case backup

8/8/2019 Case Backup

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UPH DR. JOSE G. TAMAYO MEDICAL UNIVERSIT

STO. NINO BINAN LAGUNA

COLLEGE OF NURSING

A Case Study about:

TB Meningitis


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INTRODUCTION


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Tuberculosis Meningitis aka Bacterial Meningitis is a medical term used to

describe an inflammation of the layers of tissue (meninges) that surround the brain orthe spinal cord.

Tuberculous (TB) meningitis occurs when tuberculosis bacteria (Myobacteriumtuberculosis ) invade the membranes and fluid surrounding the brain and spinal cord.The infection usually begins elsewhere in the body, usually in the lungs, and thentravels through the bloodstream (SEPSIS) to the meninges where small abscesses(called microtubercles) are formed. When these abscesses burst, TB meningitis is the

result.If the infection or resulting inflammation progresses past the membranes of the brainor the spinal cord, then the condition is called encephalitis (inflammation of the brain).

Meningitis is a potentially life-threatening condition that can rapidly progress topermanent brain damage, neurologic problems, and even death.

The inflammation causing meningitis is normally a direct result of either abacterial infection or a viral infection. However, the inflammation can also be causedby more rare conditions, such as cancer, a drug reaction, or a disease of the immune

system.


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Meningitis in newborns usually results from an infection of the bloodstream(sepsis). Bacteria that infect older infants and children include Streptococcuspneumoniae and Neisseria meningitidis. Haemophilus influenzae type b was the mostcommon cause of meningitis, but widespread vaccination against that organism hasnow made it a rare cause. Newer, improved vaccines against Streptococcus pneumoniaeand Neisseria meningitidis (pneumococcal and meningococcal conjugate vaccines)should also make these organisms rare causes of childhood meningitis. TB meningitisnormally begins with vague, non-specific symptoms of aches and pains, low-grade fever,generally feeling unwell, tired, irritable, not being able to sleep or eat properly, andgradually worsening headache. This lasts for two to eight weeks.In the elderly, symptoms are even more subtle, often just drowsiness and feeling unwell.

It is not until weeks later that more obvious symptoms like vomiting, severeheadache, dislike of lights(photophobia), neck stiffness and seizures occur. Withoutmedical treatment, the disease will progress causing confusion, obvious signs of nervedamage and eventually resulting in coma.

Older children and adolescents with meningitis typically have a few days ofincreasing fever, headache, confusion, and a stiff neck. Newborns and infants rarely

develop a stiff neck and are unable to communicate specific discomfort. These youngerchildren become fussy and irritable (particularly when they are held) and stop feedingimportant signs that should alert parents to a possibly serious problem. Sometimesnewborns and infants have fever, vomiting, or a skin rash. One third have seizures. Adoctor diagnoses bacterial meningitis by examining and culturing a sample of cerebrospinal fluid obtained through a spinal tap (lumbar puncture). Doctors also orderblood cultures to look for bacteria in the bloodstream and PPD (purified proteinderivative) test to establish if person is infected with TB. Ultrasonography, computedtomography (CT) or MRI may be used to determine if an abscess is present.


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Objectives

We have chosen this case because we want to exploremore on how to handle patient with this diseases. We

also want to acquire new knowledge prior to the diseasesfor future encounter.

Reason for choosing this case

We have chosen this case because we want to explore

our knowledge on this disease. We chose meningitisbecause we only encounter this rarely, hence we can sharesome information about meningitis. Also we want toacquire knowledge prior to handling cases like this in thenear future. In addition for us knowing the various factorinvolve in occurrence of the diseases would allow us to give

health teaching easily especially when it comes toprevention.


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PATIENTS PROFILE


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Name: Ms. J. P. A.

Age: 16 y/o

Address: 120 C Brgy. Balagbag, PasayCity

Birthday: 11/23/1993

Sex: Female Nationality: Filipino

Religion: Catholic

Date of Admission: 12/26/2009

Time: 7:30

Admitting Physician: Dr. A.M, MD


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General Data:This is a case of a 16 y/o female, presently residing atPasay City who was admitted last December 26,2009

Chief Complaint:On and off fever for almost 2 weeks

History of Present Illness:

Two weeks prior to confinement, patient developedmoderate to high grade fever, on and off fever,headache, dizziness, loss of apettite and bodyweakness.

four days prior to confinement, presence of nausea,admitted at a local hospital for 1 day, persistence ofsymptoms prompted consultation.

one day prior to admission, patient had twoepisodes of vomiting.


