50F L4-L5 INFECTIVE SPONDYLODISCITIS SECONDARY TO TUBERCULOSIS

CHIEF COMPLAINTS 


50/F HOUSEWIFE BY OCCUPATION CAME TO ORTHOPAEDICS OPD WITH COMPLAINTS OF  LOWER BACK PAIN SINCE 2 MONTHS RADIATING TO RIGHT LOWER LIMB


HISTORY OF  PRESENT ILLNESS:


PATIENT WAS APPARENTLY ASYMPTOMATIC 2 MONTHS BACK THEN HE DEVELOPED LOWER BACK PAIN WHICH WAS INSIDIOUS IN ONSET, GRADUALLY PROGRESSIVE, DRAGGING TYPE, AGGREVATED BY BENDING AND SITTING .RADIATING TO RIGHT LOWER LIMB. TINGLING, NUMBNESS + IN RIGHT LOWER LIMB

H/O TRAUMA 16 DAYS BACK BUT NO H/O LOC, ENT BLEED, HEAD INJURY LATER PATIENT WAS TAKEN TO NIMS FOR PET CT, AFTER ADVICING IN VIEW OF TUMOUR OF UNKNOWN ETIOLOGY WHICH SHOWED METOBOLICALLY ACTIVE CAVITATORY LESIONS IN BOTH THE LUNGS, MULTIPLE PULMONARY NODULES, NODAL DISEASE AND SKELETAL LESION.RENAL PARAMETERS WAS DERRANGED.

NO H/O FEVER

H/O NEUROLOGICAL CLAUDICATION PRESENT

BOWEL &BLADDER REGULAR

NON ALCOHOLIC NON SMOKER 

APPETITE REDUCED 


PAST HISTORY

N/K/C/O HTN, DM, TB, BA, EPILEPSY, CVA, CAD, ASTHMA 


GENERAL EXAMNATION :

PATIENT IS CONCIOUS ,COHERENT , COOPERATIVE

TEMP-AFEBRILE

PR-84BPM

RR-18CPM

BP-140/80 MMHG

SP02- 98% AT RA 

GRBS-150 MG/DL


LOCAL EXAMINATION OF SPINE:


SKIN NORMAL

DEFORMITY ABSENT

CREPITUS ABSENT

SWELLING ABSENT

SWELLING ABSENT

LOCAL RISE OF TEMPERATURE PRESENT

TENDERNESS PRESENT

ABNORMAL MOBILITY ABSENT

ROM- RESTRICTED

RIGHT LEFT

SLRT 80 DEGREE 80DEGREE

HIP FLEXION 5/5 5/5

EXTENSION 5/5 5/5

KNEE FLEXION 5/5 5/5

EXTENSION 5/5 5/5

ANKLE

DORSIFLEXION 5/5 5/5

PLANTAR FLEXION 5/5 5/5

EHL 5/5 4/5

FHL 5/5 5/5

EXTENSION 5/5 5/5

ANKLE

DORSIFLEXION 5/5 5/5

PLANTAR FLEXION 5/5 5/5

EHL 5/5 4/5

FHL 5/5 5/5

SENSATIONS INTACT INTACT

DISTAL PULSES PRESENT ON BOTH SIDES

Investigations 




ECG- NORMAL SINUS RHYTHM


2D ECHO

NO RWMA, MILD LVH +, SCLEROTIC AV, NO AS/MS, IAS INTACT, EF + 55%, RVSP = 32+10= 42

MM HG, GOOD LV SYSTOLIC FUNCTION, DIASTOLIC DYSFUNCTION, MINIMAL PE, IVC SIZE -

1.15 CMS NON-COLLAPSING


CULTURE AND SENSITIVITY(SAMPLE FROM SURGICAL SITE) ON 18/1/24 -

NO GROWTH AFTER 48 HRS OF INCUBATION



DIAGNOSIS: L4-L5 INFECTIVE SPONDYLODISCITIS


Treatment Given


PATIENT WAS CLINICO-RADIOLOGICALLY DIAGNOSED WITH L4-L5 INFECTIVE SPONDYLOLITIS SECONDARY TO KOCHS AND PLANNED FOR L3,4,L5 FIXATION + L4 LAMINECTOMY.

