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I. OVERVIEW OF THE DISEASE
Infection of a knee joint is a very serious medical condition. A septic (infected) knee is mostoften caused by bacteria (such as staph or strep), but in rare instances can be caused by other
microorganisms. Prompt diagnosis and treatment is essential in the native knee to avoid rapid
destruction of the cartilage and bone in the knee.
When diagnosed early, treatment is usually arthroscopic irrigation and debridement.
However, an open debridement may be required. Despite early diagnosis and treatment, joint
destruction may still occur. Late effects of joint infection (septic arthritis) may require treatment with
joint replacement as long as there is no persistent infection remaining within the knee.
Predisposing Factors
Diabetic patient
Trauma such as injury or wound
Bacteria/microorganism
Drug use Alcoholism
Kidney dialysis
Malnutrition
Advanced age
Orthopaedic surgery
Signs and Symptoms
Bone pain Swelling and redness of the skin Fatigue
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Fatigue
III. PATIENT HISTORY
History of Present Illness/InjuryPatient X is a 8 year old boy who was admitted last May 31, 2011, 3 weeks prior to
consultation, patient X hit his right big toe while playing football with (+) manipulation done 3times and (+) swelling persisted with involvement/swelling of right ankle noted and (+) fevernoted.
Past Medical History
Vomited and treated
Family Medical History
Uncle (father side): (+) Explore Laparotomy due to Acute Appendicitis with GeneralizedPeritonitis
Grandmother (mother side): (+) Hypertension with maintenance antihypertensive drugs
Grandmother (father side): (+) Diabetes Mellitus
Both parents: Deceased due to vehicular accident
Socioenomic History
Patient X was on his 4th grade. Both parents are deceased due to vehicular accident, therewere six in the family and he was the youngest, their auntie is the one who support their needs, workas a Brgy. Health Worker with the monthly income of P3,000.
IV. ANATOMY AND PHYSIOLOGY
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The metatarsus or metatarsal bones are a group of
five long bones in the foot located between the tarsal
bones of the hind- and mid-foot and the phalanges of thetoes. Lacking individual names, the metatarsal bones are
numbered from the medial side (side of big toe):
the first, second, third, fourth, and fifth metatarsal. The
metatarsals are analogous to themetacarpal bones of
the hand.
Normal Abnormal
http://en.wikipedia.org/wiki/Long_bonehttp://en.wikipedia.org/wiki/Foothttp://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Phalanges_of_the_foothttp://en.wikipedia.org/wiki/Anatomical_terms_of_locationhttp://en.wikipedia.org/wiki/First_metatarsal_bonehttp://en.wikipedia.org/wiki/Second_metatarsal_bonehttp://en.wikipedia.org/wiki/Third_metatarsal_bonehttp://en.wikipedia.org/wiki/Fourth_metatarsal_bonehttp://en.wikipedia.org/wiki/Fifth_metatarsal_bonehttp://en.wikipedia.org/wiki/Metacarpushttp://en.wikipedia.org/wiki/Handhttp://en.wikipedia.org/wiki/Handhttp://en.wikipedia.org/wiki/Handhttp://en.wikipedia.org/wiki/Metacarpushttp://en.wikipedia.org/wiki/Fifth_metatarsal_bonehttp://en.wikipedia.org/wiki/Fourth_metatarsal_bonehttp://en.wikipedia.org/wiki/Third_metatarsal_bonehttp://en.wikipedia.org/wiki/Second_metatarsal_bonehttp://en.wikipedia.org/wiki/First_metatarsal_bonehttp://en.wikipedia.org/wiki/Anatomical_terms_of_locationhttp://en.wikipedia.org/wiki/Phalanges_of_the_foothttp://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Tarsus_(skeleton)http://en.wikipedia.org/wiki/Foothttp://en.wikipedia.org/wiki/Long_bone8/4/2019 Case Pres Block 2
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V. PATHOPHYSIOLOGY
ove
Predisposing factors:
Modifiable:Compromised Immune systemInvasive procedures (catheterinsertion, etc.)Unsafe sexIV drug abuse
Bacterial infections alreadypresent in the bodyTrauma
Non Modifiable:Age extremes
Trauma
Tissue damageManipulation
Exposure of joints
Entrance ofmicroorganism to
synovial membrane
Growth ofmicroorganism
