1. Headache
1.1. Causes pain and discomfort in Head, Scalp or Neck
1.1.1. Result of:
1.1.1.1. Traction or irritation of the meninges and blood vessels
1.1.1.1.1. May be due to Head Trauma or Tumours
1.1.1.1.2. Blood vessels spasms, Dilated blood vessels, Inflammation or Infection of Meninges and Muscular Tension
1.2. Symptoms of many medical condition and illness
1.3. Not stated how long the patient has headache
2. SCENARIO
2.1. A Man
2.2. 22 years old
3. Presented with:
4. Intermittent Confusion
4.1. Characterized by:
4.1.1. Intermittent memory loss
4.1.2. Confusion
4.1.3. Disturbed sleeping pattern and appetite
4.1.4. Difficult in mainting and shifting attention
4.1.5. Incoherent or Disordered Speech
4.2. Confusion that does not occur continuously.
4.3. Delirium
5. Feeling Warm at Night
5.1. Known as Night Sweats
5.1.1. Repeated episodes of extreme perspiration that soaks the night clothes or bedding
5.2. Related to underlying medical condition such as Nocturnal Fever
5.2.1. Results from Exaggeration of Normal Circadian Temperature Rhythm
6. Malaise
6.1. Feeling of Weakness and discomfort
6.2. Occur as symptom of almost any health condition
6.3. Occurs with fatigue
6.4. Inability to fully feel healthy even through a proper rest
6.5. Suddenly or gradually develop
6.6. Persist for a long period
7. Vomiting
7.1. Emesis
7.2. Forcible emptying of stomach
7.2.1. Involves a series of contractions of the smooth muscles lining the digestive tract
7.3. Symptom of underlying disease, not a specific illness itself
7.4. By stimulation from the higher brain centre: Chemoreceptor Trigger Zone (CTZ)
8. Clinical Diagnosis
9. Enterocolitis
9.1. Vomitting + Headache + Malaise
9.2. Inflammation of the small and large intestine
9.3. Patient is presented with vomiting indicating he might have gastrointestinal tract problem
9.4. Malaise and headache may due to excessive fluid loss from vomitting that may cause hypovolumic shock
9.4.1. excessive fluid loss lead to reduce in oxygen flow in body = intermittent confusion
10. Meningitis
10.1. thus disturbance in the motor and sensory cortex lead to vomitting, malaise and intermittent confusion
10.2. Vomiting + Headache + Intermittent confusion + Malaise
10.3. The brain consist both of the sensory and the motor cortex
10.4. infection to the meninges of the brain can lead to the disturbance of these cortex
10.5. aside that when there infection and inflammation in the brain it will increase the intracranial pressure (ICP) of the brain
10.6. while increase in ICP lead to headache
11. Transient Intermittent Attack (TIA) (Minor Stroke)
11.1. Vomiting + Headache + Intermittent confusion + Malaise
11.2. TIA is a temporary period of symptoms similar to those of symptoms.
11.3. When TIA occur there will be a temporary blockage of blood to the brain this will cause hypoxia of the brain tissue.
11.4. This will affect the brain normal physiology to disrupt and cause the disturbance in both the motor and sensory cortex.
12. TRIGGER 1
12.1. Brudzinski Test
12.1.1. A test that physically demonstrate the symptom of meningitis.
12.1.2. The test is positive when passive forward flexion of the neck causes the patient to involuntarily raise his knees or hips in flexion.
12.1.2.1. Techniques:
12.1.2.1.1. 1.
12.1.2.1.2. 2.
12.1.2.1.3. 3.
12.1.2.1.4. 4.
12.2. Kernig Test
12.2.1. Kernig sign is a bedside physical exam maneuver used to help in the diagnosis of meningitis
12.2.2. A positive test is elicitation of pain or resistance with passive extension of the patient's knees.
12.2.2.1. 1.
12.2.2.1.1. Clinicians typically perform the exam with the patient lying supine with the thighs flexed on the abdomen and the knees flexed.
12.2.2.2. 2.
12.2.2.2.1. The examiner then passively extends the legs.
12.2.2.3. 3.
12.2.2.3.1. In the presence of meningeal inflammation, the patient will resist leg extension or describe pain in the lower back or posterior thighs, which indicates a positive sign
12.3. Realibility of the tests
12.3.1. Sensitivity of 5% and specificity of 95% for both Kernig's and Brudzinski's signs. Although there is high specificity, the poor sensitivity of the two tests is a concern when diagnosing meningitis.
