Submitted by:

 
Rostum Harold B. Serrano
Joshua Meolyn O. Ibarrola
Eva Merlyn V. Tagle
Camille Kaye R. Ortiz
 
Group 11
BSN III-SLSU
 
A. General Objective
After further assessment, providing care to
the client and conducting a careful and
thorough study of the client’s condition, the
student will be able to gain knowledge,
develop skills and enhance attitude in
rendering quality nursing care in actual
situation to the client with diagnosis of
pyogenic discitis.
B. Specific Objective
State the definition of discitis.
Enumerate the clinical
manifestations shown by the
client.
Review of the anatomy &
physiology of the involved system.
Trace the pathophysiology of the
disease.
Determine and state latest issues
regarding the disease.
Establish a therapeutic nurse-
patient relationship.
Determine the client’s status through
General and Demographic data
Present History of the Illness
Family Health History
Physical Assessment
Analyze laboratory results; correlate it with the
client’s present condition and manifestations;
and apply appropriate nursing interventions.
Familiarize self with the diagnostic
procedures done to the patient in
determining the present illness and possible
interpretation in accordance to its normal
values.
Identify and understand the importance of
pharmacological interventions to the
patient’s present condition.
Render quality nursing care through
implementation of nursing care plan.
Evaluate the effectiveness of the nursing care
plan and medical management.
II. INTRODUCTION OF THE DISEASE
Diskitis is swelling (inflammation) and
irritation of the space between the bones
of the spine (intervertebral disk space).
III. ANATOMY AND PHYSIOLOGY
A musculoskeletal system (also known as
the locomotor system) is an organ system
that gives animals (including humans) the
ability to move using the muscular and
skeletal systems. The musculoskeletal
system provides form, support, stability,
and movement to the body.
It is made up of the body's bones (the
skeleton), muscles, cartilage, tendons,
ligaments, joints, and other connective
tissue (the tissue that supports and binds
tissues and organs together). The
musculoskeletal system's primary functions
include supporting the body, allowing
motion, and protecting vital organs. The
skeletal portion of the system serves as the
main storage system for calcium and
phosphorus and contains critical
components of the hematopoietic system.
This system describes how bones are
connected to other bones and muscle fibers
via connective tissue such as tendons and
ligaments. The bones provide the stability
to a body in analogy to iron rods in
concrete construction. Muscles keep bones
in place and also play a role in movement of
the bones. To allow motion, different bones
are connected by joints. Cartilage prevents
the bone ends from rubbing directly on to
each other. Muscles contract (bunch up) to
move the bone attached at the joint.
There are, however, diseases and disorders
that may adversely affect the function and
overall effectiveness of the system. These
diseases can be difficult to diagnose due to
the close relation of the musculoskeletal
system to other internal systems. The
musculoskeletal system refers to the system
having its muscles attached to an internal
skeletal system and is necessary for humans
to move to a more favorable position.
Complex issues and injuries involving the
musculoskeletal system are usually handled
by an orthopedic surgeon.
 
