clinical pharmacist interventions

1. CASE
PRESENTATION
ON LEFT
TEMPORAL
PARIETAL
TUBERCULOM
A
DONE BY A.J.VISHALI

2. PATIENT DEMOGRAPHIC
DETAILS:
PATIENT NAME:manemma
AGE: 53yrs
SEX: female
WEIGHT:51kgs
HEIGHT:161cms
BMI:19.7
IBW:53.3kgs
BSA:1.51m2
DOA:30-10-18
DOD:08-12-18
DEPARTMENT: NEUROLOGY

3. S-SUBJECTIVE EVIDENCE
CHIEF COMPLAINTS: c/o altered sensorium for
1hr, 1 episode of seizure lasting for 3 months,
inappropriate consultation with neighbours ,loss
of recognition of family members.
HISTORY: slurred speech lasts for 15mins,
headache
PAST MEDICAL HISTORY: NIL

4. PRELIMINARY DIAGNOSIS: ?ICSOL ?postictal
edema
FINAL DIAGNOSIS: Left temporal parietal
tuberculoma

5. O-OBJECTIVE EVIDENCE
30-10-10
ADULT ONSET GTCS ? ICSOL ?POSTICTAL EDEMA
Vitals:
Bp- 100/60mmHg
PR-90/min
CVS-s1s2+
Rs-BAE+
Altered sensorium

6. 31-10-18
Altered sensorium
Vitals:
PR-86/min
BP-110/70mmHg
4-11-18
SEIZURES IN EVALUATION , ICSOL LEFT TEMPORAL
REGION (2lesions)
R/O- tuberculoma neurocyticercosis
Nausea
PR-84bpm
BP-90/70mmHg
CVS-s1s2+
RS-BAE+

7. 5-11-18:
Vitals:
PR- 84bpm
BP-100/70mmHg
6-11-18:
SEIZURES EVALUATION , ICSOL LEFT TEMPORAL REGIO
? TUBERCULOMA
Vitals:
PR: 80bpm
BP:110/70mmHg

8. 7-11-18:
LEFT TEMPORAL TUBERCULOMA WITH FOCAL
SEIZURES
C/O-vomitings
Vitals:
PR-88bpm
BP-110/80mmHg
8-11-18:
ICSOL LEFT TEMPORAL TUBERCULOMA WITH FOCAL
SEIZURES
C/O-vomitings

9. 9-11-18:
Vitals:
PR-84/min
BP-110/70mmHg
10-11-18:
9am-
No fresh episodes of seizures
c/o- nausea
Vitals:
PR-86/min
BP-130/80mmHg

10. 4am-
c/o- numbness, tingling sensation
CNS TUBERCULOMA IN PARIETAL LOBE COMPLAINING
OF DIPLOPIA BLURRED VISION
11-11-18
Vitals:
PR- 86bpm
BP-120/80mmHg

11. 12-11-18:
c/o- irrelevant talking, headache
Vitals:
PR- 80/min
BP-110/70mmhHg
13-11-18:
Vitals:
PR-82bpm
BP-110/70mmHg

12.  Fever – 1 month
 Altered sensorium-4 days
 Headache- 1month
 Right focal seizures-10days
MRI- GRANULOMATOUS LESIONS IN LT
PARIETAL TEMPORAL REGION

13. 14-11-18:
C/O- cough with expectoration
Vitals:
PR:86/min
BP-120/60mmHg
15-11-18:
c/o – cough
Vitals:
PR-88/min
BP- 110/70mmHg

14. 16-11-18:
LEFT PARIETAL AND TEMPORAL TUBERCULOMOUS
WITH FOCAL SEIZURES
c/o-altered sensorium
GRBS- 192 mg/dl
MRI:
Ring enhancing lesions in left superior temporal gyri
IMPRESSION:symptomatic seizures with werners
asphasia(resolving)

15. 17-11-18:
c/o- cough with sputum , fever, altered behavior, post
punctured headache
Vitals:
PR: 86/min
BP-110/70mmHg
18-11-18:
LEFT TEMPORAL PARIETAL LOBE TUBERCULOMA WITH
PERILESIONAL EDEMA WITH FOCAL SEIZURES
c/o-headache

16. Vitals:
PR-26/min
BP-110/70mmHg
20-11-18:
vitals:
PR-87/min
BP-110/80mmHg

17. 22-11-18:
LEFT TEMPORAL LOBE TUBERCULOMA WITH SEIZURES
Vitals:
PR-76/min
BP-140/90mmHg
23-11-18:
Vitals:
PR-28/min
BP-100/60mmHg
GRBS:369mg%

18. 24-11-18:denova DM
Vitals:
PR-80/min
BP-100/60mmHg
GRBS-134mg/dl
27-11-18:
Left temporal lobe tuberculoma , denovoDM ?
CEREBELLAR LESION
Vitals:
PR-86bpm
BP-110/70mmHg
GRBS-80mg/dl

