Juan Victor M.

Gamo
MD19-078506

SUBJECTIVE
General Data & Chief Complaint
J.M. is a 45-year-old male, married, Catholic, Cignal technician, from Taytay, Rizal with a chief
complaint of low back pain.

History of Present Illness

1 day PTA, patient was installing cable wires on the rooftop when the platform he was standing
on collapsed. He fell ~10 feet, landing on the buttocks area, before assuming a supine position.
Patient noted low back pain, non-radiating, dull aching in character, 10/10 PS, aggravated by
movement, relieved by rest, associated with electric-like sensation from lower back radiating to
bilateral lower extremities with 5/10 PS. Patient also noted weakness and numbness of bilateral
lower extremities. A bystander called for an ambulance, which arrived 1 hour after; the patient
was brought to Fatima University Medical Center Antipolo with a transit time of 20 minutes. At
the ER, the patient seen by an EM specialist, given unrecalled IV pain medications, which
afforded minimal relief of pain from 10/10 to 8/10. MRI was allegedly done, but results were not
retrieved Patient was advised surgery and was referred to POC. Patient was transferred to POC
via ambulance with a transit time of 1 hour. At the POC ER, seen by orthopedic surgery service,
referred to the spinal surgery unit, IFC inserted due to inability to void, referred to Department of
Rehabilitation medicine for co-management.

Review of Systems
General [-] weight gain, weight loss, weakness, fatigue

MSK/Integumentary [-] rashes, lumps, sores, itching, muscle pains, joint pains, joint swelling,
changes in color, changes in hair/nails

HEENT [-] blurring of vision, tinnitus, deafness, epistaxis, frequent colds, hoarseness,
dry mouth, gum bleeding, enlarged LN

Respiratory [-] dyspnea, hemoptysis, dry cough, wheezing

Cardiovascular [-] palpitations, chest pain, syncope, orthopnea

Gastrointestinal [-] dysphagia, heartburn, constipation, diarrhea, rectal bleeding, jaundice

Last BM: 1 day PTA

Endocrine [-] excessive sweating, heat intolerance, polyuria, excessive thirst, cold
intolerance

Genitourinary [+] urinary retention

[-] dysuria, sexual dysfunction

Neurological [-] seizures, tremors

Past Medical History
The patient has no history of Hypertension, Pulmonary TB, DM, Cirrhosis, CAD, High
Cholesterol, PVD, Bleeding tendencies, DVT/Clots, Stroke, Claudication, COPD, or Chronic
Bronchitis/Asthma. The patient has had no previous surgeries or previous hospitalizations. He
has no allergies to food or medications.

Immunization History
The patient has allegedly complete COVID-19 vaccines (Sinovac x 2) and boosters
(Astrazeneca x 2)

Family Medical History

The patient has no family history of Hypertension, Pulmonary TB, DM, Cirrhosis, CAD, High
Cholesterol, PVD, Bleeding tendencies, DVT/Clots, Stroke, Claudication, COPD, or Chronic
Bronchitis/Asthma.

Personal and Social History

The patient has a 19 pack-year history of smoking, and drinks 2-3 bottles of beer per week. HE
denies illicit drug use.

Stakeholder Analysis
Stakeholder Stake? WIIFM Stand on Intensity Deg. of Insight/Action
Issue on Influence
Stand

Wife Primary Caretaker Supportive High High Educate the wife about the
prognosis of the patient and
the possible timeline of
recovery of her husband. To
promote continuity of care,
the wife must be educated
as to the necessary
supportive measures that
need to be done in the
setting of their home.

Child Secondary Supportive Medium Medium Educate the child how he

caretaker can take care of his father
in the household setting.

