I15193

Diagnosis: Lumbar Canal Stenosis with severe paraparesis secondary to spondylodiscitis/epidural abscess. Laminectomy L3 performed at another center

Clinical History: - The patient had been evaluated multiple times at the Primary Care Center (CAP) for lumbar canal stenosis. - Arthrodesis L2-L5 was planned but has not been performed. - Severe paraparesis post-laminectomy L3. - Post-surgery complications include requiring home oxygen therapy and presenting with a urinary catheter with mild hematuria. - General condition is stable, but there is an active herpes labialis infection.

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Current Clinical Course:

1. Gastrointestinal Evaluation:

  1. Assessed by Internal Medicine (MDI) for suspected paralytic ileus, likely secondary to lumbar pathology and/or opioid use.
  2. Plan: CT abdomen to rule out obstructive cause. Offer of nasogastric tube insertion for discomfort/nausea, but patient opted to wait for urgent CT results.
  3. Following CT, if negative for obstruction, initiate diet to stimulate peristalsis given patient's minimal intake since admission (absolute diet since 28-10).

2. Physical Examination:

  1. Blood Pressure: 148/97 mmHg, Heart Rate: 68 bpm, Oxygen Saturation: 98% on room air. Afebrile.
  2. Abdomen: Soft, non-tender, with reduced bowel sounds, no signs of peritonitis. Reports no recent passage of gas or stool.

3. Laboratory and Imaging Results:

  1. CT Abdomen and Pelvis (with contrast): Normal caliber of colon and small bowel, no signs of obstruction or mesenteric fat inflammation. Mild rectosigmoid wall edema without adjacent fat involvement. No free fluid, intra-abdominal collections, or pneumoperitoneum noted. Severe degenerative changes in the lumbar spine.
  2. Thoracic CT Findings: Centrilobular branching opacities suggesting distal airway inflammation/infection. Rib fracture calluses on the lower right side.
  3. Laboratory Results: Normal renal function and electrolytes, slight cholestasis, CRP < 3, hypoalbuminemia, and bicitopenia (leukopenia and anemia), with normal platelet count.

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Management Plan: - Abdominal/Gastrointestinal: With no evidence of intestinal obstruction, paralytic ileus, or Ogilvie syndrome, abdominal pathology is ruled out. Initiate diet to promote intestinal motility and assess bowel movements following dietary reintroduction. - Internal Medicine Consultation: MDI will continue monitoring; patient remains under combined care with Endocrinology for nutritional support and general management. - Neurological Follow-up: The patient remains pending lumbar puncture for further analysis related to suspected epidural abscess.

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The team remains available for further consultation and adjustments to the management plan.