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CHINESE GENERAL HOSPITAL COLLEGE OF NURSING AND LIBERAL ARTS

Adult Assessment

Yr/Sec/Grp: IV-A, grp4 Area: San Lazaro Hospital, Pavilion 4

Name: JDB Date Admitted: June 11, 2009 Admission #: 348877


Age: 29 y/o Sex: Male Birth date: Aug. 26, 1979 Birth place: Manila
Civil Status: Married Religion: Seventh day Adventist
Address: Tecson St. Sta. Ana Manila

Personal / Social History: Father


(+) smoker (-) Hypertension, (-) DM, (-)
(-) occasional alcoholic CA, (-) asthma
beverage drinker Mother
(-) Hypertension, (-) CA, (-)
DM,
(-) asthma

Family History:
Diagnosis/ Impression: Meningitis

Operation: none
Chief Complaint:
Fever with decreased sensorium, abnormally sleepy

History of Present illness:


The patient is a diagnosed case of meningitis. Five weeks prior to
admission (May 14, 2009), the patient experienced febrile episodes
associated with headache. The patient sought consult with private physician
and was given an unrecalled medication. The unrecalled medications brought
no improvement on the above signs and symptoms.
Two weeks prior to admission, the patient sought consult in Ospital ng
Makati Clinic and he was given with unrecalled medications and was then
advised to be sent home. His condition progressed.
One week prior to admission, patient was noted to have a loss of
bladder control and was noted to have a lesser movement on both of the
lower extremities and no consult to health care practitioners was done. Four
days prior to admission, the patient was noted to have a decrease in
sensorium and the persistence of above signs and symptoms prompt to
consult.

History of Past Illness:


Medical History:
When patient was 15 years old, the patient is then the care taker in
raising their ducks in their owned poultry. The wife of the patient told that the
smell in the cages were extremely noxious. And the patient is not even using
any protection like simple hankerchief or face mask to protect himself. Since
then, it started the on-and-off cough, colds and fever and the patient would
usually take solmux which will cause no alarm.
A year prior to admission, the patient was hit by a gang and his head
had the most injury and the patient did not seek medical advice after the
incident.
none
I. General Physical Assessment and Cranial Nerve Testing
Vital signs upon assessment were:
T: 37.80C PR: 82bpm RR: 22bpm BP: 120/70mmHg

Vital statistics were:


Ht: 163 cm Wt: 60Kg (before hosp. admission)
Patient is conscious and coherent. He is relaxed and able to talk and
sit. Has good mood as evidenced by smiling and greeting back when greeted.
Not in any form of distress.

Skin:
Patient skin color is light brown. There is no sign of cyanosis and
jaundice. Skin is dry and warm in temperature. Texture is slightly rough and
with fine skin turgor.

Head:
Patient head is symmetrical and normocephalic. Hair color is black,
silky and resilient. Scalp is smooth and has no lesions, lumps. With visible
dandruffs but with no infestations of nits/lice. Has no signs of alopecia.
Mandible is intact. No signs of sinusitis, tenderness or lumps. Cranial nerve
no. 7 is intact as evidenced by symmetry of face.

Neck and Shoulders:


Neck is symmetrical. Trachea is in the midline of the neck. Presence of
minimal bruit in the thyroid. With minimal cervical lymphadenopathy. Cannot
flex, extend, hyperextend and rotate neck actively.

Eyes:
Patient eyebrows are symmetrical in position and size. Eyes are not
sunken. Palpebral conjunctiva is pink. Sclera is icteric. No signs of lesions, but
with excessive drainage. Lacrimal sac are not swollen. Cranial nerve no. 2 is
intact as evidenced by dilation of both pupils 2-3mm but in slow reaction to
light. Cranial no. 3 is cannot be assessed. Visual acuity test is not done.
Cranial nerve no.5 is intact as evidenced by mastication.

Ears:
Patient ears are symmetrical. There are no signs of lesions, masses, or
excessive discharge. Inner ear is not assessed. Webber’s and Rinne’s test is
not done. Romberg’s test is not done
Nose:
Patient nose is symmetrical. With NGT in place on right nares. Absence
of discharge or flaring. Nose is also patent. Cranial nerve no.1 is not
assessed.

Mouth/ Throat:
Patient mouth is symmetrical. He has a dark pink and dry lips. With
one well-fitted denture on right upper mollar. Tongue has whitish
membranous plaques on the tongue and the papillae are raised. No presence
of swelling and ulceration. Floor of the mouth is pinkish and has no swelling
and ulceration. Tonsils has no discharges and lesions and is not inflamed.
Cranial nerve 9 -11 is not assessed. Cranial nerve no. 12 is intact as
evidenced by non-deviated tongue.

