobe),
hepatic hilar, peripancreatic,
paraceliac, perigastric and
aortocaval spaces.
Partly visible thoracolumbar
junction displays osteolytic
changes of T12, L1 and L2
vertebral bodies, gibbus
deformity at L1-2, and adjacent
perivertebral soft tissue abscess.

Impression:
Most probably calcified
granulomatous lesions of the
bilateral lungs, predominantly
right upper lobe.
Calcified, variably enlarged
mediastinal and right lower
jugular lymphadenopathy
Trace pleural effusion, bilateral
Thoracic straightening
Multiple hepatic parenchymas
and calcified lymphadenopathy in
the upper abdominal spaces
Thoracolumbar osteolytic
changes, gibbus deformity,
adjacent perivertebral abscess
SWS2 CHEST X-RAY AP (Philippine CBC BLADDER: BOWEL:
ACHAZO, ARIEL-QUIJANO Orthopedic Center, Initial reading, On IFC w/ clear, Every 2-3 days
48/M (+) PH May 3, 2021) DATE Hgb Hct RBC MCV MCH WBC Neut Lym Mono Eos Baso Plt CRP ESR Blood free-flowing output with suppository
CN: 1214146  No infiltrates 140- 0.37- 4.0-6.0 82- 28-32 4.8- 0.40- 0.19- 0.03- 0.00- 0-0.02 150- <0.6 <20 Type use
ADD: 42 A San Nicasio St., Brgy 180 0.57 92 10.8 0.74 0.48 0.09 0.07 450 mg/dl mm/h
 Trachea is in midline r
Gulod, Novaliches, Quezon City BED MOB N/A
 The heart is normal in
DOA: 05/03/2021
size 05/03 123 0.35 3.95 88 31 7.25 0.8 0.13 0.06 0.01 0.00 234 3.41 11 B (+)
DOB: 11/11/71
Contact #: 091923559811  The aorta is TRANSFER N/A
unremarkable 05/10 134 0.38 4.25 89 32 8.70 0.64 0.18 0.08 0.10 0.00 377
CC: Low back pain  Both SITTING TOL N/A
hemidiaphragms,
costophrenic sulci SITTING BA N/A
Admitting Diagnosis: and visualized bones DATE UIBC T. Fe binding Iron(Ferene) PROTHROMBIN TIME INR % APTT CLOTTING BLEEDING
 Acute spinal cord injury, are intact (Ferene) capacity (64.81- 11-15 seconds activit 22-45 seconds TIME TIME
STANDING TOL NA
(69.28- (250.30-400.04 174.87) y 5-15 mins 1-7 mins
incomplete, sensory level
240.24) ug/dl)
T12, secondary to Burst THORACIC SPINE X-RAY (Philippine STANDING BAL NA
Fracture of L2 vertebrae Orthopedic Center, Initial reading,
secondary to fall, in spinal May 3, 2021)
shock 05/03 15.6 1.18 79.00 34.9 10’ 2’30 Brace For fabrication of
AP View KT Brace
 T/C Conus Medullaris  Intact intervertebral
Syndrome disc spaces
BLOOD CHEM Wheelchair NA
 Intact vertebral body
height of thoracic
Admitting/Present MMT: vertebrae
DATE HBA1C FBS BUN CREA CHOLES TRIGLY HDL LDL VLDL SGOT SGPT ALP SLDH DIET: DAT w/ SAP
 Intact interpedicular (4.8-5.9)
Right Left distances of thoracic
Problem Lists:
vertebrae 4.1-5.9 2.1- 71-115 <5.17 <1.69 >1.5 0- 0-0.77 17-59 <50 <270 <248 1.
C5-T1 5 5 7.1 5 2.85
Lateral View PT: (Bed level)
L2-S1 5 5  Intact vertebral body 05/03 5.17 8.08 86.54 3.64 0.92 1.15 2.07 0.42 24.69 18.46 1. GBCE, DBCE
height of thoracic 2. AROMES to B shoulders, elbows,
MIS = 100/100 vertebrae wrist, MCP & IP joints; to B hips,
 Intact intervertebral knees, ankles (please observe
disc spaces precaution)
SERUM ELECTROLYTES. ETC 3. GPS to B pecs, traps and heelcords
Admitting / Present Sensory:
LUMBOSACRAL XRAY (Philippine 4. PRES to B UE and LE major muscle
DATE Na K Cl Total Ca iCa T Protein Albumin Globulin A/G groups
Right Left Orthopedic Center, Initial reading, 135-145 3.5-5.5 98-108 2.10-2.55 63-82 35-50 28-32 Ratio 5. Bed mobility skills
May 3, 2021) 1.5-3.1 6. Pressure relief techniques
C2-T12 2 2 7. Core activation exercises
AP View 05/03 143.8 4.55 105.6
L1-L2 2 2  Decreased vertebral
body height of 50%
of L2 vertebra OT/PSYCH/SOC/VOC: (Bed level)
L3-S2 2 2
 Increased - IE
interpedicular - OT supportive activities
S3 1 1 distance of L2
vertebra
S4-S5 1 1  Intact intervertebral Medications:
disc spaces of other 1. Gabapentin 300mg/cap, 1 cap PO
SIS: 104/112 lumbar vertebrae ODHS
 Intact vertebral body 2. Tramadol 50mg/cap, 1 cap po q6
height of other 3. Ascorbic acid 500mg/tab, 1 tab PO
lumbar vertebrae BID
Patellar: Hyper-reflexive  Intact interpedicular 4. Methycobalamin 500mcg/tab, 1 tab Q8
Ankle: Hypo-reflexive 5. Paracetamol 500mg/tab, 1 tab Q6 for
distances of other
(-) BCR, (+) DAP, (+) VAC pain
lumbar vertebrae

