A Case Study about:

TB Meningitis
INTRODUCTION
 Tuberculosis Meningitis aka Bacterial Meningitis is a medical term used to
describe an inflammation of the layers of tissue (meninges) that surround the brain or
the spinal cord. 
 
Tuberculous (TB) meningitis occurs when tuberculosis bacteria (Myobacterium
tuberculosis ) invade the membranes and fluid surrounding the brain and spinal cord.
The infection usually begins elsewhere in the body, usually in the lungs, and then
travels 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 brain
or the spinal cord, then the condition is called encephalitis (inflammation of the brain).

Meningitis is a potentially life-threatening condition that can rapidly progress to

permanent brain damage, neurologic problems, and even death.
 
The inflammation causing meningitis is normally a direct result of either a
bacterial infection or a viral infection. However, the inflammation can also be caused
by more rare conditions, such as cancer, a drug reaction, or a disease of the immune
system.
  
  
Meningitis in newborns usually results from an infection of the bloodstream
(sepsis). Bacteria that infect older infants and children include Streptococcus
pneumoniae and Neisseria meningitidis. Haemophilus influenzae type b was the most
common cause of meningitis, but widespread vaccination against that organism has
now made it a rare cause. Newer, improved vaccines against Streptococcus pneumoniae
and Neisseria meningitidis (pneumococcal and meningococcal conjugate vaccines)
should also make these organisms rare causes of childhood meningitis. TB meningitis
normally 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, and
gradually 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, severe
headache, dislike of lights(photophobia), neck stiffness and seizures occur. Without
medical treatment, the disease will progress causing confusion, obvious signs of nerve
damage and eventually resulting in coma.
Older children and adolescents with meningitis typically have a few days of
increasing fever, headache, confusion, and a stiff neck. Newborns and infants rarely
develop a stiff neck and are unable to communicate specific discomfort. These younger
children become fussy and irritable (particularly when they are held) and stop feeding—
important signs that should alert parents to a possibly serious problem. Sometimes
newborns and infants have fever, vomiting, or a skin rash. One third have seizures. A
doctor diagnoses bacterial meningitis by examining and culturing a sample of
cerebrospinal fluid obtained through a spinal tap (lumbar puncture). Doctors also order
blood cultures to look for bacteria in the bloodstream and  PPD (purified protein
derivative)  test to establish if person is infected with TB. Ultrasonography, computed
tomography (CT) or MRI may be used to determine if an abscess is present.
 Objectives
We have chosen this case because we want to explore
more on how to handle patient with this diseases. We
also want to acquire new knowledge prior to the diseases
for future encounter.

 Reason for choosing this case

We have chosen this case because we want to explore
our knowledge on this disease. We chose meningitis
because we only encounter this rarely, hence we can share
some information about meningitis. Also we want to
acquire knowledge prior to handling cases like this in the
near future. In addition for us knowing the various factor
involve in occurrence of the diseases would allow us to give
health teaching easily especially when it comes to
prevention.
PATIENT’S PROFILE
 Name: Ms. J. P. A.
 Age: 16 y/o
 Address: 120 –C Brgy. Balagbag, Pasay
City
 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
NURSING HISTORY
 General Data:
This is a case of a 16 y/o female, presently residing at
Pasay 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 developed
moderate to high grade fever, on and off fever,
headache, dizziness, loss of apettite and body
weakness.
four days prior to confinement, presence of nausea,
admitted at a local hospital for 1 day, persistence of
symptoms prompted consultation.
one day prior to admission, patient had two episodes
of vomiting.
 Past medical history
in the year 2004, patient was diagnosed with
TB meningitis and sinusitis.
 Family medical history
patient’s father was diagnosed with PTB.
PHYSICAL ASSESSMENT
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 frontal
and parietal bone.
 Long black hair and evenly distributed.
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.
 