 
Subsystems
Skeletal
The Skeletal System serves many important functions; it
provides the shape and form for our bodies in addition to
supporting, protecting, allowing bodily movement, producing
blood for the body, and storing minerals. The number of bones
in the human skeletal system is a controversial topic. Humans
are born with about 300 to 350 bones, however, many bones fuse
together between birth and maturity. As a result an average
adult skeleton consists of 206 bones. The number of bones varies
according to the method used to derive the count. While some
consider certain structures to be a single bone with multiple
parts, others may see it as a single part with multiple bones.
. There are five general classifications of
bones. These are Long bones, Short bones,
Flat bones, Irregular bones, and Sesamoid
bones. The human skeleton is composed of
both fused and individual bones supported
by ligaments, tendons, muscles and
cartilage. It is a complex structure with two
distinct divisions. These are the axial
skeleton and the appendicular skeleton.
 Function
The Skeletal System serves as a framework for tissues
and organs to attach themselves to. This system acts
as a protective structure for vital organs. Major
examples of this are the brain being protected by the
skull and the lungs being protected by the rib cage.
Located in long bones are two distinctions of bone
marrow (yellow and red). The yellow marrow has fatty
connective tissue and is found in the marrow cavity.
During starvation, the body uses the fat in yellow
marrow for energy. The red marrow of some bones is
an important site for blood cell production,
approximately 2.6 million red blood cells per second
in order to replace existing cells that have been
destroyed by the liver. Here all erythrocytes, platelets,
and most leukocytes form in adults. From the red
marrow, erythrocytes, platelets, and leukocytes
migrate to the blood to do their special tasks.
 Muscular
There are three types of muscles—cardiac,
skeletal, and smooth. Smooth muscles are used to
control the flow of substances within the lumens
of hollow organs, and are not consciously
controlled. Skeletal and cardiac muscles have
striations that are visible under a microscope due
to the components within their cells. Only
skeletal and smooth muscles are part of the
musculoskeletal system and only the skeletal
muscles can move the body. Cardiac muscles are
found in the heart and are used only to circulate
blood; like the smooth muscles, these muscles are
not under conscious control.
 Contraction initiation
In mammals, when a muscle contracts, a series of
reactions occur. Muscle contraction is stimulated by
the motor neuron sending a message to the muscles
from the somatic nervous system. Depolarization of
the motor neuron results in neurotransmitters being
released from the nerve terminal. The space between
the nerve terminal and the muscle cell is called the
neuromuscular junction. These neurotransmitters
diffuse across the synapse and bind to specific
receptor sites on the cell membrane of the muscle
fiber. When enough receptors are stimulated, an
action potential is generated and the permeability of
the sarcolemma is altered. This process is known as
initiation.
Tendons
A tendon is a tough, flexible band of fibrous
connective tissue that connects muscles to
bones. Muscles gradually become tendon as
the cells become closer to the origins and
insertions on bones, eventually becoming
solid bands of tendon that merge into the
periosteum of individual bones. As muscles
contract, tendons transmit the forces to the
rigid bones, pulling on them and causing
movement.
 Joints, ligaments, and bursae
Joints
Joints are structures that connect individual
bones and may allow bones to move against each
other to cause movement. There are two
divisions of joints, diarthroses which allow
extensive mobility between two or more articular
heads, and false joints or synarthroses, joints that
are immovable, that allow little or no movement
and are predominantly fibrous. Synovial joints,
joints that are not directly joined, are lubricated
by a solution called synovia that is produced by
the synovial membranes. This fluid lowers the
friction between the articular surfaces and is kept
within an articular capsule, binding the joint with
its taut tissue.
Ligaments
A ligament is a small band of dense, white, fibrous
elastic tissue.[6] Ligaments connect the ends of bones
together in order to form a joint. Most ligaments limit
dislocation, or prevent certain movements that may
cause breaks. Since they are only elastic they
increasingly lengthen when under pressure. When
this occurs the ligament may be susceptible to break
resulting in an unstable joint.
Ligaments may also restrict some actions:
movements such as hyperextension and hyperflexion
are restricted by ligaments to an extent. Also
ligaments prevent certain directional movement.
Bursa
A bursa is a small fluid-filled sac made of
white fibrous tissue and lined with synovial
membrane. Bursa may also be formed by a
synovial membrane that extends outside of
the join capsule. It provides a cushion
between bones and tendons and/or muscles
around a joint; bursa are filled with synovial
fluid and are found around almost every
major joint of the body.
Spinal Anatomy
The spinal column is one of the most vital
parts of the human body, supporting our
trunks and making all of our movements
possible. Its anatomy is extremely well
designed, and serves many functions, including:

Movement
Balance
Upright posture
Spinal cord protection
Shock absorption
 
All of the elements of the spinal column and
vertebrae serve the purpose of protecting the spinal
cord, which provides communication to the brain
and mobility and sensation in the body through the
complex interaction of bones, ligaments and muscle
structures of the back and the nerves that surround
it.
The normal adult spine is balanced over the pelvis,
requiring minimal workload on the muscles to
maintain an upright posture.
Loss of spinal balance can result in strain to the
spinal muscles and spinal deformity. When the spine
is injured and its function impaired, the
consequences may be painful and even disabling.
Regions of the Spine
Humans are born with 33 separate vertebrae.
By adulthood, we typically have 24 due to the
fusion of the vertebrae in the sacrum.
The top 7 vertebrae that form the neck are
called the cervical spine and are labeled C1-C7.
The seven vertebrae of the cervical spine are
responsible for the normal function and
mobility of the neck. They also protect the
spinal cord, nerves and arteries that extend
from the brain to the rest of the body.
The upper back, or thoracic spine, has 12
vertebrae, labeled T1-T12.
The lower back, or lumbar spine, has 5
vertebrae, labeled L1-L5. The lumbar spine
bears the most weight relative to other
regions of the spine, which makes it a
common source of back pain. The sacrum
(S1) and coccyx (tailbone) are made up of 9
vertebrae that are fused together to form a
solid, bony unit.
Spinal Curvature
When viewed from the front or back, the
normal spine is in a straight line, with each
vertebra sitting directly on top of the other.
Curvature to one side or the other indicates a
condition called scoliosis.
When viewed from the side, the normal spine
has three gradual curves:
The neck has a lordotic curve, meaning that it
curves inward.
The thoracic spine has a kyphotic curve,
meaning it curves outward.
The lumbar spine also has a lordotic curve.
These curves help the spine to support the
load of the head and upper body, and
maintain balance in the upright position.
Excessive curvature, however, may result in
spinal imbalance.
 Elements of the Spine
The elements of the spine are designed to
protect the spinal cord, support the body
and facilitate movement.
A.Vertebrae
The vertebrae support the majority of the weight
imposed on the spine. The body of each vertebra is
attached to a bony ring consisting of several parts. A
bony projection on either side of the vertebral body
called the pedicle supports the arch that protects the
spinal canal. The laminae are the parts of the vertebrae
that form the back of the bony arch that surrounds and
covers the spinal canal. There is a transverse process on
either side of the arch where some of the muscles of the
spinal column attach to the vertebrae. The spinous
process is the bony portion of the vertebral body that can
be felt as a series of bumps in the center of a person's
neck and back.
B. Intervertebral Disc

