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DIAGNOSIS
C3 TO C7 Cervical Compression Myelopathy.
CASE HISTORY AND CLINICAL FINDINGS
Patient came with C/o weakness of both upper and lower limbs since 6yrs.
No history of trauma, fever, vomiting, loose stools.
H/O Urinary Incontinence + since 2 months.
HISTORY OF PRESENT ILLNESS
Patient was apparently asymptomatic 6yrs back, then developed weakness in B/ L lower limbs which was insidious in onset. Gradually progressive, associated with numbness of B/L foot with tingling of B/L
lower limbs and aggravated with movements, facing difficulty in walking.
H/O swaying away while walking.
K/C/O DM HT non medication.
N/K/C/O Asthma, TB, Epilepsy, CVA, CAD, Thyroid Disorders.
O/E of spine:- No deformity
Skin :- Normal, Surgical scar on lumbar region.
No local swellings, tenderness, mild and diffuse around L1 to L5 level.
Range of movements:- Restricted grossly at both neck and lower back.
RL shoulder ABD 5/5 5/5. ABD
Elbow F 5/5 5/5 IF.
Wrist - F 5/5 5/5 IF
Hand grip 5/5 5/5
Sensations- Intact.
10-10-2024
INVESTIGATIONS
COMPLETE URINE EXAMINATION (CUE)
Colour - Pale yellow.
Appearance - Clear
Reaction - Acidic
SP Gravity - 1.010
Albumin + Sugar +Bile salts - Nil.
Bile pigments - Nil.
Pus cells - 3
Epithelial cells - 2.3
Red blood cells - Nil.
Casts - Nil
Amorphous deposits - Absent.
Others - Nil
10-10-2024
LFT (LIVER FUNCTION TEST)
Total bilurubin - 0.55mg/dl
Direct bilurubin - 0.19mg/dl
SGOT (AST) - 20 IU/L
SGPT (ALT) - 14 IU/L
Alkaline phosphatase - 228 IU/L
Total proteins - 7.3gm/dl
Albumin - 3.4gm/dl
A/G Ratio - 0.90
ABG
PH - 7.27
PCO - 225.6
PO2 - 109
HCO - 311.6st.
HCO - 313.7
BEB - 13.7
BEECF - 13.9
TCO - 225.202
SAT - 97.702
Count - 11.5
11-10-2024
RFT (RENAL FUNCTION TEST)
Urea - 64mg/dl
Creatinine - 2.5mg/dl
Uric acid - 4.5 mmol/L
Calcium - 10.0mg/dl
Phosphorus - 4.3mg/dl
Sodium - 139mmol/L
Potassium - 4.5 mmol/L
Chloride - 104mmol/L
17-10-2024
COMPLETE BLOOD PICTURE (CBP)
Hemoglobin - 9.6gm/dl
Total count - 12,700 cells/cumm
Neutrophils - 50%
Lymphocytes - 40%
Eosinophils - 01%
Monocytes - 09%
Basophils - 00%
Platelet Count - 2.45
Smear normocytic, normochromic anemia with leukocytes.
17-10-2024
SERUM ELECTROLYTES
(NaKCL)
Sodium - 136mmol/L
Chloride - 106mmol/L
TREATMENT GIVEN (ENTER ONLY GENERIC NAME)
Patient was Clinico Radiologically diagnosed as C3 to C7 PSF+C4,C5,C6
Laminectomy under general anaesthesia.
PAC fitness was taken. Cardiology fitness was given under moderate risk. General physician opinion was taken in I/V/O high blood sugars and they gave high risk for surgery.
1. Tab.XY KAA IG PO/BD
2. Tab.Pan 40mg PO/BD
3. Tab.Telma 40mg PO/OD
4. Tab.Evion LC PO/BD
5. Tab.Nodosis 500mg PO/BD
6. Orofer XT PO/OD
7. Tab.Urimax PO/OD
8. Tab.Glimi M2 PO/OD to continue.
FOLLOW UP
Discharge at request:- Patient and attenders have been informed about condition of the patient in their own understandable language. Need for further management and surgery need have been explained clearly and complications associated. But the patient and patient attenders are not willing to stay in the hospital and want to get discharged due to personal reasons.
The hospital management and staff, doctors are not willing responsible for any eneventful circumstances.
WHEN TO OBTAIN URGENT CARE
In case of any emergency immediately contact your consultant Doctor or attend emergency department.
PREVENTIVE CARE
Avoid self medication without doctor's advice. Do not miss medication. In case of emergency or to speak to your treating faculty for appointments please contact the hospital management number for treatment enquiries.
PATIENT/ATTENDANT DECLARATION
The medicines prescribed and the advice regarding Preventive aspects of care, when and how to obtain urgent care have been explained to me in my own language.
SIGNATURE - PATIENT/ATTENDANT
SIGNATURE - PG / INTERNEE
SIGNATURE OF ADMINISTRATOR
SIGNATURE OF FACULTY
DISCHARGE DATE- 21-10-2024
WARD - ORTHOPEDICS
UNIT - 1
DRUG DOSAGE
Airacal - D.Tab (Calcium D3
Tab.Ampimol - 1000mg, Tab paracetamol
Asthalin - 2.5ml
Daxytral - 100mg
Caps.(Itraconazole Doxypill-LB caps(doxycyclin)
Evec-LC Tab.(vitamin E and Levocarnitine)
Ferocyn XT
Tab.Ferrio - XT (Tab iron)
Glucourn- M2.Tab(Glimiprid Metformin) Ipravent Respules - 2ML - Jetrol- CZ
Tab.(Calcium +Calcitriol)
Panras - 40mg Tab.(Pantaprazole)
Sodajet 500mg (Tab Sodium bicarbonate)
Supratel40mg
Tab.Tamstone -D
Tab.Telmilong 40mg (Tab Telmisartan)
Uridax -0.4mg (Tab.Tamsulosin)
18-10-2024
OPD Referral from spinal surgeon for a 64M with gradual lower limb paralysis once in 1988, diagnosed lumbar canal stenosis operated in the lumbar region with spinal decompression and recovered better walking capabilities till last 3yrs back since when he has again developed lower limb paralysis and walks only with support.
hypertrophy. Paper based notes from referral consultant and resident's sugar charting of 7 point Fasting and ost medicines.
21-10-2024
Paper based inputs from medicines to stop OHAS that weren't read.
Diligently taken sugar values.
A 70yr old male with C3 to C7 Cervical Compressive Myelopathy with weakness of both upper and lower limbs since 6yrs back then developed weakness in B/L lower limbs which was insidious in onset, gradually progressive aggravated with movements, facing difficulty in walking.
EMR SUMMARY
Age - 70yrs
Gender - Male
Discharge type - Relieved
Admission Date - 10-10-2024
Discharge date - 21-10-2024