Lateral View
 Straightening of
Present MMT: lumbar curvature
 Decreased vertebral
Right Left body height 25-50%
of L2 vertebra with
C5-T1 5 5 greater involvement
of anterior portion
L2-S1 5 5  Intact vertebral body
height of other
MIS = 100/100 lumbar vertebrae
 Intact
intervertebral disc
Present Sensory: spaces

Right Left
PELVIS AP (Philippine Orthopedic
C2-S3 2 2 Center, Initial reading, May 3, 2021)

S4-S5 1 1  No cortical
irregularity or breaks
SIS: 110/112
seen

SWA2 CHEST X-RAY AP (Philippine Orthopedic CBC BLADDER: BOWEL:

PANAL, MARLON-SORIANO Center, Initial reading, May 3, 2021) On IFC w/ clear, Every 2-3 days
46/M (+) PH  No infiltrates
DATE Hgb Hct RBC MCV MCH WBC Neut Lym Mono Eos Baso Plt CRP ESR Blood free-flowing output with suppository
 Trachea is in midline
CN: 1213941 140- 0.37- 4.0-6.0 82- 28-32 4.8- 0.40- 0.19- 0.03- 0.00- 0-0.02 150- <0.6 <20 Type use
 The heart is normal in size 180 0.57 92 10.8 0.74 0.48 0.09 0.07 450 mg/dl mm/h
ADD: Sta Cruz Village, Brgy Borol  The aorta is unremarkable r
1st, Balagtas, Bulacan  Both hemidiaphragms, BED MOB N/A
DOA: 05/03/2021 costophrenic sulci and
DOB: 02-11-75 05/03 150 0.42 5.13 83 29 10.48 0.65 0.20 0.13 0.01 0.01 209 0.10 19 B (+)
visualized bones are
TRANSFER N/A
Contact #: 09070435130 intact

