AIP & HIV Presentation: CNS Toxoplasmosis

GRAND WARD ROUND
25/11/2017
AIP & HIV PRESENTATION
AIP & HIV STUDENTS 25/11/2017

Introduction
• We are presenting to you T .E, 32 year old
male ,Bafumbira by tribe , seventh day
Adventist by religion whose next of kin is the
father, both from Butogota upper, Butogota
town council
• He was admitted on 19th Nov 2017

Presenting complaints
1. Acute pain of the right lower limb for 2/12
2. Swelling of the right lower limb for 2/12
3. Speechless 1/12
• Source of history is the father

Hx of presenting complaint
• The father reports that 2 months prior to
admission, the son started complaining of
acute pain in the right lower limb that was
progressive in nature.
• Pain then progressed to the upper limbs and
lips with subsequent limping and failure to
walk and use the hand.
• Pain was associated with swelling of the right
lower limb and ascending to the upper limbs.

Review of other systems
CVS
• Hx of heart palpitations
• Hx of lower right limb swelling
• Hx of fatigue
Respiratory system
• Hx of cough that was productive 2/14
• Hx of difficulty in breathing

Genital urinary
• Hx of failure to control urine (urine incontinence)
• No hx of frequent urination
• No hx of painful urination
G IT
• Hx of reduced appetite for 2/7 prior to admission
• Hx of failure to feed for 1/7 prior to admission
• No hx of nausea and vomiting
• No hx of diarrhea and constipation

Past medical history
• This is the 2nd admission
• The 1st was in 2016 at BCH with diarrhea but
can’t remember the treatment
• Initiated on ART clinic in Dec 2015 and is on 1st
line regimen (TDF/3TC/EFV)
• Hx of poor drug adherence
• No hx of chronic illness such as diabetes and
hypertension

Past surgical history
• Hx of trauma
• No hx of blood transfusion, fractures burns and
major or minor operations
Family hx
• He is the 2nd born of the three children
• Both parents alive but divorced
• No hx of chronic illness from both parents

Social hx
• He lives with the father in a permanent house with 4
rooms, separate kitchen and grass thatched latrine
• They rare goats, and chicken but have no other animals
like cats at home
• Hx of smoking and alcohol use for approximately 10
years
• They mainly feed on posho, potatoes, rice ,beans and
g.nuts
• They collect water from the spring and take it boiled
• He rejected going to school while in p6

Summary
• We are presenting to you TE, a 32year old
male, known ISS who came in complaining of
acute pain of the right lower limb for 2/12,
swelling of the lower right limb 2/12,
speechless 1/12 that proceeded with failure to
eat for 1/7 .
• There is hx of poor drug adherence

Differentials?????

Physical examination
General examination
 A sick looking man, lying in supine position with an NG
tube, cannula on left upper limb and an in dwelling catheter
in situ.
 Hair is well distributed on the head, eyes symmetrical to the
ears, no yellowing of the sclera and two nostrils present and
panting
 Lips are dry, no discharge from ears, eyes and nose, both
limbs upper and lower present.
 Lower right limb is externally located ,mild swelling on
right lower limb and no peripheral cyanosis.
 Capillary refill returns at less than 2 sec, sclera pink in color
and has sunken eyes.

VITALS & Anthropometric
measurements
 Pulse 76b/m
 spO2 96%
 Temperature 36.2oC
• RR 20c/m
 MUAC is 19.5cm
 Height 162cm
 Weight ????

Systemic exam
• CVS
 Hands are warm and capillary refill returns at less than
2 seconds
 No splinter hemorrhage
 Radial pulse synchronous, strong and regular
 No jugular venous distention and cervical lymph nodes
are palpable
 Apex beat is at the 5-6th intercostal space mid clavicular
line
 Heart sounds s1 & s2 and no added sounds
 BP 119/84mmHg

P/A
• No visible therapeutic /surgical scar
• The abdomen moves in line with the chest
• Bowel sounds were heard and normal
• No tenderness on light and deep palpation
• No organomegally
• No abdominal distention

CNS
• Babisnk’s sign positive
• Muscle tone of the right side is hyper tonia
• Reflex is hyper reflexed
• Pupil equal and reactive to light
• Muscle power is 0/5
• No neck stiffness
• Kerning’s sign negative
• Glasgow coma scale =11/15
• E=4/4 v=1/5, M=6/6

Respiratory system
Trachea is centrally located
There is equal chest expansion
Chest movements are in line with the abdomen
There is equal bilateral air entry
Resonant sound heard on percussion
RR 20c/m

TREATMENT
• Ceftriaxone IV 2g Od
• Prednisolene PO 25mg
• RHZE
• Fluconazole
• Paracetamol 1g tds

FINAL DIAGNOSIS
• CNS Toxoplasmosis secondary to HIV

NURSING CORCERNS
o Patient was unable to feed for 1/7
o Patient was unable to move and turn himself
on the bed
o Patient had unilateral right sided weakness
2/12
o Patient is unable to talk
o Patient unable to perform activities of daily
living

S IONS
nutrition
imbalance less
than body
requirements
related to lack
of interest in
food and in
ability to
swallow
evidenced by
sunken eyes
and MUAC of
19.5 cm
To improve
sufficient
nutrient intake
with in time of
stay in hospital
Normal RBS
levels will be
restored
Initiate NG
tube feeding
NG tube was
inserted and
patency
maintained
Reduces risk
for
regurgitation
and aspiration
nutrient intake
improved but
not sufficient
Educate the
attendant on
how to feed
using NG tube
Milk was fed to
the patient
using NG tube
Monitor blood
sugar levels
RBS was taken
every 2 days
Position
patient in
proper
alignment
when feeding
Head of bed
was elevated
using pillows
Restrict solid
feeds
Fluid like feeds
like milk were
given
Smaller
amounts
enhance
digestion and
client tolerance
to nutrients
increase
Divide feeds
into smaller
amounts and
give regularly
A cup of milk
was divided
into halves and
given per 30
minutes
Administer
medications as
ordered
Multi vitamins
were
administered
Boosts
appetite