Infection of
metatarsal (R) foot
H t d
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Risk Factor : Poor Environmental Sanitation, Living in a congested area,Trauma: Fall
MYCOBACTERIUM TUBERCLE BACILLI
Lungs
Circulation
Potts Disease
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VI. PHYSICAL EXAMINATION
Procedure Technique Normal Findings Actual Findings Interpretation Analysis1. MonitorTemperature
Using thermometer 35.6-37.7 C Normal Normal
2. Monitor PulseRate
Palpation 70-100 BPM Normal Normal
3. MonitorRespiration Rate
Observation 20-28 BPM Normal Normal
4. Monitor ApicalPulse Rate
Auscultation 60-100 BPM Normal Normal
5. Skin Inspection Pink, smooth, turgor present Normal Normal6. Hair Inspection Lustrous and shiny Normal Normal7. Eyes Inspection Clear, moist surfaces,
transparent corneaNormal Normal
8. External Ear Inspection Non-tender auricle, tragus Normal Normal
9. Internal Ear Inspection Free from any discharge Normal Normal10. External Nose Inspection Color same as face, smooth and
symmetrical appearanceNormal Normal
11. Sinuses Palpation Non-tender upon palpation Normal Normal12. Lips Inspection Pink, smooth, moist Normal Normal13. Tongue Inspection Deep red with papillae Normal Normal14. Gums Inspection Smooth, firm, pink Normal Normal15. Teeth Inspection Straight with no cavities With missing
upper central andlateral incisor
Abnormal Not related to the case,the patient was at his
deciduous teethextraction
16. Neck Inspection Smooth, controlled movements,
ROM flexion 45, extension 55,
lateral abduction 40, rotation70
Normal Normal
17. Thyroid Inspection/Palpation Midline, smooth, firm, non- Normal Normal
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tender18. Trachea Inspection Midline position, symmetrical,
landmarks identifiableNormal Normal
19. Abdomen Inspection Rounded or flat Normal Normal20. Umbilicus Inspection Sunken, centrally located Protrude Abnormal Poor nutritional status
21. Bowel Sounds Auscultation 2 or 3 times/minute Normal Normal22. Extremities Inspection Fair color over the body, warm
to touchNormal Normal
23. Nails Inspection Pinkish nail beds. Nail firm Normal Normal24. PeripheralPulses
Palpation Bilateral pulses strong and equal Normal Normal
25. CarotidArteries
Palpation Palpable, equal and strong Normal Normal
26. TemporalArteries
Palpation Palpable, equal and strong Normal Normal
27. ROM
-Cervical Spine Inspection/Observation Flexion/extension 45 Normal
Normal
Lateral Bending 40 Normal Normal
-Elbow Inspection/Observation Flexion 160Extension 180 Normal Normal
Pronation/Supination 90 Normal Normal
-Wrist Inspection/Observation Flexion/Hypertension 90 Normal Normal
Ulnar deviation 55 Normal Normal
Radial deviation 20 Normal Normal
-Fingers Inspection/Observation Flexion 90 Normal Normal
Hyperextension 20 Normal Normal
-Ankles Inspection/Observation Dorsiflexion 20 Limited ROM Abnormal Due to accumulation ofmicroorganism in thearea, swelling occurs
thus causing pain whenmoving
Plantar flexion 45 Limited ROM Abnormal Due to accumulation of
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microorganism in thearea, swelling occurs
thus causing pain whenmoving
Eversion 20 Limited ROM Abnormal Due to accumulation of
microorganism in thearea, swelling occurs
thus causing pain whenmoving
Inversion 30 Limited ROM Abnormal Due to accumulation ofmicroorganism in thearea, swelling occurs
thus causing pain whenmoving
Abduction 10 Limited ROM Abnormal Due to accumulation ofmicroorganism in the
area, swelling occursthus causing pain when
moving
Adduction 20 Limited ROM Abnormal Due to accumulation ofmicroorganism in thearea, swelling occurs
thus causing pain whenmoving
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VII. DIAGNOSTIC TEST
Test Name Actual Findings Normal Findings Interpretation Clinical significanceof this test
HematologyMay 31, 2011 August 31,
2011May 31 August 31 To provide valuable
information about theblood and to some
extent the bonemarrow, which is the
blood-forming tissue. To
monitor the plateletand WBC count for
patient with infection.