Between the spinal vertebrae are discs, which function as

shock absorbers and joints. They are designed to absorb
the stresses carried by the spine while allowing the
vertebral bodies to move with respect to each other. Each
disc consists of a strong outer ring of fibers called the
annulus fibrosis, and a soft center called the nucleus
pulposus. The outer layer (annulus) helps keep the disc's
inner core (nucleus) intact. The annulus is made up of
very strong fibers that connect each vertebra together.
The nucleus of the disc has a very high water content,
which helps maintain its flexibility and shock-absorbing
properties.
C. Facet Joint

The facet joints connect the bony arches of each of the

vertebral bodies. There are two facet joints between each
pair of vertebrae, one on each side. Facet joints connect
each vertebra with those directly above and below it, and
are designed to allow the vertebral bodies to rotate with
respect to each other.
D. Neural Foramen

The neural foramen is the opening through which the

nerve roots exit the spine and travel to the rest of the
body. There are two neural foramen located between each
pair of vertebrae, one on each side. The foramen creates a
protective passageway for the nerves that carry signals
between the spinal cord and the rest of the body.
E. Spinal Cord and Nerves

The spinal cord extends from the base of

the brain to the area between the bottom of
the first lumbar vertebra and the top of the
second lumbar vertebra. The spinal cord
ends by diverging into individual nerves
that travel out to the lower body and the
legs. Because of its appearance, this group
of nerves is called the cauda equina - the
Latin name for "horse's tail." The nerve
groups travel through the spinal canal for a
short distance before they exit the neural
foramen.
The spinal cord is covered by a protective
membrane called the dura mater, which
forms a watertight sac around the spinal
cord and nerves. Inside this sac is spinal
fluid, which surrounds the spinal cord.
The nerves in each area of the spinal cord
are connected to specific parts of the body.
Those in the cervical spine, for example,
extend to the upper chest and arms; those
in the lumbar spine the hips, buttocks and
legs. The nerves also carry electrical signals
back to the brain, creating sensations.
Damage to the nerves, nerve roots or spinal
cord may result in symptoms such as pain,
tingling, numbness and weakness, both in
and around the damaged area and in the
extremities.
Spinal Muscles
Many muscle groups that move the trunk
and the limbs also attach to the spinal
column. The muscles that closely surround
the bones of the spine are important for
maintaining posture and helping the spine
to carry the loads created during normal
activity, work and play. Strengthening these
muscles can be an important part of
physical therapy and rehabilitation.
Nervous System
All of the elements of the spinal column
and vertebrae serve the purpose of
protecting the spinal cord, which provides
communication to the brain, mobility and
sensation in the body through the complex
interaction of bones, ligaments and muscle
structures of the back and the nerves that
surround it.
The true spinal cord ends at approximately
the L1 level, where it divides into the many
different nerve roots that travel to the lower
body and legs. This collection of nerve roots
is called the cauda equina, which means
"horse's tail," and describes the
continuation of the nerve roots at the end
of the spinal cord.
 IV. OVERVIEW OF THE DISEASE
Diskitis is an inflammation of the vertebral disk space
often related to infection. Infection of the disk space
must be considered with vertebral osteomyelitis, as these
conditions are almost always present together and share
much of the same pathophysiology, symptoms, and
treatment. Although diskitis and associated vertebral
osteomyelitis are uncommon conditions, they are often
the causes of debilitating neurologic injury.
Unfortunately, morbidity can be exacerbated by a delay
in diagnosis and treatment of this condition. The lumbar
region is most commonly affected, followed by the
cervical spine and, lastly, the thoracic spine.
Axial CT scan in a patient with diskitis
demonstrates extensive destruction of the
vertebral endplate. Note the preservation of
the posterior elements, including facet
joints, lamina, and spinous process. This is
characteristic for pyogenic diskitis and less
common in tuberculosis (Pott disease).
Sagittal T1-weighted MRI of the lumbar
spine in a 74-year-old man, revealing
diskitis of the L4-L5 disk space. Note
extensive destruction of the endplates of
the adjacent vertebral bodies. No
compression of the thecal sac is present,
which is an important consideration when
contemplating surgical intervention.
Contrast-enhanced sagittal T1-weighted
MRI image in a 55-year-old woman shows
thoracic diskitis with an associated epidural
abscess and spinal cord compression.
Because of the significant cord
compression, this patient underwent