DIAGNOSI
S
GOAL OUTCOM
E
INTERVEN
TION
IMPLEME
NTATION
RATIONAL
E
EVALUATE
Self care
deficit
related to
neuromus
cular
impairme
nt
evidenced
by
inability to
dress
himself,
feed
himself
and
provide
hygiene
To ensure
performan
ce of
activities
of daily
living
within 2
days of
nursing
interventi
ons
T E will
participat
e in self
care
activities
at his own
Encourage
the
attendant
to assist
the
patient
The
attendant
assisted
patient
put on
clothes
To meet
the
standards
of daily
living
To
maintain
body
hygiene
Bed bathe
was done
daily Continuou
s bladder
drainage
Indwelling
catheter
was
inserted Reduce
risk for
pressure
sores
Bed linen
was
changed
For
eliminatio
n
A bed pan
was given

DIAGNOSI
S
GOAL OUTCOM
E
INTERVENT
IONS
IMPLEMEN
TATIONS
RATIONAL EVALUATI
ON
Impaired
physical
mobility
related to
neuromus
cular
damage
evidenced
by limited
range of
motion
To restore
functionin
g of both
right
lower and
upper
limbs
within the
time of
hospitaliza
tion
The
functionin
g and
strength
of limbs
will be
restored
Asses the
function
ability and
extent of
impairment
Muscle
power and
tone were
assessed
daily
To provide
baseline
data for
interventio
ns
Change
positions
T E was
turned
every 2
hours
Regular
turning
reduces risk
of pressure
sores and
tissue
ischemia
Maintain
proper
body
alignment
Patient was
put in
supine
position
once a day
Support the
limbs
Foot rest
was used
To prevent
complicatio
ns such as
foot drop

DIAGNOSIS GOAL OUTCOME INTERVENTIONS IMPLEMENTATIONS RATIONALE EVA
Infections
related to
compromis
ed
immune
system
evidenced
by oral
thrush
to prevent
access of
pathogeni
c
microorga
nisms
until
discharge
TE will be
free from
opportunis
tic
infections
throughou
t his
hospitaliza
tion
Maintain hygiene A daily bed bath &
oral care were done
To reduce
accumulatio
n of
pathogenic
micro
organisms
Turning the
patient
reduces risk
of tissue
ischemia and
skin
breakdown
TE was changed in bed
per 2 hours
Regular turning of
the patient
Changes in
vitals
indicate
pathogenic
accumulatio
n
Temp, BP, pulse,
SPO2, RR were taken
and documented
Monitor vitals
Prophylaxis
opportunistic
infections
Administer
medications
Fluconazole 400mg ,
CTX 960mg were given
To confirm
medication
intake
Encourage drug
adherence Directly observed

DIAGNOSIS GOAL OUTCOME INTERVENT
ION
IMPLEMEN
TATION
RATIONALE EVALUATIO
N
Risk for
Impaired
skin
integrity
related to
limited
mobility
To maintain
skin
integrity
Skin
integrity
will be
maintained
throughout
nursing
interventio
n
Prevent
pressure
sores
Bed bathe
was done
daily
To maintain
body
hygiene
Normal skin
integrity
was
maintained
Bed linen
was
changed
Reduce risk
for pressure
sores
Changing
positions of
the patient
Reduced
tissue
ischemia
and tissue
break down

DIAGNOSI
S
GOAL OUTCOM
E
INTERVEN
TIONS
IMPLEME
NTATION
RATIONAL
E
EVALUATI
ON
Impaired
verbal
communic
ation
related to
neuromus
cular
impairme
nt ,oral
muscle
tone and
control as
evidenced
by
inability to
speak
To
establish a
method of
communic
ation
throughou
t his
admission
The
patient
will
communic
ate in his
easiest
format
Assess the
type and
degree of
dysfunction
The patient
was asked
to greet
using the
left hand
,which he
did
This helps
to
determine
the area
and degree
of brain
involvemen
t .
The patient
was asked
to speak
but he
couldn’t
Provide
alternative
methods of
communica
tion
Visual dues
such as
gestures
were used
To meet the
patients
needs and
desires
The
attendant
was asked
to stay
with the
patient

DIAGNOSI
S
GOAL OUTCOM
E
INTERVEN
TIONS
IMPLEME
NTATIONS
RATIONAL
E
EVALUATI
ON
Unilateral
neglect
related to
neurovasc
ular
impairme
nt of the
left
hemisphe
re
evidenced
by failure
to move
eyes to
the right
side and
focusing
only to
the left
side
To
increase
awareness
of the
right side
T E will be
aware of
presence
of both
sides of
his body
Visualize
the
neglected
side
A mirror
was
placed at
the foot of
the bed
The mirror
reflects
the entire
body with
the
neglected
side
Encourage
client to
turn head
to the
right and
eyes to
scan the
environm
ent
The
patients
head was
turned to
his right
side
To
visualize
the
neglected
side

AIP & HIV Presentation: CNS Toxoplasmosis

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AIP & HIV Presentation: CNS Toxoplasmosis