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Past medical history

in the year 2004, patient was diagnosed withTB meningitis and sinusitis.

Family medical history

patients father was diagnosed with PTB.


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PHYSICAL ASSESSMENT


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Vital signs:

B.P: 160/ 70 mmHg

P.R: 92 bpm R.R: 18cpm

Temp: 38oC

General Status:

weak looking

lethargic

Head:

Shaped is gently curved with the prominences of frontaland parietal bone.

Long black hair and evenly distributed.


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Eyes:

Symmetrically aligned with the ears.

Dilated pupil at 3-4 mm Pinkish palpebral conjunctiva.

(-) jaundice

Ears:

No active discharged.

Palpable lymph nodes.

Nose:

No active discharged.


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Neck:

(+) Nuchal Rigidity

Heart: Normal rate and regular rhythm

No murmurs

Chest and lungs:

Symmetrical and lungs expansion

No retraction

With clear breaths sound

(-) murmurs


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Abdomen:

With abdominal scales rashes

No tenderness

Flabby abdomen

Skin:

Good skin turgor

Flushed skin

(+) eczema on anterior left leg

Musculoskeletal:

Full pulse and equal No edema

(+) Kernig's sign

(+) Brudzinski's sign


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REVIEW OF SYSTEM


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Anatomy and Physiology

Central Nervous System

The central nervous system (CNS) is the largest part of thenervous system, and includes the brain and spinal cord. The

spinal cavity holds and protects the spinal cord, while thehead contains and protects the brain. The CNS is covered bythe meninges, a three layered protective coat. The brain isalso protected by the skull, and the spinal cord is alsoprotected by the vertebrae. The central nervous system(CNS) is the part of the nervous system that functions to

coordinate the activity of all parts of the bodies ofmulticellular organisms. In vertebrates, the central nervoussystem is enclosed in the meninges.

.


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The meninges (singular meninx) are the system ofmembranes which envelops the central nervous system. The

meninges consist of three layers: the Dura mater, thearachnoid mater, and the Pia mater. The primary function ofthe meninges and of the cerebrospinal fluid is to protect thecentral nervous system. The space between thesemembranes is bathed with a spinal fluid much like lymph,

which serves as a protective cushion for the delicate nervetissue, and allows some expansion space for the brain whenits blood supply is increased.


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3 layers of Meninges:

Dura mater - (also rarely called meninx fibrosa, or pachymeninx) is a thick,

durable membrane, closest to the skull. It consists of two layers, the periosteallayer, closest to the calvaria and the inner meningeal layer. It contains largerblood vessels which split into the capillaries in the Pia mater. It is composed of

dense fibrous tissue, and its inner surface is covered by flattened cells like thosepresent on the surfaces of the pia mater and arachnoid. The Dura mater is a sac

which envelops the arachnoid and has been modified to serve several functions.

The Dura mater surrounds and supports the large venous channels (duralsinuses) carrying blood from the brain toward the heart. The falx cerebriseparates the hemispheres of the cerebrum. The falx cerebelli separates the

lobes of the cerebellum. The tentorium cerebelli separates the cerebrum fromthe cerebellum. The epidural space is a potential space between the Dura mater

and the skull. If there is hemorrhaging in the brain, blood may collect here.

Adults are more likely than children to bleed here as a result of closed headinjury. The subdural space is another potential space. It is between the Duramater and the middle layer of the meninges, the arachnoid mater. When

bleeding occurs in the cranium, blood may collect here and push down on


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the lower layers of the meninges. If bleeding continues, brain damage will resultfrom this pressure. Children are especially likely to have bleeding in the subdural

space in cases of head injury.

Arachnoid mater - The middle element of the meninges is the arachnoidmembrane, so named because of its spider web-like appearance. It provides a

cushioning effect for the central nervous system. The arachnoid mater exists as athin, transparent membrane. It is composed of fibrous tissue and, like the Pia

mater, is covered by flat cells also thought to be impermeable to fluid. The

arachnoid does not follow the convolutions of the surface of the brain and solooks like a loosely fitting sac. In the region of the brain, particularly, a largenumber of fine filaments called arachnoid trabeculae pass from the arachnoid

through the subarachnoid space to blend with the tissue of the Pia mater. Thearachnoid and pia mater are sometimes together called the Leptomeninges. The

subarachnoid space lies between the arachnoid and Pia mater. It is filled with

cerebrospinal fluid. All blood vessels entering the brain, as well as cranial nervespass through this space. The term arachnoid refers to the spider web likeappearance of the blood vessels within the space.