surgical decompression.
Trajectory of a needle in a biopsy of the
infected disk space guided by CT scan. Care
is taken to avoid the thecal sac and nerve
roots.
Physical
Localized tenderness over the involved
area with concomitant paraspinal muscle
spasm is the most common physical sign. If
the cervical or lumbar segments are
involved, restricted mobility secondary to
pain occurs. Reported rates of neurologic
deficit (eg, radiculopathy, myelopathy) vary
widely from 2% to 70%. Cervical disease is
associated with a much higher rate of
neurologic deficit.
Causes
Diskitis is thought to spread to the
involved intervertebral disk via
hematogenous spread of a systemic
infection (eg, urinary tract infection [UTI]).
Many sites of origin have been implicated,
but UTI, pneumonia, and soft-tissue
infection seem to be the most common.
Direct trauma has not been conclusively
shown to be related to diskitis. Intravenous
drug use with contaminated syringes offers
direct access to the bloodstream for a
variety of organisms. Often, no other site of
infection is discovered.
Staphylococcus aureus is the organism
most commonly found; however,
Escherichia coli and Proteus species are
more common in patients with UTIs.
Pseudomonas aeruginosa and Klebsiella
species are other gram-negative organisms
observed in intravenous drug abusers,
although they are not seen as commonly as
S aureus. Not surprisingly, medical
conditions that predispose patients to
infections elsewhere in the body are
associated with diskitis. Diabetes, AIDS,
steroid use, cancer, and chronic renal
insufficiency are common comorbidities.
Although rare, infection of the disk space
can also occur following surgical
intervention at the site. The rate of
infection following anterior cervical
diskectomy has been quoted at 0.5% of
cases. The rate of infection for lumbar
diskectomy is half of that. In such cases,
infection is transmitted through direct
inoculation of the operative site. As in
spontaneous diskitis, the most common
organism is S aureus, but Staphylococcus
epidermidis and Streptococcus species also
should be considered.
Childhood diskitis has not been
consistently associated with an initial
causative infection elsewhere in the body. S
aureus is the most common organism
found.
Laboratory Studies
Hematology
Elevated erythrocyte sedimentation rate
(ESR) and C-reactive protein (CRP) are
the most consistent laboratory
abnormalities seen in cases of diskitis.
The mean ESR for patients with diskitis
is 85-95 mm per hour. ESR utility can be
extended by serial measurements during
treatment.
A 50% decline in ESR can usually be
expected with successful treatment, and
ESR often continues to decline after
treatment.
Frequently, ESR may not return to
normal levels despite adequate therapy.
Leukocytosis is often present in systemic
disease but is frequently absent in diskitis
cases. Diskitis is generally accompanied by
a normal peripheral white blood cell (WBC)
count if the primary site of infection has
been treated.
Microbiology
Blood cultures must be obtained on a
frequent basis for any patient suspected
of harboring an infected disk.
Appropriate therapy may be instituted
for positive blood cultures without the
need for invasive tests.
Unfortunately, blood cultures are
positive in only one third to one half of
diskitis cases.
Sputum and urine cultures are necessary to
locate any other sources of infection,
including respiratory and genitourinary
sites.
Imaging Studies
Plain radiography
Although radiographic films of the spine can be
very useful in diagnosing diskitis, abnormalities are
visible only after several weeks following the onset
of disease.
The most common early finding on plain films is
disk-space narrowing, followed by irregularities
and erosion of the adjacent endplates and
calcification of the anulus around the affected disk.
As osteomyelitis progresses, bone density
decreases, with loss of the normal trabeculation of
the vertebra. If bone destruction continues,
subluxation (with possible instability of the spine)
becomes evident.
Nuclear medicine
Gallium-67 and technetium-99m have
been utilized in the detection of diskitis
with similar results. Radionuclide
scanning has demonstrated a high degree
of sensitivity shortly after the onset of
symptoms. Diffuse initial uptake is
followed by more focal uptake on delayed
scans. Technetium-99m has been
recommended more often because of its
lower cost and smaller radiation dose.
Because of the availability and sensitivity
of other tests, radionuclide scans may be
most useful in the workup of patients
with fever of unknown origin.
Indium-111 WBC scintigraphy has been
shown to have a low sensitivity for
diskitis and is not the test of choice.
CT scan
CT scanning has the ability to detect
diskitis earlier than plain radiographs.
Findings include hypodensity of the
intervertebral disk and destruction of the
adjacent endplate and bone, as seen in
the image below, with edematous
surrounding tissues. Organisms at the
