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My Case study is due tomorrow morning. I have to present it to the class. I
will try to paste it to this page so you all can see. I hope it works. If
you have any suggestions please let me know. The name on it is not my own but
the rest is me except for I was playing the doctor so that isin't my doctors
name. At the end is facts.
Sarah
S. O. A. P. note
Subjective
The patient was a normal active 15 year old girl. She now can not move her
lower extremities or feel them. Her chief complaint is ôI canÆt move my
legsö.
Objective
The information note in the subjective section was again noted along with
bilateral weakness also noted. Given her spinal fluid findings, her lack of
clinical improvement in MRI findings it was decided to begin her on a three
day course of Solu Medrol per day followed by Prednisone taper.
Assessment
Acute Transverse Myelitis
Plan
¸ Physical therapy- to have daily until discharged and as on outpatient we
will
decide at a later time. Focus on flexibility and trunk control.
Strengthening of
lower extremities especially in the left leg and hip.
¸ Occupational therapy for activities of daily living, lower extremity and
hygiene and dressing, and toilet transfers.
¸ Social Services may be needed if paresis continues.
¸ I will see the patient while in the hospital and then I would like for her
to
come in for checkups thereafter which will be later noted.
Case Study
Identifying data
Patient: Brianna Taylor
Female, 15 years old
Date seen: November 24, 1996
Date of diagnosis November 1996
Facility Data
Facility: Mercy Hospital, Des Moines, IA
Department: Pediatric Intensive Care Unit
Doctor: Dr. Sarah Sullivan
Referral: Dr. Kimberly Blakeslee, ER
History
Brianna is a 15 year old whom I originally saw at DMGH ER and whose
transfer we arranged to Mercy Hospital Medical Center. She says the
difficulty began yesterday at approximately 2:30 p.m. when she was washing
dishes with a friend, and then fell. She says she did not slip but that her
legs
just gave out form underneath her. She stated that she sat around most of the
day, although went to a birthday party last evening but had to walk c
assistance. This a.m. the patient awakened and took a shower. Afterwards
she could still walk, but with a limp. She got dressed and then sat down and
then could not move unexpectedly her bilateral lower extremities. There is a
positive numbness on both legs. Positive tingling down both legs. The
patient stated that the signs and symptoms of weakness and paralysis started
below the knees and now have progressed to the whole legs bilaterally.
Past History: Past medical history has been unremarkable
Habits: She does not smoke cigarettes nor drink alcohol. She denies the use
of street drugs.
Allergies: No known medical allergies.
Medications: None.
Family History: No family history of neuromuscular disease.
The patient has a 24 hour history with progressive bilateral leg weakness,
left
greater than right. She exhibits hyporeflexia on her examination. Spinal
cord
lesion, acute inflammatory demyelinating neuropathy (Guillain-Barre
syndrome) should be considered.
I recommend to place her in the PICU. Brianna will need a MRI of her spinal
cord today A probable lumbar puncture will be required also.
Assessment
Laboratory Data:
White blood count 5.2
Hemoglobin 14.9
Hematocrit 40.8
Platelets 163
Sodium 146
Potassium 3.9
Chloride 111
CO2 28
BUN 97
Creatinine .6
Over the week I feel that Brianna's reflexes in her rt. lower extremity at her
knee have become somewhat brisker and given her abnormal spinal fluid she
is more suggestive of a myelitis than peripheral neuropathy. She has also
developed some difficulty with emptying her bladder and foley catheter has
been inserted. She developed a post LP headache that eventually subsided
with IV fluids. On 12-2-96 she remained paraparetic with a neurogenic
bladder.
I feel that her study has been cosistent with transverse myelitis.
Diagnosis: Acute Transverse Myelitis
Treatment:
¸ Physical Therapy for bed mobility, transfers wheelchair mobility, standing
and balance, strengthening, and endurance as tolerated
¸ Occupational Therapy for activities of daily living, lower extremity and
hygiene and dressing, and toilet transfers.
¸ Social Services will be needed while she is inpatient if paresis is
continued.
Patient may need an AFO brace on her left leg to assist her with walking so
that hyporeflexia won't be as much of an issue, also to help for foot drop.
I have instructed the parents that I wish for the patient to remain here at
Mercy Hospital until she is stable and her paresis lessens.
Definitions and Fact sheet for Transverse Myelitis
"Myelitis" is a nonspecific term for inflammation of the spinal cord
"Transverse" refers to involvement across one level of the spinal cord.
"Transverse Myelitis" is a neurological syndrome caused by inflammation of the
spinal
cord.
PICU- Pediatric Intensive Care Unit
DMGH- Des Moines General Hospital
ER- Emergency Room
c- with
LP- Lumbar puncture (spinal tap) drawing spinal fluid from your spine
neuromuscular- concerning both nerves and muscles
bilateral- affecting two sides
hyporflexia- diminished function of the reflexes
MRI-magnetic resonance imaging
neuropathy-any disease of the nerves
paresis-partial or incomplete paralysis
Paralysis-temporary suspensino or permanent loss of
function, loss of function, loss of sensation or voluntary
motion
Rt.-right
Foley catheter-a urinary tract catheter that has a balloon
attachment at one end.
IV-intravenously
Neurogenic-originating form nervous tissue
Paraparetic-(paraparesis) partial paralysis affecting the
lower limbs
Physical Therapy consists of exercises and activities to improve muscle
control in the
area of weakness. Teaches patient how to control certain muscles and
maintain.
Occupational Therapy tries to concentrate on skills needed for independence
when the
patient is discharged from the hospital.
Transverse Myelitis Facts
¸ TM occurs without any apparent underlying cause.
¸ Approximately one third of patients with TM report a febrile illness in
close
relationship to the onset of neurological symptoms.
¸ TM symptoms develop rapidly over several hours to several weeks.
¸ Approximately 45% of patients worsen maximally within 24 hours.
¸ Age of onset of this condition can be from infancy to older adult.
¸ Peak ages are from 10-19 and after 40 years of age.
¸ Males and females are equally diagnosed.
¸ Yearly rate of TM diagnosis is 1.34 per million population.
¸ Most patients with TM show good to fair recovery which begins within 1 to 3
months.
¸ Small percentage of patients suffer a reoccurrence of this condition.
¸ Symptoms of TM include limb weakness, sensory disturbance, bowel and bladder
dysfunction, back pain and radicular pain.
Normal readings for testing done
Hemoglobin-- 12-16 g/100 of blood
Hematocrit-- 37-97%
Sodium-- 135-145m Eq/L
Potassium-- 3.5-5m Eq/L