CC: Weakness of both upper and CERVICAL SPINE X-RAY (Philippine SITTING TOL N/A
Orthopedic Center, Initial reading, April 29,
lower extremities DATE UIBC T. Fe binding Iron(Ferene) PROTHROMBIN TIME INR % APTT CLOTTING BLEEDING
2021) (Ferene) capacity (64.81- 11-15 seconds activit 22-45 seconds TIME TIME
AP View
SITTING BA N/A
(69.28- (250.30-400.04 174.87) y 5-15 mins 1-7 mins
 Intact intervertebral disc 240.24) ug/dl)
Admitting Diagnosis: spaces STANDING TOL NA
 Acute spinal cord injury,  Intact vertebral body
incomplete, sensory level height
STANDING BAL NA
 Intact interpedicular 05/03 13.9 1.05 93 27.9 11’ 2’00”
C3, secondary to C1-C2
instability, to consider distances
Odontoid fracture, Lateral View Brace For fabrication of
 Straightening of cervical BLOOD CHEM KT Brace
secondary to Hyperflexion spine
Injury secondary to Bicycle  Slight posterolisthesis of
Accident; AIS-D C4-C5 Wheelchair NA
 Central Cord Syndrome  Intact intervertebral disc DATE HBA1C FBS BUN CREA CHOLES TRIGLY HDL LDL VLDL SGOT SGPT ALP SLDH
spaces (4.8-5.9)
 Intact vertebral body
DIET: DAT w/ SAP
height 4.1-5.9 2.1- 71-115 <5.17 <1.69 >1.5 0- 0-0.77 17-59 <50 <270 <248
Admitting:
7.1 5 2.85 Problem Lists:
Swimmer’s View
Right Left 1.
 Unremarkable cervico-
05/03 8.11 85.52
thoracic junction PT: (Bed level)
C5 3 3 1. GBCE, DBCE
Open Mouth View 05/05 5.6 6.96 3.2 0.84 0.88 1.94 0.38 38.79 39.31 55.95 179.67
 Unremarkable odontoid 2. FES to B elbow flexors, L triceps
C6 2 3 process distances, tip of 3. ES to B wrist extensor, R triceps and
odontoid not visualized B hand intrinsics
C7 1 3 4. PROMES to R elbow towards
CERVICAL SPINE X-RAY (Philippine SERUM ELECTROLYTES. ETC extension, B MCP & IP joint
Orthopedic Center, Initial reading, May 3, 5. AAROMES to B elbow towards flexion,
C8 0 1 2021) DATE Na K Cl Total Ca iCa T Protein Albumin Globulin A/G L elbow towards extension, B wrist
AP View
135-145 3.5-5.5 98-108 2.2-2.65 2.10-2.55 63-82 35-50 28-32 Ratio towards extension
T1 0 0  Intact intervertebral disc
spaces 1.5-3.1 6. AROMES to B hips, knees and ankles
 Intact vertebral body 7. Maintenance ex to B LE major muscle
L2 4 4 height 05/03 128.2 4.84 91.4 groups
 Intact interpedicular 8. Strengthening of accessory muscle of
L3-S1 5 5 distances
05/05 2.09 68.67 40.48 28.19 1.44 respiration
Lateral View 9. Diaphragmatic strengthening
 Straightening of cervical exercises
MIS = 64/100 spine 05/06 120 10. Chest expansion exercises
 Slight posterolisthesis of
C4-C5 11. Rood’s inhibitory tech to spastic
 Intact intervertebral disc muscles
Admitting: spaces URINALYSIS 12. Bed mobility skills with assistance to
 Intact vertebral body progress to without assistance
Right Left height 13. Pressure relief techniques
DATE COLOR pH TRANSPARENCY SP. GRAV GLUC CHON RBC PUS EPITH BACT Cryst
Open Mouth View
als
C2-C3 2 2  Unremarkable odontoid
process distances, tip of 05/03 Yellow 6.0 Slightly Turbid >1.025 Trace - 5-10 10-25 1+ A.Urat
C4-S3 1 1 odontoid not visualized es OT/PSYCH/SOC/VOC: (Bed level)
Few - Initial Evaluation
THORACIC X-RAY (Philippine Orthopedic - OT supportive activities
S4-S5 1 1 Center, Initial reading, April 29, 2021) - For fabrication of resting hand
AP View 05/07 Light 7.0 Slightly Turbid 1.015 - - 2-5 25-50 0-2 Few splint, B
SIS: 60/112  Intact intervertebral disc
- Activities to allay anxiety
spaces
  Intact vertebral body Yellow
height of thoracic
vertebrae Medications:
 Intact interpedicular
1. Tramadol + Paracetamol tab, 1 tab
distances of thoracic
(+) BCR, (+) PAS, (+) PAW, (+) vertebrae PRN q8
ABG
VAC Lateral View 2. Paracetamol 500mg/tab, 1 tab if with
 Intact intervertebral disc fever
spaces DATE pH pCO2 pO2 HCO3 B.E. O2 sat RR FI02 Interpretation 3. Paracetamol 300mg/IV, PRN if with
Hyper-reflexive Upper Extremity
 Intact vertebral body fever >38.5C
Impaired position sense on left
height of thoracic 05/04 7.434 28.0 86.4 18.3 -4.3 97% 27 cpm RA Adequate 4. Vit D + Ca tab, 1 tab PO OD
upper extremity vertebrae Oxygenation 5. Gabapentin 300mg/cap, 1 cap PO BID
Grade 1 spasticity on bilateral (1-0-1)
elbow flexors LUMBOSACRAL XRAY (Philippine Fully Compensated 6. Baclofen 10mg/tab, 1 tab PO BID
Orthopedic Center, Initial reading, April 29, Respiratory 7. NaCl tab, 1 tab PO TID
2021) Alkalosis 8. Ceftriaxone 2gm/IV OD x 7 days