PULMONOLOGY REFERRAL WAS DONE ON 26/12/23 I/V/O PET CT FINDINGS AS METABOLICALLY ACTIVE CAVITATORY LESIONS IN BOTH THE LUNGS, MULTIPLE PULMONARY NODULES,NODAL DISEASE AND SKELETAL LESION-ADVISED FOR BRONCHOSCOPY, PT,APTT, INR,BT,CT AND REVIEW WITH REPORTS.


BRONCHOSCOPY WAS DONE ON 27/12/23 AND ADVISED FOR BRONCHIAL WASHINGS FOR CYTOLOGY, TC,DC,GRAM STAIN,FUNGAL STAIN,FUNGAL CULTURE, CULTURE AND SENSTIVITY,AFB, TRUENAAT.REPORT SHOWED THICK SECRETIONS PRESENT THROUGHOUT.UNHEALTHY NASAL MUCOSA WITH SECRETIONS WITH SWOLLEN ARYEPIGLOTTIC FOLDS WITH UNHEALTHY TRACHEAL MUCOSA WITH THICK SECRETIONS.NARROWED RIGHT UPPER LOBAR BRONCHUS WITH THICK MUCUS PLUGS AND SECRETIONS PRESENT


ON 27/12/23 PULOMONOLOGY REVIEWED THE CASE AND ADVISED FOR NEPHROLOGY OPINION IN VIEW OF DERANGED RFT


ON 27/12/23 NEPHROLOGIST REFERRAL WAS DONE AND ADVISED FOR USG ABDOMEN I/NIO DECREASED KIDNEY SIZE AND RPD CHANGES

PAC WAS DONE ON 28/12/23. ADVISED FOR PULMONOLOGY OPINION IN VIEW OF TB,AND ALSO NEPHROLOGY OPINION FOR DERANGED RFT.

ON 29/12/23 PULMONOLOGY REVIEWED THE CASE AND ADVISED FOR GENERAL MEDICINE I/V/O DERANGED LFT 

OPINION I/NIO DERRANGED RFT

ON 27/12/23 NEPHROLOGIST REFERRAL WAS DONE AND ADVISED FOR USG ABDOME I/V/O DECREASED KIDNEY SIZE AND RPD CHANGES

PAC WAS DONE ON 28/12/23. ADVISED FOR PULMONOLOGY OPINION INIO TB,AND ALSONEPHROLOGY OPINION FOR DERANGED RFT.

ON 29/12/23 PULMONOLOGY REVIEWED THE CASE AND ADVISED FOR GENERAL MEI REFERRAL INIO DERANGED LFT

USG DONE ON 29/12/23: IMPRESSION-BILATERAL GRADE 2 RPD CHANGES

CULTURE SENSITIVITY REPORT:

ZN STAIN -ACID FAST BACILLI SEEN

KOH MOUNT-NO FUNGAL ELEMENTS SEEN

GRAM STAIN-FEW INFLAMMATORY CELLS ,FEW GRAM NEAGTIVE BACILLI SEEN

PSEUDOMONAS AEURAGINOSA ISOLATED

ON 29/12/23 NEPHROLOGIST REVIEWED THE CASE AND ADVISED TO START ATT - C ISONIAZID,PYRAZINAMIDE, RIFAMPICIN AT REGULAR DOSES AND ETHAMBUTOL @1/2DOSE

 PATINET WAS STARTED ON ATT ON 29/12/23 - TAB ISONIAZID 300MG PO OD, TAB RIFAMPICIN 600MG PO OD, TAB PYRIZINAMIDE 1500 MG PO OD, TAB ETHAMBUTOL 400MG PO OD.