affected site can also produce a gas that is
easily detected on CT scans.
The advantage of CT scans over
radiographs is that associated paraspinal
disease can also be detected, especially
when combined with intravenous
contrast or myelography.
Use of CT scanning can supplement
magnetic resonance imaging (MRI), as it
is better at distinguishing between bone
and soft tissue than MRI.
CT can help monitor successful
treatment, which is accompanied by
increased bone density and sclerosis.
MRI
The most sensitive and specific test for
diskitis is MRI. T1-weighted images, as seen
in the image below, show narrowing of the
disk space and low signals consistent with
edema in the marrow of adjacent vertebral
bodies. MRI is very useful in helping
distinguish between infectious diskitis,
neoplasia, and tuberculosis. Diffusion-
weighted imaging is useful in distinguishing
between degenerative and infectious
endplate abnormalities. Compared with
positron emission tomography, diffusion-
weighted MRI costs less, has faster imaging
times, and lacks ionizing radiation.
Disk space involvement directs attention
to infection, as it only is involved late in
tuberculosis and very rarely in neoplasia.
With the use of intravenous contrast, as
seen in the image below, MRI, like CT,
can detect paraspinal disease (eg,
paraspinal phlegmon, epidural abscess.
A large amount of paraspinal soft-tissue
swelling and a psoas abscess are often
associated with spinal tuberculosis.
Bone scans are not specific for infection
over inflammation; therefore, they are
ineffective in postoperative patients.
Other Tests
Echocardiography can detect bacterial
endocarditis, which is a common source of
diskitis and embolic infection throughout
the body.
Procedures
Needle biopsy
Needle or trocar placement into the
infected area is a minimally invasive test
used to obtain histologic confirmation of
the disease and tissue samples for culture.
Yield and safety of the procedure are
maximized by the use of CT scanning for
guidance.
As in blood cultures, positive tissue
cultures occur in only half of biopsies,
especially if antibiotic therapy has already
been initiated. In such cases, needle
biopsy can be repeated or the patient can
be referred for open surgical biopsy.
Surgical biopsy
Open biopsy has been found in some
studies to have the highest yield in terms
of positive cultures and diagnosis
confirmation.
Open biopsy is the most invasive test.
While some surgeons prefer to combine
open biopsy with surgical debridement,
no difference has been found between
antibiotics and debridement when
compared with antibiotics alone in cases
of early diskitis.
Histologic Findings
The histologic findings of diskitis are
similar to those of any bacterial pyogenic
infection. Local destruction of the disk and
endplates occurs with infiltration of
neutrophils in the early stages. Later, a
lymphocytic infiltrate predominates.
Medical Care
Antibiotic treatment must be tailored to
the isolated organism and any other sites of
infection.
Broad-spectrum antibiotics must be used
if no organism is isolated; however, this is
very rare, and other disease processes (eg,
spinal tuberculosis) must be considered
in the face of persistently negative
cultures.
Parenteral treatment is usually administered for 6-8
weeks. Before parenteral therapy is discontinued,
the ESR should have dropped by one half to one
third, the patient should have no pain on
ambulation, and there should be no neurologic
deficits.[1, 3]
The use of oral antibiotics following intravenous
treatment has not been shown to be of added
benefit.
Any laboratory or clinical sign of persistent
infection should prompt another biopsy and
continued antibiotic therapy.
Immobilization is necessary, especially in
the initial stages of the disease.
Two weeks of bed rest should be
followed by external immobilization with
a brace when the patient gets out of bed.
Any pain on ambulation is an indication
for continued bed rest.
The goal of immobilization is to provide
the opportunity for the affected vertebrae
to fuse in an anatomically aligned
position.
Generally, bracing is used for 3-6 months
following initiation of treatment;
however, even with the use of appropriate
antibiotics and bracing, collapse of the
vertebral segments and kyphos formation
may occur.
Pain control is an important adjunct to
antibiotics and immobilization.
Surgical Care
Indications for surgery beyond open biopsy
include neurologic deficit, spinal deformity,
disease progression, noncompliance, and
antibiotic toxicity. The goal of surgery is to
remove diseased tissue, decompress neural
structures, and ensure spinal stability.
Although in most cases the vertebrae fuse
spontaneously following diskitis and
osteomyelitis, operative fusion can be a useful
adjunct by allowing earlier mobilization of the
patient. Despite early concerns, use of a fusion
plug and metallic instrumentation in an
infected field has not been shown to impede
successful treatment.
Consultations