PhilHealth Membership Services/ Medium Medium Monetary benefits in order

benefits, benefits to help with
mandated by law rendered healthcare-associated
costs.
 OBJECTIVE
General Survey
The patient is awake, conversant, not in cardiorespiratory distress, stretcher-borne

Vital signs
BP 110/70
HR 90 bpm
RR 19 cpm
O2 saturation 99% at room air
Temperature 36.7

Anthropometrics
Height 5’6”
Weight 71 kg
BMI 24.6 (Overweight by WHO Asian-BMI classification)

Physical Examination
HEENT Anicteric sclerae, no naso-aural discharge, no tonsillopharyngeal
congestion

Neck No masses, trachea is midline

Respiratory Equal chest expansion, no retractions, (-) Litten’s sign, functional cough,
good diaphragmatic strength

Cardiovascular Adynamic precordium, normal rate, regular rhythm, no murmum, point of

maximal impulse at the 5th ICS left mid-clavicular line

Gastrointestinal Flat, normoactive bowel sounds, soft, nontender abdomen, no masses on

palpation
DRE: (+) Grade 2 internal hemorrhoids, circumferential, non-bleeding,
non-tender, no discharge

Extremities No edema, CRT < 2 seconds on all extremities, no cyanosis

Genitourinary Grossly male, no suprapubic tenderness, no urethral discharge, on IFC

with free flowing urine

Neurological GCS 15 (E4V5M6)

Musculoskeletal Exam

Inspection No swelling, no atrophy

Palpation No warmth, no edema, no spasticity

Range of Motion Full ROM of bilateral shoulders, elbows, and

wrists, MCPs and IP joints, actively done,
pain-free

Limited ROM of both hips due to pain,

actively done

Full ROM of knees & ankles, actively done,

pain-free

Manual Muscle Testing

Right Left

C5-T1 5 5

L2 4* 4*

L3-S1 5 5

UE MIS = 50/50
LE MIS 48/50
* with pain

Sensory Exam
Right Left

C2-L2 2 2

L3-L5 1 1

S1-S3 1 1

S4/S5 0 0

SIS = 98/112
ASIA Grade

Deep Tendon Reflexes

Right Left

Biceps Normoreflexive Normoreflexive

Triceps Normoreflexive Normoreflexive

Brachioradialis Normoreflexive Normoreflexive

Patellar Normoreflexive Normoreflexive

Achilles tendon Normoreflexive Normoreflexive

Sacral Reflexes
● (-) Bulbocavernosus reflex
● (-) Perianal wink
● (-) Voluntary anal contraction
● (-) Deep anal pressure
● (-) Perianal sensation

Pathological Reflexes
● (-) Babinski, bilaterally
● (-) Hoffman’s, bilaterally
● (-) Clonus, bilaterally
 ASSESSMENT
Workup
● X-ray (March 29, 2023 - Day 1 of admission)
○ Compression deformity of L1
■ Decreased vertebral body height of L1 vertebral
■ Increased intervertebral space between T12 and L1

Fig 1. Compression Deformity of L

Salient Features
● Patient J.M. 45/M Cignal technician from Taytay, Rizal, Roman Catholic
● CC: low back pain
● Fall (~10 ft)
● Urinary retention
● LE MIS 48/50; SIS = 98/112; ASIA D
● Saddle anesthesia
● (-) Sacral reflexes
● Limited ROM of both hips due to pain, actively done

Problem List
Biomedical Problems Nonmedical Problems

Low back pain 19 pack-year history of smoking (currently

inactive)
Differential Diagnoses

Differential Diagnoses Rule-in Rule-out

Conus medullaris syndrome Low back pain radiating to legs

Sensory dysfunction
Bladder and bowel dysfunction
Saddle anesthesia
Sudden onset and bilateral

Cauda equina syndrome Low back pain radiating to legs Sudden onset and bilateral
Sensory dysfunction Early onset of bladder and
Bladder and bowel dysfunction bowel dysfunction
Saddle anesthesia

Rationale/Pathophysiology of Primary Impression

Conus medullaris syndrome is caused by an injury or insult to the conus medullaris and lumbar
nerve roots. Injuries at the level of T12 to L2 vertebrae are most likely to result in conus
medullaris syndrome. Conus medullaris injury may result from lumbar canal stenosis due to
herniation of intervertebral discs, trauma, tumors, vascular lesions, or infection.

PLAN
Short Term Goals
● Adequate pain Control
● Stabilization of spinal fracture
● Timely mobilization with appropriate brace, unless advised surgery by the Orthopedic
service
● Prevention of nosocomial complications such as pneumonia and pressure sores

Long Term Goals

● Independent bipedal ambulation
● Community reintegration and return to work, especially since the patient is the
breadwinner of the family
● Socially acceptable bladder and bowel habits