REVIEW PAC WAS DONE ON 3/1/24 AND PLANNED FOR SURGERY ON 8/1/24

PULMONOLOGY REFERRAL WAS DONE ON 8/1/24 AND ADVISED REVIEW IN DOTS CENTRE AFTER 3 DAYS WITH LFT REPORTS

NEPHROLOGY REFERRAL WAS DONE ON 8/1/24 AND ADVISED FOR TREATMENT -

1.IV FLUIDS NS @50ML/HR

2. INJ LASIX 20MG IV BD

3. T.NODOSIS 500MG PO BD

4. T.OROFER XT PO OD

PULMONLOGY REFERRAL DONE ON 11/1/24 AND ADVICED -

1.T.LEVOFLOX 750 MG PO OD

2. T.ETHAMBUTOL 15 MG/KG THRICE WEEKLY

3. WITHOLD T.PYRAZINAMIDE

4. T.UDILIV 300MG PO BD



PULMONLOGY REFERRAL DONE ON 16/1/24 AND ADVICED -

1. T.LEVOFLOX 750 MG PO OD

2. T.RIFAMPICIN 10MG/KG PO OD

3. T.BENADON 40MG PO OD


4.IN VIEW OF NEPHROLOGY OPINION - T.ETHAMBUTOL 15MG/KG THRICE WEEKLY

5. WITHOLD T.PYRAZINAMIDE



REVIEW PAC ON 16/1/24 - REPEAT LFT TO OT


SURGERY WAS DONE ON 17/1/24 BY DR.CH ANIL KUMAR AND THE SURGERY DONE WAS L3-L4-L5 PSF + L4 LAMINECTOMY


PATIENT WAS HEMODYNAMICALLY STABLE AND SHIFTED TO POW.FOLEYS REMOVED ON DOD 1 AND UNDER ASPETIC CONDITIONS POST OPERATIVE DRESSING DONE ON POD-0,2,5,10.2. T.ETHAMBUTOL 15 MG/KG THRICE WEEKLY

3. WITHOLD T.PYRAZINAMIDE

4. T.UDILIV 300MG PO BD

PULMONLOGY REFERRAL DONE ON 16/1/24 AND ADVICED -

1.T.LEVOFLOX 750 MG PO OD

2.T.RIFAMPICIN 10MG/KG PO OD

3. T.BENADON 40MG PO OD

4.I/V/O NEPHROLOGY OPINION - T.ETHAMBUTOL 15MG/KG THRICE WEEKLY

5. WITHOLD T.PYRAZINAMIDE

REVIEW PAC ON 16/1/24 - REPEAT LFT TO OT

SURGERY WAS DONE ON 17/1/24 BY DR.CH ANIL KUMAR AND THE SURGERY DONE WAS L3-L4-L5 PSF + L4 LAMINECTOMY

PATIENT WAS HEMODYNAMICALLY STABLE AND SHIFTED TO POW.FOLEYS REMOVED ON POD 1 AND UNDER ASPETIC CONDITIONS POST OPERATIVE DRESSING DONE ON POD-0, 2,5,10. WOUND HEALTHY. COMPLETE SUTURE REMOVAL DONE ON POD 12.

POST OPERATIVE CLINICAL FINDINGS:

RIGHT LEFT

KNEE FLEXION 5/5 5/5

EXTENSION 5/5 5/5

ANKLE

DORSIFLEXION 5/5 5/5

PLANTAR FLEXION 5/5 5/5

EHL 5/5 4/5

FHL 5/5 5/5

NO WOUND SOAKAGE

ACTIVE TOE AND ANKLE MOVEMENTS

DISTAL PULSES PRESENT

CLINICAL FINDINGS DURING DISCHARGE - NO WOUND SOAKAGE, ACTIVE TOE AND ANKLE MOVEMENTS RIGHT LEFT

KNEE FLEXION 5/5 5/5

EXTENSION 5/5 5/5

ANKLE

DORSIFLEXION 5/5 5/5

PLANTAR FLEXION 5/5 5/5

EHL 5/5 4/5

FHL 5/5 5/5

SENSATIONS INTACT INTACT


FINAL DIAGNOSIS - L4-L5 INFECTIVE SPONDYLODISCITIS SECONDARY TO KOCH’S

SURGERY DONE L3-L4-L5 PSF + L4 LAMINECTOMY 


SHE WAS BEING DISCHARGED ON 17TH JANUARY 2024.

T.AKT 4 ONE PACK PER DAY PO OD T.CEFTAS CL 200MG PO BD X 5 DAYS

T.PAN 40MG PO OD X 5 DAYS T.BENADON FORTE 20MG PO OD T.LIMCEE 500MG PO BD X 15 DAYS

TAB NEUROKIND LC PO HS X 21 DAYS

TAB SHELCAL CT PO OD X 21 DAYS


PATIENT CAME FOR FOLLOW UP ON FEBRUARY 26TH - PAIN WAS REDUCED AS COMPARED TO BEFORE. PATIENT IS COMPLIANT TO MEDICATION.

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