Block 12B Estacio, Paulo Lorenzo Leonor, Sarah Jane Dela Cruz, Joanna Marie Montalbo, Mark John Villasoto, Michelle

IntroductionPott's disease is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. It is named after Percivall Pott (17141788), a London surgeon who trained at St Bartholomew's Hospital, London. The lower thoracicand upper lumbar vertebrae are the areas of the spine most often affected. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine.

Demographic Data Name: Mr. Potter Address: Brgy. Tagpos Binangonan, Rizal Age: 14 years old

Gender: Male Religion: Roman Catholic Birthday: September 26, 1996 Attending Physivian: Dr. Almeron Admitting Diagnosis: Potts Disease

Chief Complaint Weakness of both lower extremities

History of Present IllnessInformant: Patient Reliability: 80% 1 yr PTA patient experience upper back pain, non-

radiating, graded 10/10. 8 mos. PTA persistence of deformity of spine with no associated symptoms. 4 mos. PTA persistence of deformity of spine prompted consult at National Childrens Hospital where thoracolumbar spine xray was requested however patient did not comply because of financial constraints.

1 mo. PTA patient experienced numbness and

weakness of lower extremities described as heaviness of both ankles, which gradually progressed to difficulty in ambulation which required 2 men assist. 1 wk PTA persistence of symptoms prompted consult at National Childrens Hospital where patient was diagnosed to have Potts Disease. 1 day PTA patient sought consult at Philippine Orthopedic Center care of Out Patient Department, and was subsequently admitted and referred to POC service, hence this admission.

Past Medical History

Family Medical History

Personal, Social and Environmental History

Developmental TaskRobert Havighurst ( Adolescence ) its tasks are to achieve new

and more mature relations with age-mates of both sexes, accept ones own capabilities and achieve emotional, economic and social independence.

Sigmund Freud ( 6 years to puberty) is characterized of energy

that is directed to physical and intellectual activities. Sexual impulses are repressed and the person tends to develop relationships between peers of the same sex.

Erik Erikson (12 to 20 years/Identity versus Role Confusion ) Identity as described by

Erikson is the ability of the person to self-actualize and realize his potential and capabilities. Role confusion is the opposite in which the person is not able to realize his potential and establish his identity in the community.

Jean Piaget ( Formal operations phase- 11 to 15 yrs. and above ) where its significant

behavior is use of rational thinking or reasoning is deductive and futuristic.

Lawrence Kohlberg ( Conventional- Adolescent age to adulthood ) person in this stage as having

the wants to establish rules from authorities. Decisions for the behavior are based upon law and order being imposed in the community.

James Fowler ( Stage 3 Syntheticconventional Adolescent or Adult ) the person in these stage

focuses on the worlds reaction and judgment towards his actions. In general it focuses more on interpersonal relationships.

Gordons Assessment

Health Perception/ Health Management Pattern Nutrition/ Metabolic Pattern Elimination Pattern Activity and Exercise Pattern Sleep and Rest Pattern Cognitive Perceptual Pattern Self-Perception Pattern Role/Relationship Pattern Coping/Stress Management Pattern Sexuality/Reproductive Pattern Value/Belief Pattern

Physical AssessmentAugust 25, 2010 General Appearance: alert, awake, afebrile, very active, not in distressed. Skin: smooth and even, moist, warm Head and Neck: symmetric with a oval face, head sometimes tilted to one side but freely movable, no swelling, tenderness, or crepitation with movement. Neck symmetric with head centered and without bulging masses. Eyes: pupil reactive to light, pink palpebral conjunctivae, (+) Ptosis both eyes, scar in left eyebrow

Ears: no discharge, decrease hearing senses Nose: symmetrical, no deformity, no skin lesions, no

swelling Mouth and Throat: no lesion, pinkish in color, moist tongue Breasts: no swelling, nodules or ulceratons Chest/Lungs: symmetrical chest expansion, no cough Heart: no murmur, no extra heart sounds, active pulse Abdomen: globular, soft, no abdominal pain reported Back: no ecchymosis, with gibbus formation, pain

Extremities: inability to move lower extremities,

can feel sensations, weakness on both lower extremities and paralyze Genitalia: no hernia and discharge Rectal: irregular bowel movement Neurologic assessment: Alert and awake, good grooming and dress, with good eye contact, cooperative and friendly, expresses feelings appropriately, familiar with objects and names of his nurses.

Review of Systems Skin: (-) rashes, (-) lumps, (-) itching, (+) dryness Head: (-) headache, (-) head injury, (+) tilted to one side Eyes: (-) eyeglasses or contact lenses, (-) pain, (-) redness,

(-) double vision (+) ptosis (-)glaucoma, (-) cataracts Ears: (-) tinnitus, (-) discharge, (+) decreased hearing sensation Nose and Sinuses: (-) nose bleeds, (-) colds Mouth and Throat: (-) sore throat, (-) lesions on gums Neck: (-) goiter Breasts: not assessed

Respiratory: (-)cough, (-) sputum, (-)hemoptysis, (+)

PTB Cardiac: (-) heart problem, (-) hypertension, (-) pain GIT: (-) vomiting Urinary: (-) dysuria Genital: (-) discharges, (-) hernias Musculoskeletal: (-) joint pains, (+) weakness on both lower extremities, (+) paralysis, (+) gibbus formation, (+) back pain, (-) sensory problems Neurological: (-) seizures, (-) numbness Hematologic: (-) easy bruising or bleeding, (-) past transfusions