Hemoglobin Mass 71 92 127-183 g/L Low LowHematocrit 0.23 0.28 0.37-0.54 Low Low
Leukocyte 11.50 8.80 4.5 - 10 x 10 9/L High NormalDifferential Count
Lymphocytes 0.38 0.21 0.20-0.40 Normal NormalSegmenters 0.51 0.64 0.50-0.70 Normal NormalMonocytes 0.06 0.08 0.00-0.07 Normal HighEosinophils 0.05 0.07 0.00-0.05 Normal High
Platelet Count 688 511 150-400 x 10 g/L High HighIndices
MCV 70 82 82-92 fl Low Normal
MCH 22 27 28-32 pg Low Low
MCHC 31 33 32-38 % Low
Chemistry To determine drugseffect taken by thepatient thus causingcholestasis and other
hepato toxicity.
SGOT 40.58 U/L
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June 3, 2011CS: No growth after 72 hoursof incubationGS:
a.) RBC: few; nomicroorganism seen; Nospore-forming bacilli seenb.) RBC: few; WBC: rare; Nomicroorganism seen; Nospore-forming bacilli seen; Noacid fast bacilli seen.
Chest X-ray -lung marking are prominent-some enlarged hilar andtransbronchial lymphodes arenoted-heart is not enlarged-diaphragm and sulci are intactImpression:Findings may relate to primaryKochs infection.
A normal chest x ray willshow normal structuresfor the age and medicalhistory of the patient.
Abnormal(some enlarged hilarand transbronchial
lymphodes are noted)
To evaluate organsand structures within
the chest forsymptoms of disease.
To determine theextent of
microorganism to thispart.
VIII. MEDICAL MANAGEMENT
Management Focus Clinical significance of this management
Medication Antibiotic Therapy To eradicate and prevent the multiplicationof infectious microorganisms
Anti-tuberculosis drugs To eradicate theMycobacterium tubercle bacilli
NSAIDS To relieve the painNutrition High calorie, High protein, High calcium diet To regain the energy lost, to achieve normal
body weight, to promote adequatecalcification of the bone and bone
remodelling and healingExercise Isometric exercise in the unaffected part To prevent paresthesia
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Blood transfusion PRBC, FWB PRBC: For OR (Arthrostomy) usedTo compensate the decreaseresult of CBC
IX. SURGICAL MANAGEMENT
Procedures Name Actual Finding Clinical significance of this procedureArthrotomy and Debridement The specimen consists of several, irregular, pale
red to tan-brown, soft tissue fragments with anaggregate measurement of 5x4x1.5 m and
labeled as intracapsular.
To remove the patient's dead, damaged,or infected tissue to improve the healingpotential of the remaininghealthytissue.
Aspiration of right knee, ankle, and bigtoe
Received specimen in a vial containing yellow,blood tinged fluid with clots, approximately 8.0
ml in volume
To examine bone marrow, the spongy liquidpart of the bone where blood cells are made.
X. DRUG STUDY
GenericName
BrandName
Action Indication Side Effects/ AdverseReactions
Nursing Considerations
Ibuprofen Advil Unknown. Mayinhibitprostaglandinsynthesis, to
produce anti-inflammatory,analgesic, andantipyreticeffects.
Ibuprofencontains the activeingredient ibuprofen, whichbelongs to a group ofmedicines called non-steroidal
anti-inflammatory drugs(NSAIDs).It works by blocking theaction of a substance in thebody called cyclo-oxygenase.Cyclo-oxygenaseis involved inthe production of variouschemicals in the body, someof which are known as
CNSHeadache, dizziness,nervousness, asepticmeningitis.
CVPeripheral edema, fluidretention, edema.EENTTinnitusGIEpigastric distress, nausea,occult blood loss, pepticulceration, diarrhea,
-Tell patient to take withmeals or milk to reduceadverse GI reactions.-Note: Drug is available at
OTC. Instruct patient notto exceed 1.2 g daily, not togive to chidren youngerthan age 12, and not totake for extended periods (longer than 3 days for feveror longer than 10 days forpain) without consultingpresciber.
http://en.wikipedia.org/wiki/Deadhttp://en.wikipedia.org/wiki/Infecthttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Healthhttp://en.wikipedia.org/wiki/Healthhttp://en.wikipedia.org/wiki/Tissue_(biology)http://en.wikipedia.org/wiki/Infecthttp://en.wikipedia.org/wiki/Dead8/4/2019 Case Pres Block 2
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prostaglandins. Prostaglandinsare produced in response toinjuryor certain diseases andwould otherwise go on tocausepain, swelling andinflammation. Ibuprofenistherefore used to relievepainand inflammation.All the medicines in thisgroup (NSAIDs) reduceinflammationcaused by thebody's own immune system,and are effective painkillers. Ibuprofencan be usedto relieve painsuch as muscular
achesandpains,period pains,headache, backache, rheumaticpain, dental painand neuralgia.It can also reducefeverishnessand the symptoms ofcoldsandflu.