19.  Nystagmus
 Trunal ataxia
 Pendula + knee jerk
 Dysdiadokinesia
Finger nose test to be perform
28-11-18
Test unable to perform

20. 30-11-18:
LT TEMPORAL PARIETAL TUBERCULOMA
DEVELOPING CEREBELLAR SYMPTOMS
Vitals:
PR-82/min
BP-110/70mmHg

21. 1-12-18:
Nystagmus decrease, ataxia improved
Vitals:
PR-28/min
BP-120/80mmHg
2-12-18:
Vitals:
PR-98bpm
BP-130/80mmHg

22. 3-12-18:
LEFT TEMPORAL PARIETAL TUBERCULOMA WITH FOCAL
SEIZURES ( RECOVERED)
Vitals:
PR-86/min
BP-110/70mmHg
4-12-18:
Vitals:
PR-84/min
BP-120/80mmHg

23. 5-12-18:
Vitals:
PR-90/min
BP-130/90mmHg
6-12-18:
Vitals:
PR-88bpm
BP-110/80mmHg
7-12-18:
Vitals:
BP-110/70mmHg
PR-88/min

24. 8-12-18:
Vitals:
PR-84/min
BP-110/70mmHg

25. A-ASSESSMENT
 FROM SUBJECTIVE AND OBJECTIVE
EVIDENCE PATIENT IS SUFFERING FROM
LEFT TEMPORAL PARIETAL
TUBERCULOMA

27. Defintion:
 Tuberculosis (TB) is a multi-systemic infectious disease
caused by different species of mycobacteria, usually
Mycobacterium tuberculosis in humans (1). Tuberculosis of
the nervous system can attack the meninges, brain, spinal
cord, cranial and peripheral nerves, ears, and eyes. Brain
tuberculosis results from spreading the bacteria which
primarily exists in the body.
 A tuberculoma is a localised caseous abscess within the
brain caused by M. tuberculosis. It is rare in the West, but
the commonest single intracranial lesion in India.

28. PATHOPHYSIOLOGY:
A tuberculoma is a chronic caseating intracranial granuloma, which may arise
from haematogenous spread during primary TB, e.g. miliary TB.

29. P-PLANING:
31-10-18:
1.INJ EPTOIN – PHENYTOIN-100ml-IV
2.Tab Bc –OD
3.Tab folvite –folicacid -5mg
4-11-18 to 6-11-18:
Rx-
Tab cefixime 200mg BD
Tab eptoin 100mg
Tab folvite 5mg OD

30. Tab bc OD
Tab calcium 500mg OD
Inj decadron 8mg IV tid
Inj zofer 8ml IV BD
7-11-18:
CST+
Tab pcm – 500mg –tid
Tab benadon 40mg -OD

31. 8-11-18:
CST
+
Inj pantop 40mg IV
10-11-18 to 13-11-18:
CST
-
Dulcolex and pcm

32. 14-11-18:
Inj decadron 4mg IV TID
Tab eptoin 100mg BD
Tab folvite 5mg OD
Tab Bc
Tab augmentin 625mg BD
Tab benadon 40mg OD
Inj monocef 250mg IV BD

33. 15-11-18:
CST
+
Inj zofer 8mg iv bd
Inj rantac 150mg bd
16-11-18:
Cst
–
Tab bc

34. 17-11-18:
Cst
+
Inj tramadol
18-11-18 to 21-11-18:
Cst
+
Folyes catherisation
22-11-18:
Cst
-
tramadol

35. 23-11-18: cst+ human insulin
24-11-18 to 27-11-18:cst + tab sporolac
28-11-18: cst+ inj mannitol, inj acyclovir
30-11-18 to 1-12-18:
Tab levipill 500mg bd
Tab benadon 40mg od
Inj acyclovir 300mg in 100ml iv tid
Inj mannitol iv tid
Inj optineuron 1amp iv OD
Tab zofer 4mg bd
Tab folvite 5mg od
Tab rantac 150mg bd

36. 2-12-18 to 5-12-18:
Cst
-
Folvite,mannitol
+
Acyclovir
6-12-18:
Cst – zofer + tab bc

37. 7-12-18:
Cat I ATT
Tab levipill
Tab benadon
Tab rantac
Tab bc
8-12-18:
cst

38. Discharge summary:
1.Cat I ATT -20
2.Tab levipill 500mg bd -20
3.Tab benadon 40mg od-10
4.Tab rantac-bd -20
5.Tab zofer –sos-10

39. Patient counselling and
interventions:
The best way to prevent TB meningitis or brain TB is to prevent
TB infections. In communities where tuberculosis is common, the
Bacillus Calmette-Guérin (BCG) vaccine can aid in controlling the
spread of the disease. This vaccine is very effective for controlling
TB infections in young children