Professional Documents
Culture Documents
on
Spinal TB
• 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
• Paradiscal: commenest
• Central
• Anterior
• Posterior
• In my patient Paradiscal type
Pathology
• 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