12.3.1.1. There is another test which can be used as an alternative to Brudzunki's and Kernig Test.
12.3.1.1.1. A new test called Jolt accentuation of headache has been used as an alternative.
12.3.1.1.2. In this test, the patient is asked to quickly move their head from side to side in a horizontal plane.
12.3.1.1.3. If there is meningeal irritation, the headache will get worse which will be regarded as an indication for a lumbar puncture, regardless of the fact that neck stickness may not be present.
13. Definitive Diagnosis
13.1. Tuberculosis Meningitis (TBM)
13.1.1. Definition
13.1.1.1. TBM is the inflammation of the membranes called meninges that surround the brain and spinal cord caused by a specific bacteria, Mycobacterium Tuberculosis
13.1.1.1.1. Occurs in patient who have or have had tuberculosis especially miliary tuberculosis or who have been exposed to the bacteria.
13.1.2. Pathophysiology
13.1.2.1. TBM develops by the entry of Mycobacterium tuberculosis by into the lung by drop inhalation and the infection escalated within the lung
13.1.2.1.1. Result in the formation of tuberculoma (i.e. Rich foci) of metastatic caseous lesion in the lung
13.1.2.1.2. Dissemination to CNS is more likely to happen especially if miliary tuberculosis develops.
14. TRIGGER 3
14.1. MRI
14.1.1. Why MRI is performed?
14.1.1.1. To form pictures of the anatomy and the physiological processes of the body
14.1.1.2. To detect conditions of the brain such as cysts, tumors, bleeding, swelling, developmental and structural abnormalities, infections, inflammatory conditions, or problems with the blood vessels.
14.1.2. MRI findings
14.1.2.1. Presence of irregular ring enhanced area in the area of basal cisterns
14.1.2.1.1. indicates the presence of tuberculoma that arises within the brain parenchyma
14.1.2.2. Presence of radiolucency which indicates the brain abscess
14.2. Seizure & Quadriplegia
14.2.1. Seizures
14.2.1.1. Definition
14.2.1.1.1. Seizure is a sudden, uncontrolled electrical disturbance in the brain. It can cause changes in your behavior, movements or feelings, and in levels of consciousness.
14.2.2. Quadriplegia
14.2.2.1. Definition
14.2.2.1.1. Quadriplegia is the paralysis or muscle weakness of the body from at least the shoulders down
15. TRIGGER 2
15.1. Bacterial Staining
15.1.1. Ziehl-Neelsen Stain
15.1.1.1. A classic differential staining procedure which uses heat to drive fucshin stain into cells
15.1.1.2. Used to identify acid fast organisms, mainly mycobacteria
15.1.1.3. Staining Results
15.1.1.3.1. Acid Fast : Red
15.1.1.3.2. Non-acid Fast : Bue
15.1.2. Acid Fast Organisms
15.1.2.1. Acid fastness, a physical property that gives bacteria to resist decolourization by acids during staining procedures
15.1.2.2. Do not contain common bacteriological stains
15.1.3. Mycobacterium Tuberculosis
15.1.3.1. Cell walls contain high concentration of lipids making them resistant to standard staining techniques
15.1.3.2. Waxy coating on cell surface composed primarily of mycolic acid
15.1.3.3. Are acid fact bacilli
15.1.3.4. Impervious to Gram staining
15.1.3.5. Ziehl-Neelson technique must be used
15.2. Anti TB Therapy
15.2.1. Antibiotics given by doctors to kill Mycobacterium Tuberculosis
15.2.2. Most common drugs
15.2.2.1. Rifampicin
15.2.2.1.1. Given orally/IV/IM
15.2.2.1.2. Inhibit DNA-dependant RNA polymerase
15.2.2.1.3. Adverse effect: Red discolouration of body fluid
15.2.2.2. Isoniazid
15.2.2.2.1. Given orally/IM
15.2.2.2.2. Inhibit mycolic acid synthesis
15.2.2.2.3. Adverse effect: Peripheral numbness, nausea and toxicity
15.2.2.3. Pyrazanamide
15.2.2.3.1. Given orally
15.2.2.3.2. Inhibit fatty acid synthase-1 gene and mycolic acid synthesis
15.2.2.3.3. Adverse effect: Hyperuricemia
15.2.2.4. Ethambutol
15.2.2.4.1. Given orally
15.2.2.4.2. Inhibit arabynosyl transferase
15.2.2.4.3. Adverse effect: Colour blindess
15.2.3. Treatment course
15.2.3.1. Continuous phase
15.2.3.1.1. 4 months, 2 drugs
15.2.3.2. Intensive phase
15.2.3.2.1. 2 months, 4 drugs
15.2.4. Guideline therapy
15.2.4.1. Given in combination to reduce development of drug reccurency
15.2.4.2. Given in DOT and in combination if pt have poor compliance
15.2.4.3. Describe the drugs according to weight
15.3. Chest Radiograph
15.3.1. why chest x-ray was performed?
