Arthur George Gonzales

Medical Officer III

Looking Back
A Case Presentation on
Spinal Tuberculosis
General Objectives
o To present a case of Spinal Tuberculosis


Specific Objectives
o To describe the epidemiology, pathogenesis and clinical manifestations
of Spinal Tuberculosis
o To discuss and apply the Clinical Practice Guidelines in the Evaluation and
Management of Spinal Tuberculosis
o To discuss key Public Health issues regarding Extrapulmonary Tuberculosis

General Data
69 y/o
Male
Filipino
Cavite

Chief Complaint
Low Back Pain
History of Present Illness
6 months PTA
o Middle to lower back pain
Heavy
Aggravated by movement
3/10
Low grade fever
o Paracetamol
o No consult done


2 months PTA
o Low back pain
Heavy in character
6/10
Aggravated by movement
o Difficulty urinating
1 month PTA
o Admitted
Urosepsis
BPH finasteride and tamsulosin

3 weeks PTA
o Low back pain
o Lower extremity weakness
Difficulty standing up and walking
Bed ridden
1 week PTA
o Progression of lower extremity weakness
o Persistent back pain 8/10

Persistence prompted consult and admission
Past Medical History
(+)Hypertensive 2 years on amlodipine 10,
metoprolol 50, HBP 160/100 UBP 130/90
(-) PTB treatment
(-) DM
(-) Previous history of hospitalization
(-) Allergy to food and drugs
Family History
(+) HPN sibling
(-) DM

Personal and Social
Non smoker
Non alcoholic beverage drinker
Denies intake of illicit drugs

Review of Systems
General : (+) weight loss 20% for 3 months
Head : (-) Headache (-) nape pain
SKIN: (-) pallor
RESP: (-) DOB, (-)cough, (-) hemoptysis
CVS: (-) chest pain, (-) orthopnea, (-) palpitation
GIT: (-) melena, (-) hematochezia, (-) diarrhea, (-)
vomiting
GUT: (+) flank pain (-) hematuria (-) discharge
HEMA: (-) spontaneous gum bleeding

Physical Examination
GENERAL SURVEY: conscious, coherent, stretcher
bourne, fairly kempt
BP: 110/70 mmHg HR: 87/ bpm RR: 21/cpm
T: 36.9c weight 75kg BMI 26.7kg/m2
SKIN: fair in complexion, warm to touch, (+) grade III
decubitus ulcer from L2 to L4, 10-12 cm in diameter
HEENT: Anicteric sclerae, pale palpebral
conjunctivae, no tonsillo-pharyngeal congestion

Neck: No neck vein engorgement; no cervical
lymphadenopathies, no carotid bruit
CHEST AND LUNGS: Symmetrical chest expansion,
no retractions, (-) crackles, (-) wheezes
HEART: Adynamic precordium, normal rate, regular
rhythm, apex beat at 5
th
LICS MCL, no murmurs
appreciated
ABDOMEN: Flat, soft, non-tender, normoactive
bowel sounds
EXTREMITIES: Grossly normal, (-) edema, (-) cyanosis,
full and equal pulse

Neurologic Examination
CEREBRUM: Oriented to 3 spheres
CEREBELLAR: No nystagmus,

CRANIAL NERVES:
i. Olfactory: intact
ii. Optic: pupils ERTL
iii. Occulomotor: Full EOM
iv. Trochear: Full EOM
v. Trigeminal: symmetric facial sensation
vi. Abducens: Full EOM
vii. Facial: (+) assymetry
viii. Vestibulococchlear: can hear
ix. Glossopharyngeal: good gag
x. Vagus: good gag
xi. Accesory: symmetric shoulder shrug
xii. Hypoglossal: midline tongue and uvula

Neurologic Examination
Motor
o 5/5 RU and LU extremities
o 3/5 RL and LL extremities

Sensory
o 100% on all extremities

DTR
o +2 on the upper extremities
o +1 on the lower extremities