Case Presentation

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

• • • • • •

Anterior longitudinal lig. Posterior long. lig. Lig. Flavum Spinou lig. Interspinous lig. Paravertebral muscles

• Lig aments:

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 ¶vertebral 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 medicalSurgical Nursing”, published by Wolters Kluwer,11th eddition.

Conclusion