Chest:
Patient chest is symmetrical. Has purpuric rash all over the trunk.
Lungs are equal in expansion and compression. Has substernal, intercostal
and clavicular retractions. Has grunting sound while breathing. Fine crackles
is heard upon percussion of chest. Normal heart beat or S1, S2 and pathologic
S3 are audible in the 5th intercostals space midclavicular line.

Abdomen:
Patient abdomen is symmetrical and is flat. No presence of swelling.
Umbilicus is clean and there is no presence of lesions and discharge. Has
normoactive bowel sounds and there is 6 bowel sounds heard.

Spine:
Not assessed.

Genitalia and Anus:


Not assessed.

Lower Extremities:

Patient lower extremities are symmetrical. Popliteal, dorsalis pedis and


posterior tibial pulse are in full palsation. Number of toes is complete. Has
presence of clubbing of the toenails. Nail plate is whitish and brittle, the
toenail itself is translucent and colorless. It is slight curved and its contour is
just proportionate to cover the nail bed. There is good blood flow to the nail
bed as evidenced by a blanch test score of less than 2 seconds.

Upper Extremities:

Patient upper extremities are symmetrical. Brachial and radial pulses


are in full pulsation. Number of fingers is complete. There is presence of stiff
clawing when the patient is awake. No clubbing of fingernails. Nail plate is
whitish, the nail itself is translucent and colorless. The nails have smooth
surface. It is flat and its contour is just proportionate to cover the nail bed.
There is good blood flow to the nail bed as evidenced by a blanch test score
of less than 2 seconds.

Cerebral Functions:
Cognitive
n/a

Sensory
n/a

Reflexes
Intact gag reflex as evidenced by being nauseous when trying to cough
out sputum
Intact blinking reflex as evidenced by frequent blinking as the wasp of
the cotton touched the sclera
The pupillary reflex is intact as evidenced by vasoconstriction when the
penlight is spotted and is dilating when the torch is out but in slowed
reaction.
Coughing reflex is altered as evidenced by multiple grunting to
produce a cough.

Language
n/a

II. Significant Health Patterns

a. Sleep
Hours: OD (8hrs) at 9pm-5am, during hospitalization, indefinite.
Frequency: Once
Disturbances: none
Bedtime Ritual: none

b. Activity & Exercise:


Exercise: basketball
Frequency: Once a week
Activity: watching tv, feeding the ducks
Frequency: Almost everyday

c. Nutrition:
Food Preferences: anything especially vegetables and fish
Frequency: 3 times a day
Dietary Restrictions: none

d. Elimination:
Bowel Movement: Urination:
Frequency: Once a day Frequency:5-6x a day
Time: Few minutes as pt Time: indefinite
woke Characteristics: yellowish,
up in the morning aromatic
Consistency: Formed, brown

e. Work
Caretaker of the duck poultry farm

f. Rest and Recreation:


Cycling, watching t.v, taking care of his children

Laboratory Works
Complete Blood Count
Results Results Results Results Results Normal
07/07/ 07/14/ 07/21/ 07/24/ 07/29/ Values
09 09 09 09 09
WBC 21.2 15.1 17.2 15.8 18.1 4.8-
10.8*10^9/L
RBC 4.01 3.27 3.4 3.58 3.4. 4.7-6.1
HGB 12.5 10.6 11.1 11.6 11.4 13-17
HCT 37.0 30.9 33.2 35.3 34.6 40-52
MCV 92 94 98 98 101 82-98fL
MCH 31 33 33 32 33 20-30 pg
MCHC 34 34 33 33 33 33-36
Plt. Count 356 499 408 519 553 150-400
Differentials
neutrophi 90.8 81.4 78.4 76.8 85.6 40-70
ls
Lymphoc 2.8 10.5 12.8 14.1 9.4 19-48
ytes
Eosinophi 0.3 0.8 0.7 0.7 1.2 2-8
ls
Monocyte 6.1 7.1 7.0 8.2 2.8 3-9
s
Basophils 0.1 0.2 1.1 0.2 1.2 0-5

Significance of Complete Blood Count:


Leukocytosis is present indicating that there is an infection in the client.
Erythrocytemia may be caused by the drugs taken by the client.
Thrombocytosis are common in patients who are affected by Meningitis due
to Haemophilus Influenzae, though it is only benign and those who are having
thrombocytopenia are in fatal condition. Neutrophils are increased to invade
the infection agent on the body compartment specifically CNS.