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Pia mater - The Pia mater is a very delicate membrane. It is the meningeal envelopewhich firmly adheres to the surface of the brain and spinal cord. As such it follows all theminor contours of the brain (gyri and sulci). It is a very thin membrane composed of fibrous

tissue covered on its outer surface by a sheet of flat cells thought to be impermeable tofluid. The Pia mater is pierced by blood vessels which travel to the brain and spinal cord,and its capillaries are responsible for nourishing the brain.

Cerebrospinal fluidis a clear liquid produced within spaces in the brain called ventricles. Like saliva

it is a filtrate of blood. It is also found inside the subarachnoid space of the meninges whichsurrounds both the brain and the spinal chord. In addition, a space inside the spinal chordcalled the central canal also contains cerebrospinal fluid. It acts as a cushion for theneuraxis, also bringing nutrients to the brain and spinal cord and removing waste from thesystem.

Choroid PlexusAll of the ventricles contain choroid plexuses which produce cerebrospinal fluid by allowingcertain components of blood to enter the ventricles. The choroid plexuses are formed bythe fusion of the pia mater, the most internal layer of the meninges and the ependyma,the lining of the ventricles.


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The frontal lobe is concerned with higher intellectual functions, such asabstract thought and reason, speech (Broca's area in the left hemisphereonly), olfaction, and emotion.Voluntary movement is controlled in theprecentral gyrus (the primary motor area).

The parietal lobe is dedicated to sensory awareness, particularly in thepostcentral gyrus (the primary sensory area). It is also concerns withabstract reasoning, language interpretation and formation of a mental

egocentric map of the surrounding area.The occipital lobe is responsible for interpretation and processing ofvisual stimuli from the optic nerves, and association of these stimuli withother nervous inputs and memories.The temporal lobe is concerned with emotional development andformation, and also contains the auditory area responsible forprocessing and discrimination of sound. It is also the area thought to beresponsible for the formation and processing of memories. The brain canbe subdivided into several distinct regions:


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Anatomy of the Brain

The brain is located in the head, protected by the skull and close to the primary

sensory apparatus of vision, hearing, balance, taste, and smell.

The brain is located in the head, protected by the skull and close to the primary sensory apparatus of vision, hearing, balance, tas


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The frontal lobe is concerned with higher intellectual functions, such asabstract thought and reason, speech (Broca's area in the left hemisphereonly), olfaction, and emotion.Voluntary movement is controlled in theprecentral gyrus (the primary motor area).

The parietal lobe is dedicated to sensory awareness, particularly in thepostcentral gyrus (the primary sensory area). It is also concerns withabstract reasoning, language interpretation and formation of a mentalegocentric map of the surrounding area.The occipital lobe is responsible for interpretation and processing ofvisual stimuli from the optic nerves, and association of these stimuli withother nervous inputs and memories.The temporal lobe is concerned with emotional development andformation, and also contains the auditory area responsible forprocessing and discrimination of sound. It is also the area thought to beresponsible for the formation and processing of memories. The brain can

be subdivided into several distinct regions:


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1. Brainstem consists of medulla oblongata, Pons and midbrain.

Medulla oblongata - is the lower portion of the brainstem. It deals with

autonomic functions, such as breathing and blood pressure. The cardiaccenter is the part of the medulla oblongata responsible for controllingthe heart rate.

Pons - relays sensory information between the cerebellum and

cerebrum; aids in relaying other messages in the brain; controls arousal,and regulates respiration (see respiratory centres). In some theories, thePons has a role in dreaming.

Midbrain (mesencephalon) - The mesencephalon is considered part ofthe brain stem. Its substantia nigra is closely associated with motor

system pathways of the basal ganglia.The human mesencephalon isarchipallian in origin, meaning its general architecture is shared with themost ancient of vertebrates. Dopamine produced in the substantia nigraplays a role in motivation and habituation of species from humans to the

most elementary animals such as insects.


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12. Cerebellum - is a region of the brain that plays an important role inthe integration of sensory perception, coordination and motor control.In order to coordinate motor control, there are many neural pathways

linking the cerebellum with the cerebral motor cortex (which sendsinformation to the muscles causing them to move) and thespinocerebellar tract (which provides proprioceptive feedback on theposition of the body in space). The cerebellum integrates thesepathways, like a train conductor, using the constant feedback on bodyposition to fine-tune motor movements.