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
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
REVIEW OF SYSTEM
Anatomy and Physiology
 
 
Central Nervous System
 
The central nervous system (CNS) is the largest part of the
nervous system, and includes the brain and spinal cord. The
spinal cavity holds and protects the spinal cord, while the
head contains and protects the brain. The CNS is covered by
the meninges, a three layered protective coat. The brain is
also protected by the skull, and the spinal cord is also
protected 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 of
multicellular organisms. In vertebrates, the central nervous
system is enclosed in the meninges.
.
The meninges (singular meninx) are the system of
membranes which envelops the central nervous system. The
meninges consist of three layers: the Dura mater, the
arachnoid mater, and the Pia mater. The primary function of
the meninges and of the cerebrospinal fluid is to protect the
central nervous system. The space between these
membranes is bathed with a spinal fluid much like lymph,
which serves as a protective cushion for the delicate nerve
tissue, and allows some expansion space for the brain when
its blood supply is increased.
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 periosteal
layer, closest to the calvaria and the inner meningeal layer. It contains larger
blood 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 those
present 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 (dural
sinuses) carrying blood from the brain toward the heart. The falx cerebri
separates the hemispheres of the cerebrum. The falx cerebelli separates the
lobes of the cerebellum. The tentorium cerebelli separates the cerebrum from
the 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 head
injury. The subdural space is another potential space. It is between the Dura
mater and the middle layer of the meninges, the arachnoid mater. When
bleeding occurs in the cranium, blood may collect here and push down on
the lower layers of the meninges. If bleeding continues, brain damage will result
from 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 arachnoid
membrane, so named because of its spider web-like appearance. It provides a
cushioning effect for the central nervous system. The arachnoid mater exists as a
thin, 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 so
looks like a loosely fitting sac. In the region of the brain, particularly, a large
number of fine filaments called arachnoid trabeculae pass from the arachnoid
through the subarachnoid space to blend with the tissue of the Pia mater. The
arachnoid 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 nerves
pass through this space. The term arachnoid refers to the spider web like
appearance of the blood vessels within the space.
 
•Pia mater - The Pia mater is a very delicate membrane. It is the meningeal envelope
which firmly adheres to the surface of the brain and spinal cord. As such it follows all the
minor 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 to
fluid. 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 fluid
is 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 which
surrounds both the brain and the spinal chord. In addition, a space inside the spinal chord
called the central canal also contains cerebrospinal fluid. It acts as a cushion for the
neuraxis, also bringing nutrients to the brain and spinal cord and removing waste from the
system.
 
 
Choroid Plexus
All of the ventricles contain choroid plexuses which produce cerebrospinal fluid by allowing
certain components of blood to enter the ventricles. The choroid plexuses are formed by
the fusion of the pia mater, the most internal layer of the meninges and the ependyma, the
lining of the ventricles.
•The frontal lobe is concerned with higher intellectual functions, such as
abstract thought and reason, speech (Broca's area in the left hemisphere
only), olfaction, and emotion. Voluntary movement is controlled in the
precentral gyrus (the primary motor area).
 
•The parietal lobe is dedicated to sensory awareness, particularly in the
postcentral gyrus (the primary sensory area). It is also concerns with
abstract reasoning, language interpretation and formation of a mental
egocentric map of the surrounding area.
•The occipital lobe is responsible for interpretation and processing of
visual stimuli from the optic nerves, and association of these stimuli with
other nervous inputs and memories.
•The temporal lobe is concerned with emotional development and
formation, and also contains the auditory area responsible for
processing and discrimination of sound. It is also the area thought to be
responsible for the formation and processing of memories. The brain
can be subdivided into several distinct regions:
 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, an
ell.

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 frontal lobe is concerned with higher intellectual functions, such as
abstract thought and reason, speech (Broca's area in the left hemisphere
only), olfaction, and emotion. Voluntary movement is controlled in the
precentral gyrus (the primary motor area).
 