Infectious disease
Neurosurgery
Orthopedic spine surgery
Diet

No particular diet has been shown to have

a clinical benefit in patients with diskitis.
Activity
Many authors believe that 2 weeks of bed
rest with initial treatment helps prevent the
development of a kyphotic deformity. Use
of an orthotic brace to help stabilize the
spine while spontaneous fusion takes place
is recommended for 3-6 months.
Ambulation is recommended only if the
patient has neither pain nor radiographic
signs of instability.
V. CASE STUDY PROPER

Name: Patient X
Age: 41 yrs. Old
Nationality: Filipino
Religion: Roman Catholic
Birthdate: 1969, July
Admission Date: March 9, 2011
Admission Time: 5:00pm
VI. PATIENT’S HISTORY
Past Medical History
 
Last December 2010, the patient was playing
badminton, while playing, she fell back on the
ground. The buttocks of the patient fell first
before the entire body. She felt severe pain
immediately. She was unable to ambulate but
there was no paralysis noted. Three days after the
incident, she consulted at Philippine General
Hospital and X-ray of the affected part was done
but there was no abnormality seen last February,
lumbar pain radiating to subchondral was felt and
decided to consult at Perpetual Las Piñas. Again,
no radiographic abnormality was observed. This
last month, symptoms persist again and consulted
at Philippine Orthopedic Center and confined on
March 9, 2011.
Family History

According to the patient, her parents have

no history of diabetes and hypertension.
But, they have history of Cancer. Cough
and colds, fever, diarrhea, etc. were also
experienced by the patient’s relatives and
manage at house only.
Social History
Before experiencing the symptoms of
the disease, the patient was actively
participating in outdoor games such as
badminton, biking, etc. Also, the patient
was always hanging out with her friends.
They sometimes drink alcohol during
occasions.
VII. PHYSICAL ASSESSMENT

General Condition

conscious and coherent

not in respiratory distress
unable to sit upright, stand, and flex spine
with complaints of severe back pain when
stretching spine
Vital Signs:
1st day2nd day 3rd day
T 37.6 C 37.4 C 37.4 C
PR 82 bpm 79 bpm 84 bpm
RR 22 bpm 24 bpm 23 bpm
BP 110/70 mmHg 110/80 mmHg 110/80 mmHg
SKIN
with fair complexion
slightly dry in texture
with fair skin turgor
no lesions noted
 
HAIR
with black hair extending to the back
evenly distributed to the scalp
with good hair texture
no head lice and dandruff noted
HEAD
Normocephalic
proportionate to body size
with symmetrical features

 EYES
with whitish sclera
with pale conjunctiva
with conjugate eye movements
with pupil equally round and reactive to
light and accommodation
no discharges noted  
EARS
auricles aligned to outer cantus of the eye
no discharges noted
 
NOSE
nasal septum aligned and intact
no nasal discharges noted
no nasal flaring noted
MOUTH AND TEETH
with pale and dry lips
able to purse lips
with good dentition
with retainer on teeth
without stains on teeth noted

NECK
Symmetrical
no distended vein noted upon palpation
with palpable carotid pulse
THORAX and LUNGS
with clear breath sounds heard on both Lung
fields upon auscultation
with symmetrical chest expansion upon
respiration
chest wall intact
with regular breathing pattern

 ABDOMEN
with soft and non-tender abdomen upon
palpation
with normoactive bowel sounds of 18 BS/min
GENITOURINARY
voiding freely into yellowish urine; moderate
in amount
 
UPPER and LOWER EXTREMITIES
symmetrical
without contraptions noted
no deformities noted
 NAILS
with pale nailbeds
with capillary refill tine of 2secs.
 VIII. COURSE IN THE WARD
March 9, 2011, the patient was admitted at
female ward, room 309, at Philippine
Orthopedic Center. The diagnostic procedures
ordered by the Dr. Pasion were CBC, ESR,
CRP, blood typing, PT, PTT, FBS, BUN, CREA,
SGOT, SGPT, lipid profile, Na, K, Cl, and
blood culture on 2 weeks. Blood transfusion of
2 “u” of PRBC was ordered after properly
typed and crossmatched. CT scan of L1 was
also ordered. Medication prescribed was
etoricoxib 70mg 1 tab once a day PRN for pain.
On March 13, 2011, IVF of PNSS 1L was
inserted and regulated for 12 hours. On the
next day at 2:15 in the afternoon, repeat
PTT, PT, CBC with platelet count was done.
 On March 15, 2011, CT scan followed up
guided biopsy. Intravenous line was
discontinued on March 17, 2011. Also, still
waiting for biopsy results.
On March 21, 2011, ciprofloxacin 500mg 1
cap BID for 7 days was started. As ordered,
urinalysis should be repeated after 7 days.
On the next day, they followed up
histopathologic results.
 On March 27, 2011, Acid Fast Bacilli for 3
days was ordered. Etoricoxib 90mg 1 tab
OD PRN for pain was given and started.
On March 28, 2011, diagnostic procedures
were ordered such as thyroid function test,
ionized calcium, CBC, ESR, ALP and LDH. On
the next day, results were referred to Endo for
further evaluation and management.
 On March 31, 2011, the patient underwent
thyroid ultrasound. Skeletal summary was
ordered on April 1, and was scheduled for
Serum Protein Electrophoresis on April 4.
Also, levofloxacin 500 mg 1 cap BID for 7 days
was started.
On April 2, 2011, awaits results of SPE and
send to Endo for suggestions. On April 11,
2011, result was submitted to
endocrinologist.
 On April 13, 2011, referral to Tumor
service was ordered and for bone marrow
aspiration under local anesthesia.
X. LABORATORY ANALYSIS
TEST NAME
X. LABORATORY
RESULTS
ANALYSIS
NORMAL
VALUES
INTERPRETATION