Present MMT: AP View

 Intact intervertebral disc
spaces
Right Left  Intact vertebral body Culture and Sensitivity
heights of vertebrae
 Intact interpedicular
C5 3 3 distances of vertebrae
05/11 Urine Enterobacter cloacae; Sensitive to Gentamycin and
Lateral View Ceftriaxone
C6 2 2  Intact vertebral body
heights of vertebrae
 Intact intervertebral disc
C7 1 3 spaces

C8 0 0 PELVIS AP (Philippine Orthopedic Center,

Initial reading, May 3, 2021)
T1 0 0
 No cortical irregularity or
L2-S1 5 5 breaks seen

MIS = 100/100

Present Sensory:

Right Left

C2-T3 2 2

T4-S3 1 1

S4-S5 1 1

SIS: 104/112

Grade 1+ elbow flexor, B spasticity

Grade 1+ knee flexors, B spasticity
(+) BCR, (+) VAC, (+) DAP
SWA2 Chest X-ray (Initial Reading, Philippine CBC BLADDER: BOWEL:
BELGADO, JACKIELYN DELA Orthopedic Center, 5/10/2021) On IFC w/ clear, Every 2-3 days
CRUZ AP view
DATE Hgb Hct RBC MCV MCH WBC Neut Lym Mono Eos Baso Plt CRP ESR Blood free-flowing output with suppository
 Diffuse reticulonodular
35/F (+) PH 140- 0.37- 4.0-6.0 82- 28-32 4.8- 0.40- 0.19- 0.03- 0.00- 0-0.02 150- <0.6 <20 Type use
densities on both lung 180 0.57 92 10.8 0.74 0.48 0.09 0.07 450 mg/dl mm/h
CN: 1214538 fields to consider diffuse r
ADD: 31 Lagusan St., Brgy military tuberculosis BED MOB N/A
Apolonio, Samson, Quezon City  Heart is not enlarged
DOA: 05/10/2021 05/11 128 0.38 4.24 89 30 9.38 0.66 0.19 0.12 0.02 0.01 473 13 64 O (+)
 No tracheal deviation
TRANSFER N/A
DOB: 07-27-1985  Bony structures are
Contact #: 0938638777 unremarkable
 No blunting of SITTING TOL N/A
costophrenic angle
CC: Inability to move both lower DATE UIBC T. Fe binding Iron(Ferene) PROTHROMBIN TIME INR % APTT CLOTTING BLEEDING
extremities (Ferene) capacity (64.81- 11-15 seconds activit 22-45 seconds TIME TIME SITTING BA N/A
Thoracic x-ray (Initial Reading, Philippine (69.28- (250.30-400.04 174.87) y 5-15 mins 1-7 mins
Orthopedic Center, 5/10/2021) 240.24) ug/dl)
AP view STANDING TOL NA
Admitting Diagnosis:  Narrowed intervertebral
 Acute spinal cord injury, disc space of T8 and T9
STANDING BAL NA
 05/03 13.5 1.02 97.00 28.70 7’00” 1’00”
incomplete SL T6, Decreased intervertebral
secondary to lytic body height of T8 and T9
destruction of T8-T9, by 30% Brace For fabrication of
 The rest of the vertebral BLOOD CHEM KT Brace
probably secondary to Pott’s body height are intact
disease, AIS-B  The rest of the
 T/C Diffuse miliary intervertebral disc space Wheelchair NA