 
 
•The parietal lobe is dedicated to sensory awareness, particularly in the
postcentral gyrus (the primary sensory area). It is also concerns with
abstract reasoning, language interpretation and formation of a mental
egocentric map of the surrounding area.
•The occipital lobe is responsible for interpretation and processing of
visual stimuli from the optic nerves, and association of these stimuli with
other nervous inputs and memories.
•The temporal lobe is concerned with emotional development and
formation, and also contains the auditory area responsible for
processing and discrimination of sound. It is also the area thought to be
responsible for the formation and processing of memories. The brain
can be subdivided into several distinct regions:
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 cardiac
center is the part of the medulla oblongata responsible for controlling
the 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, the
Pons has a role in dreaming.
 
•Midbrain (mesencephalon) - The mesencephalon is considered part of
the brain stem. Its substantia nigra is closely associated with motor
system pathways of the basal ganglia.The human mesencephalon is
archipallian in origin, meaning its general architecture is shared with the
most ancient of vertebrates. Dopamine produced in the substantia nigra
plays a role in motivation and habituation of species from humans to the
most elementary animals such as insects.
 
2. Cerebellum - is a region of the brain that plays an important role in
 1
the 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 sends
information to the muscles causing them to move) and the
spinocerebellar tract (which provides proprioceptive feedback on the
position of the body in space). The cerebellum integrates these
pathways, like a train conductor, using the constant feedback on body
position to fine-tune motor movements.
 
3. Diencephalon - (or interbrain) is the region of the brain that includes
the thalamus, hypothalamus, epithalamus, prethalamus or subthalamus
and 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 and
signalling center between the prethalamus and the thalamus.
 
•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 to
be involved with consciousness. The thalamus plays a major role in regulating
arousal, the level of awareness, and activity. Damage to the thalamus can lead to
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. Its
function 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 like
sexuality, combativeness, and hunger. The hypothalamus also plays a role in
emotion. Specifically, the lateral parts seem to be involved with pleasure and
rage, while the medial part is linked to aversion, displeasure, and a tendency to
uncontrollable and loud laughing.
 

4.Cerebrum - or top portion of the brain, is divided by a

deep crevice, called the longitudinal sulcus. The longitudinal
sulcus separates the cerebrum in to the right 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 nerve fibers
called the corpus callosum. The right hemisphere is
responsible for the left side of the body while the opposite is
true of the left hemisphere
 PHYSIOLOGY OF THE CNS
 
 Medulla- The medulla is the control center for respiratory,
cardiovascular and digestive functions.
 
 Pons- The pons houses the control centers for respiration
and inhibitory functions. Here it will interact with the
cerebellum.
 
 Cerebrum- The cerebrum, or top portion of the brain, is
divided by a deep crevice, called the longitudinal sulcus.
The longitudinal sulcus separates the cerebrum in to the
right 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 nerve
fibers called the corpus callosum. The right hemisphere is
responsible for the left side of the body while the opposite
is true of the left hemisphere.
 Cerebellum- The cerebellum is the part of the
brain that is located posterior to the medulla
oblongata and Pons. It coordinates skeletal
muscles to produce smooth, graceful motions.
The cerebellum receives information from our
eyes, ears, muscles, and joints about what
position our body is currently in (proprioception).
It also receives output from the cerebral cortex
about where these parts should be. After
processing this information, the cerebellum
sends motor impulses from the brainstem to the
skeletal muscles. The main function of the
cerebellum is coordination. The cerebellum is
also responsible for balance and posture. It also
assists us when we are learning a new motor
skill, such as playing a sport or musical
instrument.
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 emotional
lives, but also our higher mental functions,
such as learning and formation of memories.
 Peripheral Nervous System
 