3. Diencephalon - (or interbrain) is the region of the brain that includesthe thalamus, hypothalamus, epithalamus, prethalamus or subthalamusand pretectum. The diencephalon is located at the midline of the brain,above the mesencephalon of the brain stem. The diencephalon contains

the zona limitans intrathalamica as morphological boundary andsignalling center between the prethalamus and the thalamus.


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Thalamus - plays an important role in regulating states of sleep and

wakefulness. Thalamic nuclei have strong reciprocal connections with the

cerebral cortex, forming thalamo-cortico-thalamic circuits that are believed tobe involved with consciousness. The thalamus plays a major role in regulatingarousal, the level of awareness, and activity. Damage to the thalamus can leadto permanent coma.

Epithalamus is a dorsal posterior segment of the diencephalon (a segment in

the middle of the brain also containing the hypothalamus and the thalamus)which includes the habenula, the stria medullaris and the pineal body. Itsfunction is the connection between the limbic system to other parts of the brain.

Hypothalamus - is a small part of the brain located just below the thalamus on

both sides of the third ventricle. Lesions of the hypothalamus interfere with

several vegetative functions and some so called motivated behaviors likesexuality, combativeness, and hunger. The hypothalamus also plays a role inemotion. Specifically, the lateral parts seem to be involved with pleasure and

rage, while the medial part is linked to aversion, displeasure, and a tendency touncontrollable and loud laughing.


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4.Cerebrum - or top portion of the brain, is divided by adeep crevice, called the longitudinal sulcus. The longitudinalsulcus separates the cerebrum in to the right and lefthemispheres. In the hemispheres you will find the cerebral

cortex, basal ganglia and the limbic system. The two

hemispheres are connected by a bundle of nerve fiberscalled the corpus callosum. The right hemisphere isresponsible for the left side of the body while the opposite istrue of the left hemisphere


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PHYSIOLOGY OFTHE CNS

Medulla-The medulla is the control center for respiratory,cardiovascular and digestive functions.

Pons- The pons houses the control centers for respirationand inhibitory functions. Here it will interact with thecerebellum.

Cerebrum-The cerebrum, or top portion of the brain, isdivided by a deep crevice, called the longitudinal sulcus.The longitudinal sulcus separates the cerebrum in to theright and left hemispheres. In the hemispheres you will find

the cerebral cortex, basal ganglia and the limbic system.The two hemispheres are connected by a bundle of nervefibers called the corpus callosum. The right hemisphere isresponsible for the left side of the body while the oppositeis true of the left hemisphere.


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Cerebellum- The cerebellum is the part of thebrain that is located posterior to the medulla

oblongata and Pons. It coordinates skeletalmuscles to produce smooth, graceful motions.The cerebellum receives information from oureyes, ears, muscles, and joints about whatposition our body is currently in (proprioception).

It also receives output from the cerebral cortexabout where these parts should be. Afterprocessing this information, the cerebellumsends motor impulses from the brainstem to theskeletal muscles. The main function of the

cerebellum is coordination. The cerebellum isalso responsible for balance and posture. It alsoassists us when we are learning a new motorskill, such as playing a sport or musicalinstrument.


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The Limbic System

The Limbic System is a complex set of

structures found just beneath the cerebrum

and on both sides of the thalamus. It

combines higher mental functions, and

primitive emotion, into one system. It is often

referred to as the emotional nervous system.

It is not only responsible for our emotionallives, but also our higher mental functions,

such as learning and formation of memories.


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Peripheral Nervous System

The Peripheral Nervous System (PNS) resides orextends outside the central nervous system,which consists of the brain and spinal cord. Themain function of the PNS is to connect the CNSto the limbs and organs.

There are two types ofneurons, carrying nerveimpulses in different directions. These twogroups of neurons are:

The sensory neurons are afferent neurons whichrelay nerve impulses toward the central nervous

system. The motor neurons are efferent neurons which

relay nerve impulses away from the centralnervous system.


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Naming of specific nerves Ten out of the twelve cranial nerves originate

from the brainstem, and mainly control thefunctions of the anatomic structures of the headwith some exceptions. The nuclei of cranialnerves I and II lie in the forebrain and thalamus,respectively, and are thus not considered to betrue cranial nerves. CN X (10) receives visceralsensory information from the thorax andabdomen, and CN XI (11) is responsible forinnervating the sternocleidomastoid andtrapezius muscles, neither of which is exclusivelyin the head. Spinal nerves take their origins fromthe spinal cord. They control the functions of therest of the body. In humans, there are 31 pairs ofspinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5sacral and 1 coccygeal.