Hemoglobin 80 110-158 Slightly Decreased;

risk for anemia
Hematocrit 0.24 0.37-0.54 Decreased;
hemodilution
Leukocytes 4400 4500-10000/cumm Within normal
limits
Segmenters 0.60 0.5-0.7 Within normal
limits
Lymphocytes 0.33 0.2-0.4 Within normal
limits
Monocytes 0.07 0.00-0.07 Within normal
limits
Eosinophils 0.00 0.00-0.05 Within normal
limits
Platelet count 385,000/cumm 150000- Within normal
450000/cumm limits
 Nursing Responsibilities:
Transfused blood, 1st “u” of PRBC properly
crossmatched and typed.
Provide adequate rest and sleep periods.
Demonstrate and encourage on doing deep
breathing exercises to improve oxygenation.
Encourage to eat foods rich in iron such as
green leafy vegetables for iron supplement.
Encourage to eat vitamin C rich foods such as
citrus fruits to improve iron absorption.
Increase oral fluid intake.
Strict adherence to treatment regimen.
COMPLETE BLOOD COUNT (MARCH 11, 2011) 6 hours post BT

TEST RESULTS NORMAL INTERPRE

NAME VALUES TATION

Hemoglob 87 110-158 Decreased;

in anemia
Hematocri 0.27 0.37-0.54 Decreased;
t hemodiluti
on
 Nursing Responsibilities
Transfused 2nd “u” of PRBC properly typed
and crossmatched.
Provide adequate rest and sleep periods.
Encourage to eat foods rich in iron such as
green leafy vegetables for iron supplement.
Encourage to eat vitamin C rich foods such
as citrus fruits to improve iron absorption.
COMPLETE BLOOD COUNT (MARCH 13, 2011) 6 hours post BT

TEST RESULTS NORMAL INTERPRE

NAME VALUES TATION
Hemoglob 106 110-158 Slightly
in Decreased;
risk for
anemia
Hematocri 0.34 0.37-0.54 Decreased;
t hemodiluti
on
 Nursing Responsibilities:

Provide adequate rest and sleep periods.

Encourage to eat foods rich in iron such as
green leafy vegetables for iron supplement.
Encourage to eat vitamin C rich foods such
as citrus fruits to improve iron absorption.
COMPLETE BLOOD COUNT (MARCH 15, 2011)
TEST NAME RESULTS NORMAL INTERPRETATIO
VALUES N
Hemoglobin 101 110-158 Slightly
Decreased; risk for
anemia
Hematocrit 0.31 0.37-0.54 Decreased;
hemodilution
Leukocytes 3600 4500-10000/cumm Within normal
limits
Segmenters 0.56 0.5-0.7 Within normal
limits
Lymphocytes 0.34 0.2-0.4 Within normal
limits
Monocytes 0.10 0.00-0.07 Within normal
limits
Eosinophils 0.00 0.00-0.05 Within normal
limits
Platelet count 220,000/cumm 150000- Within normal
 Nursing Responsibilities:
Provide adequate rest and sleep periods.
Demonstrate and encourage on doing deep
breathing exercises to improve oxygenation.
Encourage to eat foods rich in iron such as
green leafy vegetables for iron supplement.
Encourage to eat vitamin C rich foods such
as citrus fruits to improve iron absorption.
Increase oral fluid intake.
Strict adherence to treatment regimen.
COMPLETE BLOOD COUNT (MARCH 29, 2011)