Course in the WardDate July 20, 2010 Doctors Order Nurses Notes Please admit patient to room Admitted this 13years old of choice under CO service male per wheel chair from Weight: 60 lbs OPD accompanied by nurse Height: 121 cm and relatives with chief BMI: 19.9 normal complaint of lower extremities weakness to room 405-1 under the service of Dr. Almeron Secure Consent Consent for admission signed by mother Diet as tolerated Monitor vital signs every Initial vital signs: shift T(36.7-37.2)-37.6C

Labs: CBC, ESR, CRP(Quantitative) Blood typing, CT, BT PT, PTT, BUN, Crea Na, K, Cl CXR APL Thoracolumbar APL

Hgb 120 g/L Hct 0.36 Leucocyte 12.90 Eosinophils 0.09 Platelet count 421 PT 13.3 secs Blood type AB+ CRP reactive Semi quantitative CRP 48mg/L MCV 67 MCH 20 MCHC 30 Urea Nitrogen 4.25

Meds: INH 400mg tablet All medications given. RIF 450mg capsule PZA 500mg capsule EMB 400 mg tablet Quadrouple antibiotics once a day before breakfast Paracetamol 500mg tablet every 4 hours as needed for fever Vitamin B complex syrup 5 ml once a day

Refer accordingly Dr. Almeron July 25, 2010

Referred accordingly

Refer to rehab for coReferred to rehab management Refer Dr. Almeron Carry out suggestion of rehab Suggestions of rehab carried Refer out Dr. Almeron Rehab Admitting Order To PT: IE DBE Initial evaluation done Deep breathing exercises done Maintenance exercises to both lower extremities AAROMES to both hip and Patient makes an effort in the knee joints exercise PROMES to both ankle Nurse makes the effort in the joints with GPS to both exercise with a gentle passive hamstrip and heel cords stretching

July 26, 2010

ES to both TAs and Electrical stimulation is done peroneals for paralysis of his legs To GT: initial evaluation G7 supportive activator To Psyche/VOC/Sr: initial evaluation Dr. Ballesteros August 1, 2010 2:20 pm CBC,ESR,CRP(Quantitative) Continue Meds Refer Dr. Almeron Hgb 126 Leucocyte 12.0 Eosinophils o.15 CRP reactive MCV 72 MCH 22 MCHC 31 Medications continued

August 6, 2010 1:05 pm

Please carry out PT order last July 26, 2010 Please follow up referral to nutritionist for nutritional build-up thank you Dr. Suliat

August 11, 2010 9:00am

Shift quadrouple antibiotics to syrup still to be given before breakfast 1.) INH 200mg/5ml 10ml OD 2.) RIF 200mg/5ml 10ml OD 3.) PZA 250mg/5ml 10ml OD 4.)EMB 100mg/5ml 10ml OD Refer

Medication was shifted to syrup because the patient has difficulty drinking the oral tablet.

August 22, 2010 11:00am

Revised Rehab Orders To PT: Re-evaluation DBE Maintenance exercise to both lower extremities PROMES to both GPS to both hamstrip and heel cords ES to both quads. Hamstrip, TAs peroneals Thank you

August 22, 2010 5:00pm

Continue Meds Refer Dr. Almeron

Normal Physiology

Pathophysiology

Medications Prednisone (Prolix) 10 mg/5ml syrup corticosteroid, glucocorticoid It inhibits accumulation of macrophages and leukocytes at sites of inflammation and inhibits phagocytosis and lysozomal enzyme release. Isonicotinic acid hydrazide (Isoniazid) 200 mg/5ml/3

ml OD Anti-bacterial Bactericidal: it interferes with lipid and nucleic acid

metabolism of growing bacteria, resulting in alteration of the bacterial wall

Rifampicin (Rifadin) 200 mg/5 ml Anti-bacterial It inhibits DNA-dependent RNA polymerase, which impairs RNA synthesis Vitamin B Complex Vitamins are compounds that you must have for growth and health. They are needed in small amounts only are usually available in the foods that you eat. Vitamin B12 is necessary for healthy blood. Cyanocobalamin and hydroxocobalamin are man-made forms of vitamin B12.

Nursing Care Plan1. Pain

a. b. c. d. e.

Alteration in comfort: Pain related to pressure on the sensory neurons secondary to spinal cord compression. Assess report of pain. Maintain bed rest. Provide opportunities to talk. Limit activity during acute phase as indicated. Administer analgesic as ordered

2. Weakness in lower extremities

a.

b.c. d. e.

Impaired physical mobility r/t pressure in the motor neurons secondary to spinal cord compression Schedule activity/procedures with rest periods. Provide/assist with passive and active ROM. Assist with activity/ progressive ambulation. Review proper body mechanics for participation in activities Consult with physical/ occupational therapies and rehabilitation specialist.

3.Weight loss Altered nutrition: Less than body requirement related to

fatigability, inadequate food intake, and decrease weight. a. Assess and report sign of malnutrition. b. Determine and daily caloric requirements that are realistic and adequate. c. Provide high-protein, high calorie finger foods and drinks. d. Maintain good oral intake. e. Encourage the client to eat with others. f. Explain the importance of adequate nutrition.

4. Risk for Injury Risk for Injury: Fall r/t weakness of both lower

extremities a. Keep padded side rails up with bed in lowest position. b. Stay with the patient while assisting out of the bed. c. Assist in implementing program as outlined. d. Consult with physical/occupational therapies and rehabilitation specialist.

5. Anxiety/Fear Anxiety/ Fear r/t present condition.a. Explain purpose of rest and procedures. b. Encourage family and friends to treat patient as

before. c. Promote expression of feelings and fears.