constipation, abdominalpain, bloating, GI fullness,dyspepsia, flatulence,heartburn, decreasedappetite.GUAcute renal failure,azotemia, cystitis,hematuria.HEMATOLOGICPlonged bleeding time,anemia, neutropenia,pancytopenia,thrombocytopenia, aplasticanemia, leucopenia,
agranulocystocis.METABOLICHypoglycemia,hyperkalemia.RESPIRATORYBronchospasmSKINPruritus, rash, urticaria,stevens Johnson syndrome.
-Tell patient that fulltherapeutic effect forarthritis may be delayed for2 to 4 weeks. Althoughpain relief occurs at lowdosage levels, inflammationdoesnt improve at dosagesless than 400 mg q.i.d.-Teach patient to watch forand report to prescriberimmediately signs andsymptoms of GI bleeding,including blood in vomit,urine, or stool or coffeeground vomit, and black,
tarry stool.-Warn patient to avoidhazardous activities thatrequire mental alertnessuntil effects on CNS areknown.-Advise patient to wearsunscreen to avoidhypersensitivity to sunlight.
Isoniazid Niazid The mechanism
of action ofINH is notknown, but it isthought towork throughits effects onlipids (fats) andDNA withinthe tuberculosis
INH is used to prevent
active tuberculosis inpersons who have anabnormal skin test fortuberculosis or incombination with otherdrugs for the treatment ofactive tuberculosis.Prophylaxis in specificpatients who are tuberculin
-allergic reaction (difficulty
breathing; closing of thethroat; swelling of the lips,tongue, or face; or hives);
-unusual weakness orfatigue;
-nausea, vomiting, or loss ofappetite;
Health teachings:
-Take this drug in singledaily dose.-Take drug on an emptystomach, 1 hour before or2 hours after meals. If GIdistress occurs, may betaken with food.-Take this drug regularly,avoid missing doses, do
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bacterium. It isvery selectivefor thetuberculosisbacteria, that is,it has few if anyeffects on otherbacteria.
reactors (positive Mantouxtest)) or who are consideredto be high risk for TB.
-abdominal pain;
-yellow skin or eyes;
-dark urine;
-numbness or tingling inyour hands or feet;
-seizures;
-blurred vision; or
-confusion or abnormal
behavior.
not discontinue withoutfirst consulting your healthcare provider.-Do not drink alcohol ordrink as little as possible.There is an inc. risk ofheap if these two drugs arecombined.-Avoid foods containingtyramine, consult a dietitianto obtain a list of foodscontaining tyramine orhistamine.-Have periodic medicalcheck-ups, including an eye
examination and bloodtest, to evaluate the drugeffects.-Report for weakness,fatigue, loss of appetite,n/v, yellowing of skin oreyes, darkening of theurine, numbness or tinglingin hands or feet,
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RifampinRifadin Inhibits DNA-
dependentRNApolymeraseactivity insusceptiblebacterial cells.
Treatment of PulmonaryTB in conjunction with atleast one other effectiveantituberculotic.Neisseria meningitidiscarriers, for asymptomaticcarriers to eliminatemeningococci fromnasopharynx; not fortreatment of meningitis.Unlabeled uses: Infectionscaused by Staphylococcusaureus and Staphylococcusepidermis, usually incombination therapy; gram-
negative bacteremia in infancy;Legionella pneumophilia, notresponsive to erythromycin;leprosy (in combination withdapsone); prophylaxis ofmeningitis caused byHaemophilis influenzae.
CNS: headache,drowsiness, fatigue,dizziness, inability toconcentrate, mentalconfusion, generalizednumbness, muscleweakness, visualdisturbances.Dermatologic: Rash,pruritus, urticaria, flushing,reddish discoloration ofbody fluidstears, saliva,urine, sweat, sputum.GI: heartburn, distress,anorexia, vomiting gas,
cramps, diaarhea, hepatitis,pancreatitis.GU: hemoglobinuria,hematuria, renalinsufficiency, acute renalfailure, menstrualdisturbances.Hematologic: eosinophilia,thrombocytopenia, transientleucopenia, hemolytic
anemia, decreased Hgb,hemolysis.Other: pain in extremities,osteomalacia, myopathy,fever, flulike symptoms.