TEST NAME RESULTS NORMAL INTERPRETATIO

VALUES N
Hemoglobin 99 110-158 Decreased; anemia
Hematocrit 0.30 0.37-0.54 Decreased;
hemodilution
Leukocytes 4100 4500-10000/cumm Within normal
limits
Segmenters 0.40 0.5-0.7 Within normal
limits
Lymphocytes 0.43 0.2-0.4 Within normal
limits
Monocytes 0.08 0.00-0.07 Within normal
limits
Eosinophils 0.02 0.00-0.05 Within normal
limits
Platelet count 154,000/cumm 150000- Within normal
450000/cumm limits
 Nursing Responsibilities:
Provide adequate rest and sleep periods.
Demonstrate and encourage on doing deep breathing
exercises to improve oxygenation.
Encourage to eat foods rich in iron such as green leafy
vegetables for iron supplement.
Encourage to eat vitamin C rich foods such as citrus
fruits to improve iron absorption.
Observe proper personal hygiene to prevent infection.
Increase oral fluid intake.
Keep back dry at all times to prevent pulmonary
complications.
Strict adherence to treatment regimen.
URINALYSIS (MARCH 11, 2011)
TEST NAME RESULTS NORMAL INTERPRETATI
VALUES ON
Color Light yellow Light yellow Normal
Reaction 6.0 4.5-8.0 Normal
Transparency Turbid Slightly turbid Infection
Specific Gravity 1.030 1.015-1.030 Normal
RBC 8-10 0-2/hpf Increased;
infection
Pus cells TNTC 0-2/hpf Increased;
infection
Bacteria ++++ None Increased;
infection

Epithelial Cells ++ None Increased;

infection
 Nursing responsibilities:
Increase oral fluid intake.
Instruct on proper perineal care and proper
personal hygiene.
Encourage to urinate when there’s an urge
to void.
Give vitamin C rich foods such as citrus
fruits.
Give levofloxacin 500mg 1 cap BID for 7
days
URINALYSIS (APRIL 1, 2011)

TEST NAME RESULTS NORMAL INTERPRETATI

VALUES ON

Color Yellow Light yellow Infection

Reaction 5.0 4.5-8.0 Normal
Transparency Slightly Turbid Slightly turbid Normal
Specific Gravity 1.030 1.015-1.030 Normal
RBC 0-2 0-2/hpf Normal
Pus cells 14-16 0-2/hpf Increased;
infection

Bacteria Few None Increased;

infection

Epithelial Cells Few None Increased;

infection
 Nursing Responsibilities:
Continue taking levofloxacin for antibiotic
therapy.
Increase oral fluid intake.
Encourage on regular urination.
 
URINALYSIS (APRIL 11, 2011)
TEST NAME RESULTS NORMAL INTERPRETATI
VALUES ON

Color Light Yellow Light Yellow Normal

Reaction 5.0 4.5-8.0 Normal
Transparency Slightly Turbid Slightly Turbid Normal
Specific Gravity 1.030 1.015-1.030 Normal
RBC 0-3 0-2/hpf Normal
Pus cells 3-6 0-2/hpf Increased;
infection

Bacteria Few None Increased;

infection

Epithelial Cells + None Increased;

infection
 Nursing Responsibilities
Increase oral fluid intake.
Encourage on regular urination.
LIPID PROFILE (MARCH 14, 2011)

TEST NAME RESULTS NORMAL INTERPRETATIO

VALUES N

Glucose 5.0 mmol/L 4.2-6.40 Within normal

limits

Urea 6.42 mmol/L 1.7-8.3 Within normal

limits

Creatinine 54.03 umol/L 44-115 High; risk for HTN

Cholesterol 6.40 mmol/L <5.70 High; risk for HTN
Triglycerides 2.25 mmol/L <1.70 Low; risk for HTN
HDL 0.60 mmol/L 1.67<3.00 High; risk for HTN
LDL 2.34 mmol/L <3.90 Within normal
limits

VLDL 1.02 mmol/L <0.78 Within normal

limits
 Nursing Responsibilities:
Monitor vital signs especially blood
pressure.
Instruct to avoid foods high in cholesterol
such as chicken skin, and fatty foods.
Avoid salty foods.
Eat high fiber diet.
Have an exercise in regular basis.
Give highly nutritious foods especially
fruits and vegetables
SODIUM, POTASSIUM, CHLORINE

TEST NAME RESULTS NORMAL INTERPRETATIO

VALUES N

Sodium 141.80 135-148 Within normal

limits
mmol/L

Potassium 3.64 mmol/L 3.50-5.30 Within normal

limits

Chlorine 104.90 98-107 Within normal

limits
mmol/L
 Nursing Responsibilities
Maintain low salt diet.
Increase oral fluid intake.
Avoid cholesterol-rich foods.
ACID FAST BACILLI (MARCH 31,
APRIL 1 and 2)
NO ACID FAST BACILLI SEEN.
TEST RESULTS NORMAL INTERPRE
NAME VALUES TATION

PT 15.3 11-15 Within

normal
limits

Activated 22.5 22-45 Within

PTT normal
limits
HISTOPATHOLOGICAL RESULT
 Histopathological Diagnosis
 Lumbar, L1, Left
Non-diagnostic
Bloody aspirate