tuberculosis – bilateral are intact DATE HBA1C FBS BUN CREA CHOLES TRIGLY HDL LDL VLDL SGOT SGPT ALP SLDH
(4.8-5.9)
 Grade 3 internal  Interpedicular distances
hemorrhoids are intact DIET: DAT w/ SAP
4.1-5.9 2.1- 71-115 <5.17 <1.69 >1.5 0- 0-0.77 17-59 <50 <270 <248
Lateral view 7.1 5 2.85 Problem Lists:
 Narrowed intervertebral
Admitting MMT: 1.
disc spaces of T8 and T9
 Decreased vertebral body
05/11 5.00 3.45 61.41 4.3 1.25 1.01 2.72 0.57 19.41 16.07
PT: (Bed level)
Right Left height of T8 and T9 by
1. IE
30%
 Slight kyphotic deformity 2. GBCE
C5-T1 5 5 at the level of T8 and T9 3. ES to B quads, hams, gastrocs, tibialis
SERUM ELECTROLYTES. ETC
 The rest of the vertebral anterior
L2-S1 0 0 body height are intact 4. PROMES to B hips, knees and ankles
 The rest of the DATE Na K Cl Total Ca iCa T Protein Albumin Globulin A/G followed by gentle passive stretching
intervertebral disc space 135-145 3.5-5.5 98-108 2.2-2.65 2.10-2.55 63-82 35-50 28-32 Ratio to end range
MIS = 50/100 are intact 1.5-3.1 5. AROMES to B shoulders, elbows,
wrists, MCP & IP joints
Lumbar x-ray (Initial Reading, Philippine
Orthopedic Center, 5/10/2021)
05/11 63.95 32.7 31.25 1.05 6. GPS to B hamstrings and gastrocs
Admitting Sensory: 7. PRES to B UE major muscle groups
AP view
 Lumbar vertebral body 8. Core activation exercises
Right Left heights are intact URINALYSIS 9. Pressure relief techniques
 Intervertebral disc spaces 10. Bed mobility skills
C2-T6 2 2 are intact
DATE COLOR pH TRANSPARENCY SP. GRAV GLUC CHON RBC PUS EPITH BACT Cryst 11. Rood’s inhibitory techniques to spastic
 Interpedicular distances muscle
are intact als
T1-S3 1 1
Lateral view 05/11 Dark <5.5 Slightly Turbid >1.025 - + 25-50 2-5 10-25 Few
S4-S5 1 1  Lumbar vertebral body Yellow
heights are intact OT/PSYCH/SOC/VOC: (Bed level)
 Intervertebral disc spaces - Initial Evaluation
SIS: 82/112 are intact - Activities to allay anxiety
- Procurement of wheel chair

(+) BCR, (+) PAS, (+) PAW, (-)

VAC Medications:
1. Tramadol + paracetamol, 1 tab PO
Hyperreflexive lower extremities Q8h PRN pain
Grade 1 spasticity on both knee 2. Paracetamol 500mg/tab, 1 tab PO
flexors and extensors PRN for T> 37.8C
3. Gabapentin 300mg/cap, 1 cap PO OD
4. Vitamin C tab, 1 tab PO OD
Non-tender, reducible, flesh 5. Multivitamins tab, 1 tab PO OD
colored mass, on the 3 o’ clock 6. Omeprazole 40mg/cap, 1 cap PO
position of the anal verge with no ODAC
noted active bleeding