-Teach client to take drugin a single daily dose. Takeon an empty stomach, 1 hrbefore or 2 hrs after meals.-Inform client to take thisdrug regularly; avoidmissing any doses; do notdiscontinue this drugwithout consulting thehealth care provider.-Tell client to have periodicmedical checkups,including eye examinationsand blood test, to evaluatethe drug effects.
-Inform client that he mayexperience the drugs sideeffects (especially the redcolored secretion)-Instruct client to see hisphysician if he experiencefever, chills, muscle andbone pain, excessivetiredness or weakness, lossof appetite, N/V, yellowing
of eyes/skin, unusualbleeding or bruising, skinrash or itching.-Instruct client to removecontact lenses as they maydiscolor
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Pyrazinamide Pyrazinamide Pyrazinamidemay bebacteriostatic orbactericidalagainstMycobacteriumtuberculosisdepending ontheconcentrationof the drugattained at thesite of infection.The mechanismof action is
unknown. Invitro and invivo the drug isactive only at aslightly acidicpH.
Pyrazinamide is indicatedfor the initial treatment ofactive tubercuIosis in adultsand children whencombined with otherantituberculous agents. (Thecurrent recommendation ofthe CDC for drug-susceptible disease is to usea six-month regimen forinitial treatment ofactivetuberculosis, consisting ofisoniazid, rifampin andpyrazinamide given for 2months, followed by
isoniazid and rifampin for 4months.*4)(Patients with drug-resistantdisease should be treatedwith regimensindividualized to theirsituation. Pyrazinamidefrequently will be animportant component ofsuch therapy.)
(In patients withconcomitant HIV infection,the physician should beaware of currentrecommendation of CDC.It is possible these patientsmay require a longer courseof treatment.)
General: Fever, porphyriaand dysuria have rarely beenreported.Gastrointestinal: Theprincipal adverse effect is ahepatic reaction (seeWARNINGS).Hepatotoxicity appears tobe dose related, and mayappear at any time duringtherapy. Gl disturbancesincludingnausea, vomitingand anorexia have also beenreported.Hematologic and
Lymphatic:Thrombocytopenia andsideroblastic anemiawitherythroid hyperplasia,vacuolation of erythrocytesand increased serum ironconcentration haveoccurred rarely with thisdrug. Adverse effects onblood clotting mechanisms
have also been rarelyreported.Other: Mild arthralgia andmyalgia have been reportedfrequently. Hypersensitivityreactions including rashes,urticaria, and pruritis havebeen reported. Fever, acne,photosensitivity, porphyria,
-Take this drug in singledaily dose.-Take drug on an emptystomach, 1 hour before or2 hours after meals. If GIdistress occurs, may betaken with food.-Take this drug regularly,avoid missing doses, donot discontinue withoutfirst consulting your healthcare provider.-Do not drink alcohol ordrink as little as possible.There is an inc. risk of
heap if these two drugs arecombined.
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dysuria and interstitialnephritis have beenreported rarely.
Vitamin Bcomplex
Surbex,Vicon-C, Z-
Bec
A coenzymethatstimulatemetabolicfunction and isneeded for cellreplication,hematopoiesis,andnucleoproteinand myelin
synthesis
This product is acombination of B vitaminsused to treat or preventvitamin deficiency due topoor diet, certain illnesses,alcoholism, or duringpregnancy. Vitamins areimportant building blocksof the body and help keepyou in good health. Bvitamins include thiamine,
riboflavin,niacin/niacinamide, vitaminB6, vitamin B12, folic acid,and pantothenic acid
CV:Peripheral vascularthrombosis,heart failure.GI:transientdiarrhea.Respi:pulmonaryedema.Skin:
it ching,transitoryexanthema,urticaria.Other:anaphylaxis,anaphylactoidreactions withparenteraladministration
, pain orburning atinjection site
BEFORE:~ Determine reticulocytecount, hct, Vit.B12, iron,folate levels beforebeginning therapy.~ Obtain a sensitivity testhistory beforeadministration~ Avoid I.V.administrationbec. faster systemic
elimination will reduceeffectiveness of vitamin.DURING:~ Dont give large doses ofvitaminB12 routinely; drugis lost through excretion.~ Dont mix parenteralpreparation in samesyringe with other drugs.AFTER:
~ Protect Vit.B12 fromlight. Dont refrigerate orfreeze.~ Monitor patient forhypokalemia for first 48hours, as anemia correctitself. Give potassiumsupplements, as needed
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XI. NURSING CARE PLAN