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CASE PRESENTATION ONTB
OFANKLEJOINT
By
R.S.Pavani
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SYMPTOMS
Inflammation & Swelling of joints
Fever and weight loss
Difficulty walking and muscle spasms
Pain starts in certain spots like spine, hip, and
nee
Bones become weak leading to fractures and
deformites
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COMPLICATIONS
Bones. Spinal pain and joint destruction may result fromTB that infects your bones. In many cases, the ribs areaffected.
Brain. Tuberculosis in your brain can cause meningitis, asometimes fatal swelling of the membranes that cover your
.
Liver or kidneys.Your liver and kidneys help filter wasteand impurities from your bloodstream. These functionsbecome impaired if the liver or kidneys are affected bytuberculosis.
Heart. Tuberculosis can infect the tissues that surroundyour heart, causing inflammation and fluid collections thatmay interfere with your heart's ability to pump effectively.This condition, called cardiac tamponade, can be fatal.
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RISK FACTORS
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PATIENT DETAILS
Age 45 yrs
Gender Female
Weight 35 kgs
Unit Ortho-III
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REASON FOR ADMISSION
c/o pain and swelling in left ankle of left dorsum of
foot from past 6 months which increased in
n ens y pas ays
C/0 Pain increased on walking & decreased on
rest
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PAST MEDICAL HX :
She got admitted in a private hospital , diagnosed
assynovitis of left ankle and joint debridement
Synovial biopsy was done. Biopsy showed
possibility of TB for which she was started on Anti-
rugs rom pas mon w c s e s oppetaking from 2 weeks
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PROVISIONAL DIAGNOSIS
? TUBERCULOSIS OF ANKLE JOINT
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DAY1 (25/7/13)
BP:130/80mmHg Pulse:80bpm
Patient has no fresh complaints
General condition fair and vital stable
ADV: Hb , TC , DLC, ESR, RBS , Uric acid , CRP,RA
Test , Synovial Biopsy.
Drug Dose Route frequency
T. Aceclofenac 100mg Po 1-0-1
T. Ranitidine 150mg Po 1-0-1
Inj.Diclofenac 50mg iv Sos
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LAB DATA
Hb :11.7g/dl
TC :9,000cells/cumm
DLC:N:54%
RBS:96mg/dl
Uric acid: 5.0 mg/dl
CRP: 0.00 mg/dl
B:00%
L:40%
M:00%
ESR:70mm/hrPCV:35.7%
es : nega ve
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DAY 2 (26/7/13)
BP:120/80mmHg Pulse:80bpm
Patient has no fresh complaints
General condition fair and vital stable
Adv: Treatment as per chart.
T. AKT4 from today
Chest X-Ray
Pulmonologist opinion
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DAY3(27/7/13)
BP:120/80mmHg Pulse:90bpm
Patient c/o chills and rigors and gastric irritation
after taking AKT4.
ADV: syp.aluminium hydroxide 1tsp 1-0-1
Stopped AKT4 drugs
Pulmonologist reference
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DAY4 (28/7/13)
BP:110/60mmHg Pulse:90bpm
No fresh complaints
Toe movements present
Distal pulses- present
ADV: CST
Patient will be shifted to pulmonology
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DAY5,6 (29,30/7/13)
BP:110/80mmHg Pulse:80bpm
O/E:
Patient has no fresh complaints
General condition fair, vitals stable
Adv: CST
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DAY7 (31/8/13)
BP:110/90mmHg Pulse:80bpm
O/E:
vitals stable
stopped AKT4 since 3 days
Adv : CST
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DAY9,10 (2 & 3/8/13)
BP:120/70mmHg Pulse:80bpm
o/e:
Patient has no fresh complaints
Patient conscious oriented
Adv : CST
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TREATMENT CHART
Drug Dose Route frequency Day of
Start
Day of
Stop
T. Aceclofenac 100mg Po 1-0-1 D1 Cont
T. Ranitidine 150mg Po 1-0-1 D1 Cont
Inj.Diclofenac 50mg Po Sos D1 Cont
Tab.INH+RFM+PYR
+ETH
300+450
+750+80
0mg
Po 1-0-0 D2 D3
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RECHALLENGE THERAPHYDRUG DOSE frequency day 11
(4/8/13)
Day 12
(5/8/13)
Day 13
(6/8/13)
Day 14
(7/8/13)
T.Ethambutol 800mg 1-0-0 -0-0
-0-0
1-0-0
+ + +
T.Pyrazinamide 750mg 1-0-0 -0-0
-0-0 + +
- -
T.Isoniazid
300mg 1-0-0 -0-0
-0-0
1-0-0
_
T.levofloxicin 500mg 1-0-0 -0-0
-0-0
1-0-0
T.Rabeprazole 20mg
1-0-0)
1-0-0 + + + +
T.silybin
phospholipid
120mg 0-1-0 + + + +
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PHARMACEUTICAL CARE PLAN
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SUBJECTIVE OBJECTIVE
Swelling of joints Synovial biopsy
Pain in the joints X-ray
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FINAL DIAGNOSIS
Based subjective and objective evidence of
patient she was diagnosed as tuberculosis of
ankle joint
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GOALS OF TREATMENT
To reduce the signs and symptoms.
