case management on tetanus infection

8/10/2019 case management on tetanus infection

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P G I K R I S T E L M A G N E Z A R A S P E

MEASLES


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General Data

D.A

21 years old

Male

Single Catholic

Tabangao, Ambulong, Batangas City

Admitted on December 15, 2013


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Chief Complaint

Rashes


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History of Present Illness

1 week PTA

on and off undocumented fever

Cough non productive, whitish phlegm

Colds

No consult done

Self medicate with Paracetamol 500mg/tab every 4 hours andIbuprofen


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5 days PTA

Loss of appetite

Post prandial pain

Throat pain

Generalized body weakness

No consult done

Continue self medication


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2 days PTA

Rashes, pruritic

Cough, productive, yellowish phlegm

Few hours PTA Rashes progressively spread all over his body

Difficulty of breathing


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Past Medical History

Unrecalled course of immunization

(-) surgery, accidents and blood tranfusion

(-) heredofamilial diseases


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Family History

(-) HTN, DM


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Personal and Social History

Occasional alcoholic drinker

3-4 sticks/day


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Review of System

General: (-) weight loss, (-) weight gain, (-)chill, (-)fatigue, (-) night sweats

Skin: (-) color change, (-) soreness, (-) scaling

Head and Neck: (-) headache, (-) stiffness, (-)trauma Eyes: (-) corrective lenses, (-)pain, (-) blurring of

vision, (-) dryness


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Ears: (-) hearing loss, (-) pain, (-) tinnutus

Nose: (-) nasal discharges

Mouth: (-) bleeding gums, (-) hoarseness, (-) pain,(-) dryness

Respiratory: (-) cough, (-) chest, (-) dyspnea

Cardiac: (-) orthopnea, (-) PND, (-) palpitation

Nervous: (-)dizziness, (-) seizures Extremities: (-) pain, (-) weakness, (-) tenderness,

(-) cramps


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Physical Examination

General Survey: The patient is conscious, coherent,ambulatory, weak looking and not in cardio-respiratory distress.

Vital signs:BP: 90/60 mmHg

Cardiac rate: 83beats/minute

Respiratory Rate: 19 cycles/minute

Temperature: 38.20C


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Skin: brown, warm, moist with good skin turgor , (+)maculopapular rashes all over

HEENT: conjunctival injection, hyperemic sclera, no

sunken eyeball, dry lips, (+)nasal watery discharge,moist buccal mucosa, no tonsillopharyngealcongestion, no cervicolymphadenopathy, no neck

vein engorgement, no anterior neck mass, no neck

bruit


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CHEST/LUNGS: symmetrical chest expansion, nolagging, no retractions, (+) crackles on midbasal lungfields bilateral

HEART: Adynamic precordium, point of maximalimpulse is located at the 5thICS left midclavicularline, normal rate and regular rhythm, no murmurs


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ABDOMEN: flabby abdomen, normoactive bowelsounds , soft, non-tender on light and deep palpation

EXTREMITIES: grossly normal extremities, nocyanosis and edema with full and equal pulses on

brachial and radial.

DRE: not done


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Neurological Exam

Cerebral Function: awake, alert, oriented to time,person and place, with intact remote, recentmemory,can do simple calculations, with good

judgement

Cerebellar Function: able to perform finger to nosetest, alternating supination and pronation.

Cranial Nerves: Intact


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Motor Function: no muscle atrophy, muscle strengthis 5/5 on both upper and lower extremities, notremors noted

Sensory Function: reacts to pain, touch, position andvibration sense

Reflexes: (+) deep tendon reflexes


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Admitting Impression

Measles

Community Acquired Pneumonia


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Admission: ER

IVF: D5LR 1L x 40 gtts/ min

Diet: Diet as Tolerated; Increased oral fluid intake

Diagnostics:

CBC with PC Urinalysis

Chest Xray

Sodium, Potassium

BUN, Creatinine


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U/A Color SpecificGravi

ty

pH Sugar

Albumin

PusCells

RBC AmorpUrat

es

Epithcells

Bacteria

Amber

1.025 6 (-) (-) 2-4 1-2 Moderate

Few Few


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Blood Chemistry 12/15/13

Sodium 121

Potassium 3.06

BUN 11.5

Creatinine 94.8


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Chest Xray BasalPneumonia,Left


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Course in the wards

1stHospital Day S: (+) cough

Potasium: 3.06

O: afebrile ; stable vital signs

A: Measles: Community Acquired Pneumonia

P: Continue present management

Start Kalium Durule TID for 2 days


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2ndHospital Day S: decreased severity of cough

O: stable vital signs; decreased crackles

A: Measles; Community Acquired Pneumonia

P: Continue present management


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3rdHospital Day S: no subjective complaints

O: afebrile

A: Measles; Community Acquired Pneumonia

P: May go home

Home Meds:

Cefixime 200mg/tab BID x 7days

Azithromycin 500mg/tabs OD x 3 days

Salbutamol + Ipratropium Bromide neb every 8 hours

Loratadine 10mg/tab OD as needed


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Measles


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Definition

highly contagious viral disease that is characterizedby a prodromal illness of fever, cough, coryza, andconjunctivitis followed by the appearance of ageneralized maculopapular rash

The Centers for Disease Control and Prevention :(1)a generalized maculopapular rash of at least 3 days'duration; (2) fever of at least 38.3oC (101oF); and (3)

cough, coryza, or conjunctivitis.


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Etiology

spherical, nonsegmented, single-stranded, negative-sense RNA virus

Morbillivirus

family of Paramyxoviridae antigenically monotypic virus


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Epidemiology

most highly contagious directly transmittedpathogens

common among household contacts, school-age

children, and health care workers Endemic measles has a typical temporal pattern.

As measles vaccine coverage increases or populationdensity decreases

Persons with measles are infectious for several daysbefore and after the onset of rash.


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Pathophysiology

Transmission Respiratory droplets

Small-particle aerosols

Airborne transmission

Direct contact with infected secretions

Incubation Period

10 days to fever onset 14 days to rash onset

Adults up to 3 weeks


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Clinical Manifestations


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Kopliksspots

pathognomonic ofmeasles

bluish white dots 1 mm in

diameter surrounded byerythema

buccal mucosa oppositethe lower molars but

rapidly increase innumber to involve theentire buccal mucosa


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Rash

erythematous maculesbehind the ears and onthe neck and hairline

progresses to involve theface, trunk, and armswith involvement of thelegs and feet by the end

of the second day Areas of confluent rash

appear on the trunk and

extremities

petechiae may be present

The rash fades slowly -

usually beginning on thethird or fourth day afteronset

Resolution of the rash

may be followed bydesquamation


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Differential Diagnosis

Rubella

Kawasaki disease

Infectious mononucleosis

Roseola Scarlet fever

Rocky Mountain spotted fever

Enterovirus Adenovirus infection

Drug sensitivity


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Laboratory Diagnosis

Serology

Culture

PCR


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Complications

Most common Otitis Media

Bronchopneumonia

Respiratory Tract Acute laryngotracheobronchitis

Giant-cell pneumonitis

Central Nervous System

Encephalomyelitis Measles inclusion body encephalitis

Subacute sclerosing panencephalitis


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Prevention

Passive Immunization Human immunoglobulin

within 72 h of exposure - immunocompetent persons

Administered up to 6 days after exposure

Prophylaxis - children


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Active Immunization Mumps and rubella (MMR)

Mumps, rubella, and varicella (MMR-V)

first vaccination varies from 6 to 15 months


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T H A N K Y O U !

case management on tetanus infection

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