15.3.1.1. to check the progression of the tuberculosis infection since patient stated that he was started on the anti -TB therapy
15.3.2. chest x-ray finding
15.3.2.1. fine opacity consolidation scattered on the left lung
15.3.3. opacity pattern
15.3.3.1. miliary pattern
15.3.3.1.1. 2 to 3 mm well-defined nodules (“micronodular pattern”)
15.3.4. indication
15.3.4.1. miliary tuberculosis
15.3.4.1.1. Miliary tuberculosis (TB) is the widespread dissemination of Mycobacterium tuberculosis via hematogenous spread.
15.3.4.1.2. Classic miliary TB is defined as milletlike (mean, 2 mm; range, 1-5 mm) seeding of TB bacilli in the lung, as evidenced on chest radiography.
15.4. Lumbar Puncture
15.4.1. Definition
15.4.1.1. a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid (CSF) for diagnostic testing
15.4.2. Type of position
15.4.2.1. Sitting position
15.4.2.1.1. The patient sits on the edge of a flat surface and hang their arms over a table in front of them.It helps lengthen their spine and keep them still for the procedure.
15.4.2.2. Lying position
15.4.2.2.1. The patient lies on their side on the bed or exam table with their knees tucked to their belly and their chin to their chest. This is to put the patient in a stable position that helps widen the interlaminar space where the practitioner puts the needle.
15.4.3. CSF Evaluation
15.4.3.1. Acute Bacterial Meningitis
15.4.3.1.1. White bood cell : increase and neutrophils are predominant, protein : increase, glucose : increase
15.4.3.2. Virus Meningitis
15.4.3.2.1. White bood cell : increase and lymphocytes are predominant, protein : normal or mild increase, glucose : normal
15.4.3.3. Tuberculous Meningitis
15.4.3.3.1. White bood cell : increase, protein : increase, glucose : decrease
15.4.3.4. Fungal Meningitis
15.4.3.4.1. White bood cell : increase , protein : increase, glucose : decrease
15.5. Lab Diagnosis for Tuberculosis
15.5.1. Mantoux or tuberculin skin test
15.5.1.1. To determine someone has develop immune response to bacterium causes tuberculosis
15.5.1.1.1. Procedure
15.5.1.2. This test cannot tell how long patients had been infected with tuberculosis
15.5.1.3. This test cannot tell if infection is latent or active
15.5.2. Sputum culture
15.5.2.1. Sputum collection
15.5.2.1.1. Direct into container
15.5.2.1.2. Cough up from lung secretions not saliva
15.5.2.1.3. Sputum specimen
15.5.3. Polymerase chain reaction (PCR)
15.5.3.1. Making copies of DNA sequence
15.5.3.1.1. Rapid test
15.5.4. DNA probing
15.5.4.1. To amplify the extracted DNA sequences from bacterial cells
15.5.4.1.1. Hybridize RNA molecules with flourescent DNA probe
15.5.5. Enzyme-linked immunosorbent assay (ELISA)
15.5.5.1. Serological test determine antibodies against Mycobacterium tuberculosis
15.5.5.2. Procedure
15.5.5.2.1. 1) Mycobacterium tuberculosis antigen bound to surface of wells or microtiter strips
15.5.5.2.2. 2) patient's serum diluted into wells
15.5.5.2.3. 3) binding IgA antobodies to immobilized Mycobacterium tuberculosis antigen takes place
15.5.5.2.4. 4) well diluted with wash solution remove unbound material
15.5.5.2.5. 5) Anti-human IgA peroxidase conjugate is added
15.5.5.2.6. 6) Further washing, induce development of blue dye in the wells
15.5.5.3. Highly sensitive and specific test