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Cervical spinal nerves (C1-C4)

The first 4 cervical spinal nerves, C1 through C4, split and recombine toproduce a variety of nerves that subserve the neck and back of head.Spinal nerve C1 is called the suboccipital nerve which provides motor

innervation to muscles at the base of the skull. C2 and C3 form many ofthe nerves of the neck, providing both sensory and motor control. Theseinclude the greater occipital nerve which provides sensation to the backof the head, the lesser occipital nerve which provides sensation to thearea behind the ears, the greater auricular nerve and the lesser auricularnerve. See occipital neuralgia. The phrenic nerve arises from nerve rootsC3, C4 and C5. It innervates the diaphragm, enabling breathing. If the

spinal cord is transected above C3, then spontaneous breathing is notpossible. See myelopathy

Brachial plexus (C5-T1)

The last four cervical spinal nerves, C5 through C8, and the first thoracicspinal nerve, T1,combine to form the brachial plexus, or plexusbrachialis, a tangled array of nerves, splitting, combining andrecombining, to form the nerves that subserve the arm and upper back.Although the brachial plexus may appear tangled, it is highly organizedand predictable, with little variation between people. See brachialplexus injuries.


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Lateral cord

The lateral cord gives rise to the following nerves:

The lateral pectoral nerve, C5, C6 and C7 to the pectoralis major muscle, ormusculus pectoralis major.

The musculocutaneous nerve which innervates the biceps muscle The median nerve, partly. The other part comes from the medial cord. See below

for details.

Posterior cord

The posterior cord gives rise to the following nerves:

The upper subscapular nerve, C7 and C8, to the subscapularis muscle, or

musculus supca of the rotator cuff. The lower subscapular nerve, C5 and C6, to the teres major muscle, or the

musculus teres major.

The thoracodorsal nerve, C6, C7 and C8, to the latissimus dorsi muscle, ormusculus latissimus dorsi.

The axillary nerve, which supplies sensation to the shoulder and motor to thedeltoid muscle or musculus deltoideus, and the teres minor muscle, or musculus

teres minor, also of the rotator cuff. The radial nerve, or nervus radialis, which innervates the triceps brachii muscle,

the brachioradialis muscle, or musculus brachioradialis,, the extensor muscles ofthe fingers and wrist (extensor carpi radialis muscle), and the extensor andabductor muscles of the thumb. See radial nerve injuries.


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Medial cord

The medial cord gives rise to the following nerves:

The median pectoral nerve, C8 and T1, to the pectoralis muscle

The medial brachial cutaneous nerve, T1

The medial antebrachial cutaneous nerve, C8 and T1

The median nerve, partly. The other part comes from the lateral cord. C7, C8 andT1 nerve roots. The first branch of the median nerve is to the pronator teresmuscle, then the flexor carpi radialis, the palmaris longus and the flexordigitorum superficialis. The median nerve provides sensation to the anteriorpalm, the anterior thumb, index finger and middle finger. It is the nervecompressed in carpal tunnel syndrome.

The ulnar nerve originates in nerve roots C7, C8 and T1. It provides sensation tothe ring and pinky fingers. It innervates the flexor carpi ulnaris muscle, the flexordigitorum profundus muscle to the ring and pinky fingers, and the intrinsicmuscles of the hand (the interosseous muscle, the lumbrical muscles and theflexor pollicus brevis muscle). This nerve traverses a groove on the elbow calledthe cubital tunnel, also known as the funny bone. Striking the nerve at this pointproduces an unpleasant sensation in the ring and little finger.

Neurotransmitters The main neurotransmitters of the peripheral nervous system are acetylcholine

and noradrenaline. However, there are several other neurotransmitters as well,jointly labeled Non-noradrenergic, non-cholinergic (NANC) transmitters.Examples of such transmitters include non-peptides: ATP,GABA, dopamine, NO,and peptides: neuropeptideY,VIP,GnRH, Substance P and CGRP.


