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Case presentation

on
Spinal TB

Presented by:Madhuri Khadka


Roll no 04
B.Sc nursing 3rd year
Bio Data
Name: Khushi Lal Chaudhary
Age/sex: 65/male
Marital status : married
Occupation: Farmer
Religion: Hindu
Address: Sarlahi
Admission on :2065/4/13
Diagnosis: TB spine l4-l5 region
Chief complain

• Low back pain for 3-4 months.


History of present illness

• According to patient he was apparently


well 4months back then he started to
developlow back pain acute in onset
graduallu progressive mild to moderate
radiate towards B/L legs associating with
tingling.
Past History
• No any history of any medical and surgical
illness and no any hospitalization before
this as patient says.
Personal history

• Bowel,blader :normal
• Appetite, sleep:appropriate
• Non vegetarian
• Smoker, non alchoholic
Family history

• Not significant
General examination
Vitals: temp-98F,Pulse-74
resp-16, Bp- 110/70
G/C : Fair
Oedema: No
Lymph node: Not palpable
Icterus: No
Pale: no
Dehydration: No
• Heart sounds- S1 S2 Mo
• Breath sound- vesicular
• Liver – not palpable
• Spleen- not palpable
• Capillary refill time – 1 second
Muskuloskeletal exam

• Alignment: Normal
• Tenderness: present on L4-L5region
• SLRT: rt. 70%,left- Normal
• Motor system: intact
• FHL: Rt-5/5 ,Lt-5/5
• EHL: Rt-5/5, Lt-5/5
• DNVS: intact
• ROM: painful in lower limb
Reflexes

• Pateler tendon: normal reflex


• Achilis tendon: Normal reflex
• Planter reflex: Normal reflex
Anatomy of Spine
Contd…
• Body
• Pedicle
• Lamina
• Transverse process
• Spinous process
• Articular facets
• Pars interarticularis
• Lig aments:
• Anterior longitudinal lig.
• Posterior long. lig.
• Lig. Flavum
• Spinou lig.
• Interspinous lig.
• Paravertebral muscles
Spinal Cord

• Cervical cords – correspond cervical


vertebra
• Thoracic cords – end above T 10
• L1 cord – T10 vertebra
• Lumbo sacral cords – ends at L1 – L2
TB of Spine

• Spine is commenest site for bone and joint


TB of Dorsolumbar region affected most
frequently.
• The only part of the vertebra which is
accessible to palpation is its spinous
prcess.
Types of Vertebral TB

• Paradiscal: commenest
• Central
• Anterior
• Posterior
• In my patient Paradiscal type
Pathology

• In Paradiscal type, the bacteria lodge in in the


contiguous areas of two adjacent vertebrae
• Granulation &inflamation results in erosion of the
margined of these vertebra.
• Nutrition of the intervening disc is compromised
so disc degeneration
• Weakening of the trabiculae of the vertebral
body results in collapse of vertebra.
• Cold Abscess: is collection of pus and
tubercular debris from a diseases vertebra
and associated with usual sign of
inflammation.
• Healing – lytic areas in bone are replaced
by new bone
• Complication- cold abscess, nurological
compression
Clinical features
Book Picture

• Pain
• Stiffness
• Cold abscess
• Paraplegia
• Deformity
• Constitutional symptoms
Clinical feature in patient

• Pain
• Stiffness
• Cold abscess
Investigation

• Book picture
• X-ray of spine- AP & lateral
• Chest X- ray
• CT-scan
• MRI
• Myelography
• Biopsy
• Mountex test
Investigation done

• X-ray spine-
• ,chest X-ray
• Mountex test – 7mm induration
• AFB 3 consocutive c/s no growth
• MRI finding- infective discvertebral
spondylitis L4- L5,strong possibility of Tb
spine with pre &paravertebral abscess
causing compression of thecal sac
Other Routine investigation

• Hb 9.8gm%
• WBC- 6,200, platelet-21,800mm3
• Urine rme- Normal,
• SGOT- 73mg/dl, SGPT- 98 mg/dl
• Na- 135 meq/l, K – 4.5meq/l
Treatment

According to book
-Rest
- Log rolling
-MobilizationTreatment of cold abscess
- Treatmnet of cold abscess- Aspiration,
Evacuation
- Anti tubercular therapy
Treatment done
• Complete bed rest
• Log rolling
Pharmacotherapy:
-Anti TB drug AKT4,
- Tab Besix
- Tab naproxen 500mg BD
- Pangol 40mg OD
- Shelcal 500mg OD
- Cap eldervit OD
Nursing Process

• Nursing Diagnosis
• Acute pain r/t nerve compression as
evidenced by MRI finding
• Risk for Constipation r/t immobility
• Risk for skin integrity imparement r/t
prolong bed rest
• Deficient knowledger/t treatment regimen
Nursing intrvention

Relieving pain

• Immobilizes pt
• Do log rolling
• Look for nurovascular status
• Provide analgesic
Reduce risk of constipation

• Provide high fiber diet.


• Provide adequate fluid and water
• Teach abdominal exercise
• Encourage ROM exercise of upper limbs
• Moniter intake, bowel sounds and bowel
activity
• Provide stool softner
Maintain skin integrity

• Position change every 2 hrly


• Provide wrinkle free bedding
• Provide back care as needed
Promote understanding of Diseases
condition
• Patient and family teaching on diseses
process
• Explain the treatment regimen
• Explain the nedd of diferent type of
investigation
• Explain about prognosis
Discharge treatment

• Tab AKT4 OD continue


• Tab Besix continue
• Naproxen 500 mg BD 10 days
• Panzol 40 mg 10days
• Shelcal 500 mg OD 15 days
Discharge Teaching

• The patient and family are taught about:


- The importance of strictly adhering to the
therapeutic regimen of antibiotic.
- Take high fiber diet enough fluid.
- Take complete bed rest do log rolling in
every 2hrly
- Follow-up ortho OPD after 2weeks.
Bibliography
• Maheshoweri’s “Essential Orthopedics”.Meheta
publishers, 3rd eddition, pg no 169- 200
• Ebnezar John’s, “ Text book of
Orthopedics”,Jaypee publication, 3rd edition
• Ebnezar john’s,” Orthopedics for nurses”, Japee
publication, 1st edditon
• Brunner’s & Suddarth’s, “Text book of medical-
Surgical Nursing”, published by Wolters
Kluwer,11th eddition.
Conclusion