The Peripheral Nervous System (PNS) resides or
extends outside the central nervous system,
which consists of the brain and spinal cord. The
main function of the PNS is to connect the CNS
to the limbs and organs.
There are two types of neurons, carrying
nerve impulses in different directions. These two
groups of neurons are:
 The sensory neurons are afferent neurons which
relay nerve impulses toward the
central nervous system.
 The motor neurons are efferent neurons which
relay nerve impulses away from the central
nervous system.
Naming of specific nerves
 Ten out of the twelve cranial nerves originate
from the brainstem, and mainly control the
functions of the anatomic structures of the head
with some exceptions. The nuclei of cranial
nerves I and II lie in the forebrain and thalamus,
respectively, and are thus not considered to be
true cranial nerves. CN X (10) receives visceral
sensory information from the thorax and
abdomen, and CN XI (11) is responsible for
innervating the sternocleidomastoid and
trapezius muscles, neither of which is exclusively
in the head. Spinal nerves take their origins from
the spinal cord. They control the functions of the
rest of the body. In humans, there are 31 pairs of
spinal nerves: 8 cervical, 12 thoracic, 5 lumbar, 5
sacral and 1 coccygeal.
Cervical spinal nerves (C1-C4)
 The first 4 cervical spinal nerves, C1 through C4, split and recombine to
produce 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 of
the nerves of the neck, providing both sensory and motor control. These
include the greater occipital nerve which provides sensation to the back
of the head, the lesser occipital nerve which provides sensation to the
area behind the ears, the greater auricular nerve and the
lesser auricular nerve. See occipital neuralgia. The phrenic nerve arises
from nerve roots C3, C4 and C5. It innervates the diaphragm, enabling
breathing. If the spinal cord is transected above C3, then spontaneous
breathing is not possible. See myelopathy
Brachial plexus (C5-T1)
 The last four cervical spinal nerves, C5 through C8, and the first thoracic
spinal nerve, T1,combine to form the brachial plexus, or plexus
brachialis, a tangled array of nerves, splitting, combining and
recombining, to form the nerves that subserve the arm and upper back.
Although the brachial plexus may appear tangled, it is highly organized
and predictable, with little variation between people. See
brachial plexus injuries.
 
Lateral cord
 The lateral cord gives rise to the following nerves:
 The lateral pectoral nerve, C5, C6 and C7 to the pectoralis major muscle, or
musculus 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, or
musculus latissimus dorsi.
 The axillary nerve, which supplies sensation to the shoulder and motor to the
deltoid 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 of
the fingers and wrist (extensor carpi radialis muscle), and the extensor and
abductor muscles of the thumb. See radial nerve injuries.
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 and
T1 nerve roots. The first branch of the median nerve is to the pronator teres
muscle, then the flexor carpi radialis, the palmaris longus and the flexor
digitorum superficialis. The median nerve provides sensation to the anterior
palm, the anterior thumb, index finger and middle finger. It is the nerve
compressed in carpal tunnel syndrome.
 The ulnar nerve originates in nerve roots C7, C8 and T1. It provides sensation to
the ring and pinky fingers. It innervates the flexor carpi ulnaris muscle, the flexor
digitorum profundus muscle to the ring and pinky fingers, and the intrinsic
muscles of the hand (the interosseous muscle, the lumbrical muscles and the
flexor pollicus brevis muscle). This nerve traverses a groove on the elbow called
the cubital tunnel, also known as the funny bone. Striking the nerve at this point
produces 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: neuropeptide Y, VIP, GnRH, Substance P and CGRP.
PATHOPHYSIOLOGY
 NON-MODIFIABLE
MODIFIABLE FACTORS: FACTORS:
Pollution Age
Low economic status Gender
Season
MEDICAL MANAGEMENT
Date Doctor's Order Rationale

12/26/09 >Pls. Admit to Pavillion 3 >to closely monitor the

7:35pm   patient for the specific
  disease
  >Secure consent for >for legal purposes
  admission and
  management
  >TPR every shift and >to have a record on the
  record patient's progress
   >DAT c SAP >to avoid aspiration
>IVF:PNSS IV to run for >for fluid and electrolyte
9:30pm 10hrs replacement
  >Paracetamol 500mg 1tab >to decrease fever
  q6 for temperature  
  38C
  >refer >for further management
     