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PATHOPHYSIOLOGY


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MODIFIABLE FACTORS:

PollutionLow economic status

NON-MODIFIABLE

FACTORS:

Age

Gender

Season


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MEDICAL MANAGEMENT

D t D t ' O d R ti l


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Date Doctor's Order Rationale

12/26/097:35pm

9:30pm

>Pls. Admit to Pavillion 3

>Secure consent for

admission andmanagement

>TPR every shift andrecord>DAT c SAP>IVF:PNSS IV to run for

10hrs>Paracetamol 500mg 1tab

q6 for temperature38C

>refer

>DAT for age w/ SAP>IVF PNSS 1Lx12hrs.

>IVF to ff. D5 0.9NaCl

1Lx12hrs

>follow up labs>continue meds

>to closely monitor thepatient for the specific

disease>for legal purposes

>to have a record on thepatient's progress>to avoid aspiration>for fluid and electrolyte

replacement>to decrease fever

>for further management

>to avoid aspiration>for fluid and electrolyte

replacement>for fluid and electrolyte

replacement>to have a baseline data

>treatment for fever


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12/27/092:00am

INH 300mg 1tab pls deluteper vial w/50ml PNSS

RIF 600mg 1tab od before

breakfastPZA 500mg 1tab od beforebreakfast

ETB 400/tab bid after meal

>for cranial CT scan plus and

contract, refer to MISreassistance

>still for lumbar puncture

>for official read of CXRdone out>Give INH 400mg/tab od>Rifampicin 450mg/cap od>refer

>treatment for tuberculosis

>to detection an increase of

enhancement andthickening of the meningesbeyond normal range

>to analyze the

cerebrospinal fluid

>for detection of chestcavity>TB meds>TB meds>for further management


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12/29/09BP 110/70

12/30/09

12/31/09

01/01/10

01/02/10

>CSF analysis>Ceftriaxone to 3g IV od>Continue Dexamethasone

>for CXR>Cranial CT Scan

>repeat Na,Cl, K

>IVF to follow D50.3NaCl1Lx12hrs

telephone: IVF to ff: D5 IMB

1L x 10o

>IV

F D5NM 1L x 10o

>continue management

>IVF to ff. PNSS 1L x 10o

>antibiotic>steroids>to justify having TB

>to detect an increasedegree of enhancementand thickening of the

meninges beyond normalrange>for electrolyte imbalance

>for electrolyte imbalance


>for further management



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01/03/10

01/04/10

01/05/10

01/06/10

01/07/10

>for LP>paracetamol q8o headache

>continue anti-koch's meds

>change IV site

>cranial CT scan

>for CBC and platelet count

>for follow up result of CT

scan

>for possible discharged

>for CSF analysis>anti-pyretics

>for TB treatment

>to avoid infiltration andphlebitis

>detection for thethickening of the meninges

>to have a baseline data anddetection of the presence ofinfection

>detection of the thickening

the meninges


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DIAGNOSTIC

EXAMINATIONS


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12//29/2010

CT Scan of the head

Plain and contrast. Enhanced axial 64-VCT scan images of the head show diffuse undueenhancement of the leptomeninges.

There is moderate dilatation of the ventricular system, more severe in the frontal andtemporal horns of the right lateral ventricle.

Non-enhancing periventricular hypoattenuation is seen and the lateral ventricles, also worseon the right fronto-temporal.

The rest of the supra and infra tentorial brain parenchyma is normal in attenuation.

There is no evident mass of hemorrhagic extravasation.

The peripheral sulci and the sylvian, interhemispheric and cerebellar fissures are effaced.

The left mastoid is sclerosed with soft tissue densities in the anthrum and lymphanic cavity.

The sella, extrasellar and intraorbital structures, cerebellopontis angles, right petromastoidand bony calvasion are intact.

IMPRESSION:

1.Diffuse leptomeningitis

2. Moderate communicating hydrocephalus with signs of increased intraventricularpressure.

3.Superimposed encephalomalacia with central volume loss in the right fronto-temporallobes.

4. Chronic otomastoiditis, left.


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The diagnosis of meninges requires ananalysis of cerebrospinal fluid, CT scan of the

head before performing lumbar puncture in

order to identify occult intracranial

abnormalities and thus avoid the risk of brain

herniation resulting from the removal ofcerebrospinal fluid.


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1/4/2010

Lumbar Puncture

CSF: 37.45%

Test Name

Result

Range

Significance

Glucose

2.15 mmol/l

2.2-4.13 mmol/l

Glucose level may decrease when cells that are not normally present useup (metabolized). These may include bacteria due to inflammation.

