1:CASE Index

STUDY
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ANALYSIS 03

ABASOLO, AVANCE, BAJO, BARRIOS, CATEDRAL, CORDERO, DAGADAS, 04

DALANDA, DELOSO, DUQUE, DELA PENA

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 Index

THE CASE
A 16-day-old female patient, born by normal spontaneous delivery at a
gestational age of 38 weeks with a birth weight of 2,870 g, visited the 01
emergency department because of poor oral intake and an hour of high fever
(39.4°C). The patient had no maternal and natal history and stayed at a
postnatal care center until she was taken to our hospital. 02
At the time of neonatal intensive care unit admission, her initial physical
examination revealed mottling over her whole body and prolonged capillary
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filling time more than 2 seconds. The patient's initial vital signs were noted as
follows:
❏ axillary temperature 36.8°C;
❏ heart rate 143 beats per minute; 04
❏ respiratory rate 50 breaths per minute

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LABORATORY FINDINGS
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 01
Index

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Since the patient is a
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neonate, where can
we possibly acquire a 03

csf sample?
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❏ Lumbar Puncture/Spinal Tap 01

1. Lateral recumbent position
2. Seated position
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❏ Anatomical landmark: L4-L5 interspace
❏ Angle of needle: between 70 and 90°
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❏ Needle gauge: 22 or 25 gauge
❏ Duration of procedure: 30-60 mins
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Note: Never go above the L2-L3 interspace.

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Procedure for lumbar puncture
1. Place infant on blue underpad
2. Position baby. Ensure the baby is as straight as possible (particularly avoid
rotation), but do not apply flexion to the trunk until the needle is about to be
inserted.
3. Cut 3 cm diameter hole in middle of plastic drape. Prepare the skin. Wait for
prep to dry.
4. Identify L4. It helps to keep two fingers of your left hand locating it - one each
side.
5. Enter skin strictly in midline, aiming slightly towards the head at between 70
and 90 degrees.
6. Once through the skin, stop. Wait for the infant to resettle.
7. Reorient yourself, making sure that you are still in the midline and
advancing at the appropriate angle. The subsequent advance of the needle is
less distressing than the initial insertion.

8. Advance needle about 0.5 cm. Remove stylette and observe for CSF flow. If
negative, fully reinsert the stylette and advance a little further. Repeat this
process until CSF is obtained.

9. Allow CSF to drip into at least two tubes. A minimum of 10 drops/tube is

required for microbiological and biochemical examination.

10. Measure CSF pressure using a manometer if you are doing a therapeutic
tap. For a therapeutic tap, the maximum volume to be tapped is 2 per cent of
body weight.
11. When adequate CSF has been obtained, replace the stylet and then
remove the needle. Apply pressure to the puncture site with a sterile cotton
wool ball or gauze to control ooze. When ooze has ceased, use a band-aid or
flexible collodion as dressing.

12. Wipe excessive antiseptic prep from the skin with sterile water.

13. Discard stylette and needle into sharps container.

Index

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With the given appearance
of the CSF, what is its 04
clinical significance?
Provide also the other 05
 Index

CSF BACTERIAL
EXAMINATION MENINGITIS 01
OF THE
PATIENT
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APPEARANCE TURBID TURBID

WBC COUNT:
WBC COUNT
❖ 10,470 cells Increased level of 03
❖ NEUTROPHIL: 98% neutrophil
❖ MONOCYTE: 2%

PROTEIN 378 mg/dl Increased level of protein

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40 mg/dl Decreased level of

GLUCOSE Glucose
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CSF CLINICAL DIAGNOSIS 01

APPEARANCE
Crystal clear Normal
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Hazy/Turbid/Milky/ Increased WBCs (>200/uL), Lipids & Protein,
MIcroorganisms
Cloudy
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Xanthochromic Pink = slight amount of oxyhemoglobin
Yellow = Oxyhemoglobin → Bilirubin
Orange = heavy hemolysis

Bloody Increased RBCs (>6,000/uL 04

● Traumatic tap
● Intracranial hemorrhage

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Index

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Traumatic Tap Intracranial

Hemorrhage
Definition Puncture of a blood vessel Hemorrhage inside the
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cranial cavity/intracranial
space

Blood Distribution Uneven Even 02

Clot Formation Positive Negative

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Xanthochromic Negative Positive
Supernatant

*Microscopic Absence of hemosiderin Presence of hemosiderin

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Examination granules granules

*D-dimer Absence of D-dimer Presence of D-dimer

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 Index

03 01

SOLVE FOR THE WBC

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COUNT: IF THE
PATIENT’S CSF IS CLEAR
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AND THERE WERE 35
WBC’S COUNTED, WHAT 04
IS THE WBC COUNT?
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 # of cells counted x Dilution Index

FORMULA: WBC count/uL = Area x Depth factor (0.1)

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SOLUTION:
35 WBC x 20 02
CSF WBC count =
4 X 0.1

CSF WBC count = 1,750 WBC/uL

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Explain the result of

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the CSF protein of
the patient 05
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CSF PROTEIN NORMAL 01

VALUES:
❏ ADULT: 14-45 mg/dL
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❏ INFANT: 150 mg/dL
❏ IMMATURE: 500 mg/dL
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CASE RESULTS: 378 mg/dL (elevated)
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POSSIBLE CAUSE OF ELEVATED

PROTEIN 01
01 Damage to BBB:
Meningitis
Hemorrhage 02

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Production of Ig w/in CNS:
Multiple Sclerosis
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03 Decreased normal protein clearance from the fluid

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Neural tissue degeneration
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 Index

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What is the most likely

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diagnosis for the
disease? How did you 03
arrive at that
conclusion? 04

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Bacterial Meningitis Index

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Gram stain
Culture
Limulus 03
Lysate Test
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 Index

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THANK
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YOU! 04

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