  >DAT for age w/ SAP >to avoid aspiration
  >IVF PNSS 1Lx12hrs. >for fluid and electrolyte
    replacement
  >IVF to ff. D5 0.9NaCl >for fluid and electrolyte
1Lx12hrs replacement
  >to have a baseline data
>follow up labs >treatment for fever
>continue meds
Date Doctor's Order
12/27/09 INH 300mg 1tab pls delute
2:00am per vial w/50ml PNSS
  RIF 600mg 1tab od before
breakfast
PZA 500mg 1tab od before
breakfast
ETB 400/tab bid after meal
>for cranial CT scan plus and
contract, refer to MIS
reassistance
 
>still for lumbar puncture
 
>for official read of CXR
done out
>Give INH 400mg/tab od
>Rifampicin 450mg/cap od
>refer
Rationale
>treatment for tuberculosis
 
 
 
 
>to detection an increase of
enhancement and
thickening of the meninges
beyond normal range
>to analyze the
cerebrospinal fluid
>for detection of chest
cavity
>TB meds
>TB meds
>for further management
Date Doctor's Order Rationale

12/29/09 >CSF analysis >antibiotic

BP 110/70 >Ceftriaxone to 3g IV od >steroids
>Continue Dexamethasone >to justify having TB
>for CXR >to detect an increase
>Cranial CT Scan degree of enhancement
  and thickening of the
  meninges beyond normal
  range
>repeat Na,Cl, K >for electrolyte imbalance
 
>IVF to follow D50.3NaCl
1Lx12hrs

12/30/09 telephone: IVF to ff: D5 IMB >for electrolyte imbalance

  1L x 10o  
12/31/09  >IVF D5NM 1L x 10o >for electrolyte imbalance

01/01/10 >continue management >for further management

     
01/02/10 >IVF to ff. PNSS 1L x 10o >for electrolyte imbalance

 
Date Doctor's Order Rationale

01/03/10 >for LP >for CSF analysis

  >paracetamol q8o headache
  >continue anti-koch's meds
01/04/10 >change IV site
   
  >cranial CT scan
   
01/05/10 >for CBC and platelet count
   
>anti-pyretics
>for TB treatment
>to avoid infiltration and
phlebitis
>detection for the
thickening of the meninges
>to have a baseline data and
detection of the presence of
infection

01/06/10 >for follow up result of CT >detection of the thickening

  scan the meninges
01/07/10  
>for possible discharged
 
 DIAGNOSTIC
EXAMINATIONS
12//29/2010
 CT Scan of the head
 Plain and contrast. Enhanced axial 64-VCT scan images of the head show diffuse undue
enhancement of the leptomeninges.
 There is moderate dilatation of the ventricular system, more severe in the frontal and
temporal horns of the right lateral ventricle.
 Non-enhancing periventricular hypoattenuation is seen and the lateral ventricles, also worse
on 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 petromastoid
and bony calvasion are intact.
 
IMPRESSION:
 1.Diffuse leptomeningitis
 2. Moderate communicating hydrocephalus with signs of increased intraventricular
pressure.
 3.Superimposed encephalomalacia with central volume loss in the right fronto-temporal
lobes.
 4. Chronic otomastoiditis, left.
 The diagnosis of meninges requires an
analysis 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 of
cerebrospinal fluid.
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 use
up (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 protein
are large molecules and do not cross blood / brain barrier easily.
 
 Cerebrospinal fluid cell count may help
diagnose meningitis and infection of the
brain and spinal cord, a tumor, abscess, or
area of tissue death (infarct), and it helps
identify inflammation.
 
1/4/2010
 Urinalysis
 
 A.Physical
 Sugar = negative
 Protein = negative
 
 B.Microscopic
 RBC = 1-2 0-2/hpf
 WBC = 1-2 0-5/hpf
 12/27/09
Hematology
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 iron deficiency.