Total protein

15.69 g/l 0.00035 g/l

Only small amount of protein is normally present in CSF because proteinare large molecules and do not cross blood / brain barrier easily.


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Cerebrospinal fluid cell count may help

diagnose meningitis and infection of the

brain and spinal cord, a tumor, abscess, orarea of tissue death (infarct), and it helps

identify inflammation.


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1/4/2010

Urinalysis

A.Physical

Sugar = negative Protein = negative

B.Microscopic

RBC = 1-2 0-2/hpf

WBC = 1-2 0-5/hpf


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Exam name Result Unit Ref.Value Significance

WBC 15.5 x10^9/L 4.8-10.8 Increase in wbc indicates

presence of infection.

RBC 4.1 x10^12/L 4.2-5.4 Low red blood cell

indicates anemia.

Hemoglobin 12.7 g/dL 11.6-15.5 Hemoglobin is important

to the oxygen carrying

capacity of blood.

Hematocrit 36.7 % 36-47 Conditions that can result

a low hematocrit

indicates anemia such as

that caused irondeficiency.

Platelet count 149 x10^3/uL 150-450 thou Patients with

meningococcal

meningitis have

abnormalities in the

platelet functions mainly

in aggregation and

adhesiveness.

12/27/09Hematology


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DRUG STUDY


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Drug name Mechanism of

action

Indication Contraindication Adverse effect Nursing

consideration

Generic Name

Pyrazinamide

Brand NameMycobak

ClassificationAnti-infectives

Dosage250ml/5ml 3mlBID

Unknown highly

specific andbactericidal ofmycobacteriumtuberculosis

hominis.

Treatment of

activetuberculosis inadults andselected children

Acute liver

disease,hypersensitivityperipheralneuritis.

Nausea and

vomiting,anorexia,

thrombocytopenia,

mild arthralgia and

myalgia and

hypersensitivity

reaction

-Assess patient's

condition beforetherapy.

-Monitor drugeffectiveness

-Monitor serumuric acid whichmay be elevatedand causesymptoms.

-Monitor fordrug adversereaction

-Regularly assessrenal status.


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action


consideration

Generic Name

Isoniazid

Brand NameNydrazid

ClassificationAnti tubercular

Dosage200mg/5ml25o.d.

The most effective

tuberculostaticagent. Probably

interferes with

lipid and nucleic

acid metabolism of

growing bacteria,

resulting in

alteration of the

bacterial wall.

Tuberculosis

caused byhuman bovineand BCG strainsofmycobacteriumtuberculosis.

Severe

hypersensitivityto isoniazid.Associatedhepatic injury or

side effects.

Peripheral

neuropathy,nausea andvomiting, heartburn, dizziness,optic neuritis,hepatitis.

-Note reason for

therapy,type/onset ofsymptoms.

-Monitor renaland liverfunction test

-Performpulmonary notecough/sputumcharacteristics.

-Report anyvisual

disturbances.


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consideration

Generic NameRifampicin

Brand NameNatricine Forte

Classification

Anti-infective/anti-tubercular

Dosage200ml/5ml2.5ml OD

Inhibits DNA-dependent RNA

polymerase insusceptiblestrains of

bacteria.

Short termmanagement to

eliminatemeningococcifromnasopharynx inNeisseriamengitidiscarriers.

Hypersensitivity

to rifamycin

Hypotension,

shock, headache,

drowsiness,fatigue, dizziness,

inability to

concentrate,

mental confusion,

generalized

numbness, rash,

pruritus, urticaria,

flushing, visualdisturbances,

epigastric distress,

anorexia, nausea,

vomiting, cramps,

diarrhea, soremouth and tongue,

acute renal failure,

shortness ofbreath, wheezing,muscular

weakness and pain

in extremities.

-Observe IV site closely

for extra-vasation

-Administer solutionfor injection by IV

-If D5W iscontraindication, use

sterile saline. Do not

mix with other

solutions.

-Initial final dilutions of

drug in vial are stablefor 24 hr at roomtemperature.

-Assess baseline

neurologic status andobserve for changes.

-Monitor Intake and

Output and assess for

development ofedema.

-Assess skin prior tostarting drug

treatment for rash,

pruritus, flushing,

urticaria and jaundice


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Generic Name

Paracetamol

Brand NameAeknil

ClassificationAnalgesics(Non Opiod andAntipyretics)

Dosage300mg IV q4

Paracetamol

producesanalgesia byraising thethreshold of thepain center inthe brain andobstructingimpulses at thepain mediatingchemoreceptors.The drugproducesantipyresis by anaction on thehypothalamus;

heat dissipationis increased as aresult ofvasodilation andincreasedperipheral bloodflow.