To prevent further progression of the disease
To reduce the complications of the disease
To improve the health related quality of life
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TREATMENT OPTIONS
Anti TB drugs
Isoniazid
Rifampicin
Pyrazinamide
Ethambutal
Non pharmacological treatment
Orthosis
Below knee plaster cast
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GOALS ACHIEVED
Nil
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MONITORING PARAMETERS
Disease specific Drug specific
Chest x-ray Potts-cozart test
o a oo coun p a m c exam na onPLT Liver function tests
ESR
synovial biopsy
AFB culture sensitivity
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PROBLEMS IDENTIFIED
ADR-Drug induced chills & rigors and gastric
irritation.
yri oxine was not prescri e .
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PATIENT COUNSELLING
About the disease:
Tuberculosis (TB) is an infectious disease that iscaused by a bacteria.
It spreads from person to person through airborneparticles.
Symptoms include unexplained weightloss , tiredness,fatigue, shortness of breath, fever, night sweats , chills,
and a loss of appetite. Symptoms specific to the lungsinclude coughing that lasts for 3 or more weeks,coughing up blood, chest pain, and pain with breathingor coughing
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ABOUT THE MEDICATION
Isoniazid :
Advice the patient about the signs/symptoms ofhepatotoxicity.
If taking antacids, patient should take antacid at least1h before oral INH.
Patient should take medication on empty stomach 1hbefore or 2h after food.
Patient should report sign/symptoms of peripheralneuropathy and thrombocytopenia.
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RIFAMPICIN
It decreases the effectiveness of oral
contraceptives.
Drug causes red-orange discolouration of urine,
eces, sa va ,swea ears.
It causes flu-like symptoms.
Advice patient to take this drug 1h before & 1hafter a meal with a full glass of water.
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PYRAZINAMIDE
This drug may cause nausea,vomiting.
Advice the patient to report signs/symptoms of
hepatotoxicity.
Instruct the patient to promptly report any visual
changes.
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LIFESTYLE MODIFICATIONS
Dietary Tips for Tuberculosis Patients
Eat a variety of fruit and vegetables each day. (darkgreen, orange, legumes, starchy vegetables) severaltimes a week.
Drink pasteurized milk and warm water.
Bake, broil, or grill food should be consumed.
Eat a variety of protein rich foods, with more fish,beans, peas, nuts and Choose low-sodium foods, anddo not add salt when cooking.
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LIFESTYLE MODIFICATIONS Hand hygiene :
Cleaning hands with soap and wateror an alcohol-based hand rub toprevent transmission of germs to others.
Personal protective equipment :
Use a mouthpiece, resuscitation bag, or other ventilation devices to
prevent contact wit mout an ora secretions.
Respiratory hygiene :
Cover mouth/nose when coughing/sneezing.
Use tissues and promptly dispose of them in trash.
Perform hand hygiene after soiling hands with respiratory secretions.
Environmental cleaning :
Develop procedures for routine care, cleaning, and disinfection of environmentalsurfaces, especially frequently touched surfaces in patient/resident-care areas.
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DOTS
TB DOT providers should document reasons for both refusal of DOT
and discontinuation of DOT by TB clients who are or have beenoffered this treatment option.
It ensures that the patient completes an adequate regimen.
It lets the health care worker monitor the patient regularly for side
.
By ensuring that patient takes every dose of medicine, it helps thepatient become non-infectious sooner and adherent to medication.
Health-care providers of TB services will take the time to explainto patients, in simple language .
DOT should take place anywhere the patient and health careworker agree upon provided the location is convenient and safe forboth parties
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BCGVACCINATION
The live attenuated strain ofMycobacterium
bovis known as bacillus Calmette-Gurin (BCG)
uses shared antigens to stimulate the
-tuberculosis.
1mL percutaneous.
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VACCINE ADMINISTRATION
The single dose of BCG vaccine is administered intradermally, intothe lateral aspect of the abducted left upper arm.
Patients should be advised not to cover the site with tight clothing orsealed dressings.
The BCG can be given simultaneously with other live vaccines but, ifnot given at the same time, further immunisations should be delayedfor at least 4 weeks. No other immunisations should be given in the
..
CONTRA-INDICATIONS
A past history of TB.
A positive pre-immunisation tuberculin test.
A previous anaphylactic reaction to vaccine component.
Compromised immunity due to treatment or disease.
Generalised septic skin conditions.
Acute illnesses with fever or systemic upset.
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