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

meningococcal meningitis
have abnormalities in the
platelet functions mainly
in aggregation and
adhesiveness.
DRUG STUDY
 Drug name Mechanism of Indication Contraindication Adverse effect Nursing
action consideration

Generic Name Unknown highly Treatment of Acute liver Nausea and -Assess patient's
Pyrazinamide specific and active disease, vomiting, condition before
  bactericidal of tuberculosis in hypersensitivity anorexia, therapy.
Brand Name mycobacterium adults and peripheral thrombocytopenia,  
Mycobak tuberculosis selected children neuritis. mild arthralgia and -Monitor drug
  hominis. myalgia and effectiveness
Classification hypersensitivity  
Anti-infectives reaction -Monitor serum
  uric acid which
Dosage may be elevated
250ml/5ml 3ml and cause
BID symptoms.
 
-Monitor for
drug adverse
reaction
 
-Regularly assess
renal status.
 Drug name Mechanism of Indication Contraindication Adverse effect Nursing
action consideration

Generic Name The most effective Tuberculosis Severe Peripheral -Note reason for
Isoniazid tuberculostatic caused by hypersensitivity neuropathy, therapy,
  agent. Probably human bovine to isoniazid. nausea and type/onset of
Brand Name interferes with and BCG strains Associated vomiting, heart symptoms.
Nydrazid lipid and nucleic of hepatic injury or burn, dizziness,  
  acid metabolism mycobacterium side effects. optic neuritis, -Monitor renal
Classification of growing tuberculosis. hepatitis. and liver
Anti tubercular bacteria, resulting function test
  in alteration of the  
Dosage bacterial wall. -Perform
200mg/5ml pulmonary note
25o.d. cough/sputum
characteristics.
 
-Report any
visual
disturbances.
 Drug name Mechanism of Indication Contraindication Adverse effect Nursing
action consideration

Generic Name Inhibits DNA- Short term Hypersensitivity Hypotension, -Observe IV site closely
for extra-vasation
Rifampicin dependent RNA management to to rifamycin shock, headache,  
  polymerase in eliminate drowsiness, -Administer solution
Brand Name susceptible meningococci fatigue, dizziness, for injection by IV
inability to  
Natricine Forte strains of from -If D5W is
bacteria. nasopharynx in concentrate, contraindication, use
mental confusion, sterile saline. Do not
  Neisseria
generalized mix with other
  mengitidis numbness, rash, solutions.
Classification carriers. pruritus, urticaria,
 
-Initial final dilutions of
Anti-infective/ flushing, visual drug in vial are stable
anti-tubercular disturbances, for 24 hr at room
  temperature.
epigastric distress,  
Dosage anorexia, nausea, -Assess baseline
200ml/5ml vomiting, cramps, neurologic status and
2.5ml OD diarrhea, sore observe for changes.
 
mouth and tongue, -Monitor Intake and
acute renal failure, Output and assess for
shortness of development of
edema.
breath, wheezing,
 
muscular -Assess skin prior to
weakness and pain starting drug
in extremities. treatment for rash,
pruritus, flushing,
urticaria and jaundice
 Drug name Mechanism of Indication Contraindication Adverse effect Nursing
action consideration

Generic Name Paracetamol Pyrexia of Nephropathy. . Skin eruption, -Should be given

