Buot, Ma. Luisa Y.

“Eerie” November 5, 2019

Objectives: Past Medical History
 To present a case of a 44 year old male with bilateral lower extremity Non-diabetic
weakness and lower back pain Non-hypertensive
 To discuss the epidemiology, pathogenesis, clinical presentation, No known FDA
diagnosis, prognosis and treatment of the case. S/p appendectomy 2005
 No prior history of PTB treatment
A case of N. L. 44 year old male married Filipino, Roman Catholic from Villanueva
Misamis Oriental who came in due to bilateral lower extremity weakness and lower No prior history of MI or CVD
back pain. (+) history of cough for a week 2
months ago
Patient was apparently well, able to ambulate with no assistance, worked as a laborer No recent history of vaccination
at Coca-cola, can do ADL’s with no difficulty.
Family History
One week prior to admission patient noted onset of lower back pain, gnawing in (+) Hypertension - Maternal
quality mild to moderate in intensity, non-radiating associated with tingling sensation (+) Diabetes Mellitus - Maternal
of bilateral lower extremities. Patient still can ambulate unassisted. No other (-) Cancer
associated signs and symptoms. No fever, no chills, no LBM, no change in sensorium, (-) Bronchial Asthma
no weight loss, no anorexia, no history of trauma. (-) Cardiac disorders
(-) thyroid disorders
Three days prior to admission, symptoms persisted now sought consult at local
hospital where he was given celcoxib and pregabalin which afforded no relief of pain. Personal and Social History
Laborer at Coca-cola
One day prior to admission, symptoms still persisted now pain associated with Non-smoker
weakness of bilateral lower extremities, still can ambulate but with assistance. No Non- alcoholic beverage drinker
LOC/change in sensorium. Denied illicit drug user

Review of System
On the day of admissions, patient condition worsened. Patient was not able to stand
(-) fever
and ambulate thus prompted admission.
(-) weight loss
(-) anorexia
(-) diaphoresis
Physical Exam: CVS: (-) blurring of vision
Adynamic precordium, Distinct heart (-) nausea/vomiting
General Survey sounds, NRRR. No murmur (-) epistaxis
awake, conscious, coherent, (-) hemoptysis
oriented, not in respiratory distress ABDOMEN: (-) PND
Normoactive bowel sounds, (-) chest pain
Vital Signs Soft, Non tender, No palpable (-) constipation or diarrhea
BP: 160/90 mmhg HR: 70 bpm masses noted (-) dysuria
RR: 20 cpm T: 36 C (-) genital discharges
O2sat: 98% at room air EXTREMITIES: (-) tea coloured urine
Height: 158 cm Weight: 60 kg Strong pulses, No edema (-) slurring of speech
BMI: 24 kg/m2 (-) dizziness
NEUROLOGIC (-) seizure
SKIN: Awake, conscious, Oriented
No petechiae, no cyanosis, no CN I - XII: intact Course:
jaundice, warm with good turgor Cerebellar: intact
Sensory: intact On the 3rd hospital day, still with pain and
HEENT: Propioception: intact lower extremity weakness, patient was now
anicteric sclerae, Pink palpebral Negative Babinski noted to have bladder and bowel
conjunctivae, Moist oral mucosa, DTR: 2+ incontinence.
Non-hyperemic tonsils, No LADs Motor: normal muscle bulk and tone,
No NVE no atrophy MRI of the lumbosacral spine with
cervicothoracic scanogram showed
CHEST AND LUNGS: abnormal central spinal cord signal from T4-
Muscle Strength: Left and Right
Equal chest expansion, T5 down to the conus medullaris.
Upper Limb 5/5
clear breath sounds
L1, L2 Hip flexion 4/5 Patient was then treated with IV
(-) wheeze (-) bronchi
(-) rales, No chest retractions L3 Knee extension 3/5 corticosteroids and was referred to physical
L4 Ankle dorsiflexion 3/5 therapist for rehab. Patient was discharge
L5 Big toe extension 0/5 improved with home medication of oral
S1 Ankle plantiflexion 0/5 prednisone.
S2 Knee Flexion 3/5