Bacteriology Test Result


Date Requested: 07/31/09
Specimen: Sputum
Growth: Pseudomonas + Alpha Hemolytic Strep Specie identification and
autobiogram to follow
Remarks: Gram Stain: gram (-) rods gram (-)cocci in chains
Date Released: 08/02/09
Significance:
Presence of bacteria indicates that a client may have infection in the client’s
lungs. A pseudomonas is one of the common causative agents of nosocomial
infections. Alpha Hemoltic Streptococci causes Meningitis. This test may
indicate that the client has meningitis. But this is not the confirmatory test for
meningitis.

Microbiology Presumptive Report


Specimen: Sputum
Color: Milky
Appearance: Mucoid
Ziejl- Neelsen Stain: AFB not seen
Significance: This result may rule out the possibility of a client to have
Pulmonary Tuberculosis.
Chemical Chemistry
Specimen: Serum
Test 06/20 07/31/09 08/03 Normal
Values
Sodium 125.7 127 - 135-145
Potassium 3.03 2.4 - 3.6-5.5
Chloride 104.3 - - 101-111
Calcium 1.84 - - 2.1-2.6
Creatinine - - 62 53-63

Significance:
The client has hyponatremia, hypokalemia and hypocalcemia. This means
that there are no enough electrolytes to fire impulses to his brain that may
make him stupporuous or lethargic. His reflexes may be diminished because
of these results.
ANATOMY OF MENINGES
anatomysingular meninx

Three membranous envelopes—pia mater, arachnoid, and dura mater—that


surround the brain and spinal cord. Cerebrospinal fluid fills the ventricles of
the brain and the space between the pia mater and the arachnoid. The
primary function of the meninges and of the cerebrospinal fluid is to protect
the central nervous system.

The pia mater is the meningeal envelope that firmly adheres to the surface of
the brain and spinal cord. It is a very thin membrane composed of fibrous
tissue covered on its outer surface by a sheet of flat cells thought to be
impermeable to fluid. The pia mater is pierced by blood vessels that travel to
the brain and spinal cord.

Over the pia mater and separated from it by a space called the subarachnoid
space is the arachnoid, a thin, transparent membrane. It is composed of
fibrous tissue and, like the pia mater, is covered by flat cells also thought to
be impermeable to fluid. The arachnoid does not follow the convolutions of
the surface of the brain and so looks like a loosely fitting sac. In the region of
the brain, particularly, a large number of fine filaments called arachnoid
trabeculae pass from the arachnoid through the subarachnoid space to blend
with the tissue of the pia mater. The arachnoid trabeculae are embryologic
remnants of the common origin of the arachnoid and pia mater, and they
have the frail structure characteristic of these two of the meninges. The pia
mater and arachnoid together are called the leptomeninges.

The outermost of the three meninges is the dura mater (or pachymeninx), a
strong, thick, and dense membrane. It is composed of dense fibrous tissue,
and its inner surface is covered by flattened cells like those present on the
surfaces of the pia mater and arachnoid. The dura mater is a sac that
envelops the arachnoid and has been modified to serve several functions.
The dura mater surrounds and supports the large venous channels (dural
sinuses) carrying blood from the brain toward the heart.

The dura mater is partitioned into several septa, which support the brain. One
of these, the falx cerebri, is a sickle-shaped partition lying between the two
hemispheres of the brain. Another, the tentorium cerebelli, provides a strong,
membranous roof over the cerebellum. A third, the falx cerebelli, projects
downward from the tentorium cerebelli between the two cerebellar
hemispheres. The outer portion of the dura mater over the brain serves as a
covering, or periosteum, of the inner surfaces of the skull bones.
Within the vertebral canal the dura mater splits into two sheets separated by
the epidural space, which is filled with veins. The outer of these two sheets
constitutes the periosteum of the vertebral canal. The inner sheet is
separated from the arachnoid by the narrow subdural space, which is filled
with fluid. In a few places, the subdural space is absent, and the arachnoid is
intimately fused with the dura mater. The most important area of fusion
between these two meninges is in the walls of the large venous channels of
the dura mater where elongations of the arachnoid, like fingers, penetrate
the dura mater and project into the veins. These fingerlike processes of the
arachnoid, called arachnoid villi or arachnoid granulations, are involved in the
passage of cerebrospinal fluid from the subarachnoid space to the dural
sinuses. Spinal anesthetics are often introduced into the subarachnoid space.