Paracetamol produces unknown origin hematological with care to
patients with
  analgesia by and for toxicity,
impaired hepatic or
Brand Name raising the symptomatic thrombocytopen remal function.
Aeknil threshold of the relief of fever ia and  
  pain center in and pain leukopenia, -Paracetamol
Classification the brain and associated with methemoglobin overdosage should
Analgesics obstructing common aemia which can be treated with
(Non Opiod and impulses at the nchildhood result in cyanosis gastric lavage if the
patient is seen
Antipyretics) pain mediating disorders, and long term
within 4hrs of
  chemoreceptors. tonsillitis, upper use, renal ingestion of Aeknil.
Dosage The drug respiratory tract damage can  
300mg IV q4 produces infections, post result. -If forgotten, take
antipyresis by an immunization   the missed dose as
action on the reactions, after Toxicity may soon as you
hypothalamus; tonsillectomy for result from a remember. If it is
almost time for
heat dissipation prevention of single toxic dose your next dose,
is increased as a febrile of the drug or skip the missed
result of convulsions. from chronic dose and return to
vasodilation and Headache, cold ingestion your normal dosing
increased sinusitis,muscle schedule.
peripheral blood pain, arthritis  
-Avoid alcohol
flow. and toothache.
 Drug name Mechanism of Indication Contraindication Adverse effect Nursing
action consideration

Generic Name The inhibitory Oropharyngeal Hypersensitivity . Headache, -Assess for signs ans
Ethambutol effect of the drug symptoms of
and esophageal to fluconazole, seizure, rash,
on multiplication infection; obtain C&S
candidiasis, and other azole exfoliative skin baseline and during
did not become
Brand Name apparent until vaginal antifungals. Co- disorder, nausea treatment, drug may
Odetol several hours after candidiasis, administration and vomiting, be started as soon as
culture is taken.
its addition to the prevention of with cisapride abdominal pain,
 
Classification culture. The drug candidiasis in and terfenadine. diarrhea, - Monitor
Antituberculosis/ had no effect on bone marrow leucopenia, hepatotoxicity;
Antileprosy the survival of transplant; thrombocytopen increased AST, ALT,
nonproliferating alkaline
cryptococcal ia, hepatic
cells. It had little or phosphatase,
Dosage no effect on the meningitis. reactions, bilirubin, drug will be
12mg/kg first day metabolism of including discontinued if
6mg/kg second nonproliferating abnormal LFT hepatotoxicity
day cells, but cells from occurs.
results,
 
cultures whose hepatitis, -Monitor for possible
growth had been cholestasis, adverse reactions:
inhibited by CNS headache,
ethambutol
hepatic failure.
GI:nausea, vomiting,
showed evidence of abdominal pain,
impaired diarrhea, hepatic:
metabolism. C14- hepatotoxicity Skin:
labeled ethambutol stevens-johnsons
was taken up syndrome.
rapidly by both
proliferating and
nonproliferating
cells.
 Drug name Mechanism of Indication Contraindication Adverse effect Nursing
action consideration

Generic Name Testing of adrenal Systemic Fungal Thrombocytope -Assess patient

Dexamethasone cortical
Dexamethasone, infections IM nia for
hyperfunction;
  a potent management of injection use in Fat embolism hypersensitivity
Brand Name corticosteroid, primary and idiopathic  
Drenex has been shown secondary adrenal thrombocytopeni -Monitor
  cortex insufficiency
to suppress a purpura, Patients with
rheumatic disorders,
Classification inflammation by collagen diseases, administration of serious medical
Steroids inhibiting dermatologic live virus condition such
  multiple diseases, allergic vaccines, topical as epilepsy ,
Dosage states, allergic and
inflammatory monotherapy in migraine,
inflammatory
Tablets: 0.25 cytokines ophthalmic primal bacterial asthma, heart or
mg, 0.75 mg, 1 resulting in processes, infections, kidney
mg, 1.5 mg, 2 decreased respiratory diseases, ophthalmic use in problems,
mg, 4 mg, 6 mg cerebral edema
edema, fibrin acute superficial depression.
associated w/
Injectable: deposition, primary or herpes simplex
2mg/mL  capillary leakage metastatic brain keratitis, fungal
and migration of tumor, crainiotomy, diseases of ocular
Gi diseases, multiple
inflammatory structures,
sclerosis,
cells. tuberculosis vaccinia,
meningitis, varicella, and
trichinosis w/ ocular
neurologic or
tuberculosis.
myocardial
involvement.
NURSING CARE PLAN