Mrs. X , A 63-year-old house-wife, mother of two children hailing from Y was admitted to our unit on 19.10.19 with the complaints of severe low back pain for 2 months and weakness of both lower limbs for 15 days . ---------- Case Summary for Medical Board Presented by- Dr. Lisanul Hasan, Intern Doctor, SU-3, DMCH

1. Case Summary for Medical Board
Presented by- Dr. Lisanul Hasan, Intern Doctor, SU-3, DMCH
Mrs. X , A 63-year-old house-wife, mother of two children hailing from Y was admitted to our unit on
19.10.19 with the complaints of severe low back pain for 2 months and weakness of both lower limbs for
15 days .
According to the statement of the patient she was reasonably well 2 months back since when she
developed low back pain more localized to the area of lumbar spine which was mild initially but gradually
increased in last 15 days. The pain is sharp, shooting in nature, aggravated during movement and
relieved to some extent by oral analgesic and rest. The pain radiates to back of the both thighs and both
knee joints. There is no history of trauma.
She developed sudden weakness of both lower limbs 15 days ago causing her unable to walk.
Her bladder and bowel habits are normal.
There was no history of fever or weight loss or joint pain.
The patient is hypertensive for 15 years and is controlled on medication. She is non diabetic. She has no
history of contact with TB patients.
No significant family history.
She comes from a middleclass family, lives in a brick-built house, uses sanitary latrine and drink tube well
water.
History of chewing betel leaf with betel nut and jorda for 30 years
No significant travel history.
On examination:
Patient is anxious and ill looking, decubitus on lying position, moderately anemic (2 unit transfusion
given), vitals are normal (pulse: 80 bpm, BP: 150/70mmHg, temperature: Normal, RR: 16 breaths /min,
Heart sound: S1+S2+0 ). No clubbing, lymphadenopathy, edema or dehydration.
Examination of Lower limb and Back:
On inspection no muscle wasting, no scar mark or skin pigmentation and fasciculation. Muscle tone
reduced. Muscle power is 2/5 in both lower limbs.

2. Knee jerk absent on both sides. Ankle jerk diminished. Planter response equivocal bilaterally. Clonus
absent. Position and vibration sensation, fine and crude touch sensation was intact. There is no visible
spinal deformity. Gibbus absent.
Respiratory system examination reveals chest movement diminished on the right side. Vocal resonance
increased, Percussion note dull, Breath sound is diminished on the right lower zone along right mid
clavicular line.
Abdominal system examination reveals no abnormality.
Other systemic examination reveals normal findings.
Investigation profile
MRI of lumber spine with whole spine survey
Metastasis involving L3,4,5,and sacral vertebral body and posterior element.
Central and both paracentral disc herniation and flaval thickening resulting bilateral lateral recess
obliteration and neural foraminal narrowing resulting both exciting nerve root compression.
CT guided FNAC from L4 vertebral body: Metastatic adenocarcinoma
PET CT on 29.10.19-
FDG avid soft tissue density lesion in right lower lung likely to be primary malignancy .
Another FDG avid soft tissue density nodule in right upper lung . Possibility of lung infiltration could not be
ruled out.
Right sided plural thickening with FDG uptake likely to be plural infiltration.
Right sided mild plural effusion.
Enlarged right adrenal gland with FDG avid hypodense nodule likely to be adrenal metastasis.
Extensive FDG avid bony lesion suggest skeletal metastasis .
Tumor marker:
CA 19.9- 205600 U/mL
CEA-102 ng/mL
CA 125- 57.8 U/mL

3. Urinary Bence Jones protein: Absent
Serum protein electrophoresis: Mildly elevated gamma fraction which most likely represent polyclonal
hypergammaglobulinemia. No underlying monoclonal band is noted.
CBC- Hb-8.4%, ESR-41mm in 1st hour
RBS-4.42 mmol/L
S. creatinine-0.99 mg/dL
SGPT-46 U/L,PT-12 sec, APTT-26 sec
ECG- No significant abnormality detected
Chest X ray- Shows – Opacity at the right upper lung.
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