Pyrexia of

unknown originand forsymptomaticrelief of feverand painassociated withcommonnchildhooddisorders,tonsillitis, upperrespiratory tractinfections, postimmunizationreactions, aftertonsillectomy for

prevention offebrileconvulsions.Headache, coldsinusitis,musclepain, arthritisand toothache.

Nephropathy. . Skin eruption,

hematologicaltoxicity,thrombocytopenia andleukopenia,methemoglobinaemia which canresult in cyanosisand long termuse, renaldamage canresult.

Toxicity mayresult from a

single toxic doseof the drug orfrom chronicingestion

-Should be given

with care to

patients with

impaired hepatic or

remal function.

-Paracetamol

overdosage should

be treated with

gastric lavage if the

patient is seenwithin 4hrs ofingestion of Aeknil.

-If forgotten, take

the missed dose as

soon as youremember. If it is

almost time for

your next dose,

skip the missed

dose and return to

your normal dosing

schedule.

-Avoid alcohol


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Generic Name

Ethambutol

Brand Name

Odetol

Classification

Antituberculosis/

Antileprosy

Dosage

12mg/kg first day

6mg/kg second

day

The inhibitory

effect of the drug

on multiplication

did not become

apparent until

several hours after

its addition to the

culture. The drug

had no effect on

the survival of

nonproliferatingcells. It had little orno effect on the

metabolism of

nonproliferating

cells, but cells from

cultures whosegrowth had been

inhibited by

ethambutol

showed evidence

of impaired

metabolism. C14-

labeled ethambutol

was taken up

rapidly by both

proliferating and

nonproliferatingcells.

Oropharyngeal

and esophagealcandidiasis,vaginalcandidiasis,prevention ofcandidiasis inbone marrowtransplant;cryptococcalmeningitis.

Hypersensitivity

to fluconazole,and other azoleantifungals. Co-administrationwith cisaprideand terfenadine.

. Headache,

seizure, rash,exfoliative skindisorder, nauseaand vomiting,abdominal pain,diarrhea,leucopenia,thrombocytopenia, hepaticreactions,includingabnormal LFTresults,hepatitis,cholestasis,

hepatic failure.

-Assess for signs anssymptoms of

infection; obtain C&Sbaseline and duringtreatment, drug maybe started as soon asculture is taken.

- Monitorhepatotoxicity;

increased AST, ALT,

alkalinephosphatase,bilirubin, drug will bediscontinued ifhepatotoxicityoccurs.

-Monitor for possible

adverse reactions:

CNS headache,GI:nausea, vomiting,abdominal pain,diarrhea, hepatic:hepatotoxicity Skin:stevens-johnsonssyndrome.


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Generic Name

Dexamethasone

Brand NameDrenex

ClassificationSteroids

DosageTablets: 0.25mg, 0.75 mg, 1mg, 1.5 mg, 2mg, 4 mg, 6 mgInjectable:2mg/mL

Dexamethasone,a potentcorticosteroid,has been shownto suppressinflammation byinhibitingmultipleinflammatorycytokinesresulting indecreasededema, fibrindeposition,capillary leakage

and migration ofinflammatorycells.

Testing of adrenalcortical

hyperfunction;management ofprimary andsecondary adrenalcortex insufficiencyrheumatic disorders,collagen diseases,

dermatologicdiseases, allergic

states, allergic andinflammatoryophthalmicprocesses,respiratory diseases,cerebral edemaassociated w/primary or

metastatic brain

tumor, crainiotomy,Gi diseases, multiplesclerosis,tuberculosismeningitis,trichinosis w/neurologic ormyocardial

involvement.

Systemic Fungal

infections IMinjection use inidiopathicthrombocytopenia purpura,administration oflive virusvaccines, topicalmonotherapy inprimal bacterialinfections,ophthalmic use inacute superficialherpes simplexkeratitis, fungal

diseases of ocularstructures,vaccinia,varicella, andocular

tuberculosis.

Thrombocytope

niaFat embolism

-Assess patient

forhypersensitivity

-MonitorPatients withserious medicalcondition suchas epilepsy ,migraine,asthma, heart orkidneyproblems,depression.


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