Disease & Illness

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Infection Control From A Nursing Perspectiveical Asepsis:
The practice of medical asepsis helps to contain infectious organisms and to maintain an environment free from contamination. The techniques used to maintain medical asepsis include hand washing, gowning and wearing facial masks when appropriate, as well as separating clean from contaminated or potentially contaminated materials and providing information to patients about basic hygienic practices. Appropriate hand washing by the nurse and the patient remains the most important factor in preventing the spread of microorganisms.

One common example of medical asepsis involves the steps taken by the nurse to ensure that only clean linen is applied to each patient"s bed. Clean linen remains in the clean linen cabinet until taken to the patient"s room. The hands of the health care worker are washed before handling the clean linen. Unused bed linen from one patient"s room cannot be returned to the clean linen cabinet and cannot be used for any other patient. This linen is considered soiled and placed in the soiled linen bag.

Standard Precautions:
Standard precautions combine the major features of universal precautions and body substance isolation. These standard precautions alert the health care worker to patient situations that require special barrier techniques. These barrier techniques are used when working with any patient where potential or actualized contact with blood or body fluid exists.

Universal Precautions:
Universal precautions help control contamination from blood borne viruses such as human immunodeficiency virus (HIV) and hepatitis viruses. When in contact with a patient"s blood or any body secretion that may be contaminated with blood, protective measures such as wearing gloves, gown, facial mask, and/or goggles must be followed.

Guidelines for Specific Institutions:
Methods to control the spread of infections are standardized in recommendations from the Centers for Disease Control and Prevention (CDC) and the Occupational Safety and Health Administration (OSHA). These prevention standards are applied in all health care settings and modified according to the needs of each health care facility. The health care worker must practice within the guidelines of the specific institution.

Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Fellow Nephrology in Aga Khan University Hospital, Karachi " Pakistan. For more Dissertation or seeking Dissertation help visit www.articlesbridge.com The Most popular website that offers information Research on different Disease and Case Studies. Please leave the links intact if you wish to reprint this article.

Case History

? Admitted via clinic on 25-06-2007 for
? Fever off and on-------- 8-9 months
? Abdominal Pain --------- 2-3 weeks

In Gilgit she was being treated as a case of genital Tuberculosis without any objective genitourinary complaints or symptoms
She took ATT for 2 months and then stopped b/c of drug induced Acute Hepatitis.

Fever
8-9 months off and on
High grade up to 103-104 F, no chills/rigors
No urinary or chest complaints but she had upper abd. Pain, moderate in intensity, no radiation, no vomiting but nausea was present with ass. Weight loss.

Clinical Examination:

§ Alert awake oriented, toxic look
§ Pulse Rate: 90 beats/minute regular
§ Blood Pressure: 160/80 mmHg
§ Resp. Rate: 20 b/minute
§ Temp: 36.8 centigrade
§ Pallor with Icteric
§ Malar Flush but no rash
§ B/L pitting pedal edema
Clinical Examination:

§ RHC tenderness, hepatomegaly 2 fingers below Rt costal margin, splenomegaly 1 finger, positive shifting dullness.

§ S1 and S2 audible, Panystolic murmur in mitral area radiating to axilla, no gallop.

§ Chest: B/L symmetrical shape and resp movements, equal chest expansion B/L, with NVB except at Rt basal region which had decrease air entry.

Clinical Examination:
? CNS: Alert, OrientedX3, no focal sensory or motor deficit, plantars normal.

? Musculoskeletal System: No positive findings
Labs:
11-06-2007
Hb: 10.2 gm/dl (NN)
Hct: 27.8
Wbc: 7.4
Neutrophils: 73.8%
Lymphocyte: 21.4%
Plat: 30
Retic=6.8
FBS: 110mg/dl
LDH: 8752

Labs

PTT=25.3/12 TB=5.9 Coombs ++
INR=2.12 DB=3.7 CRP = 8.3
APTT=68.7/30 IB=2.2
D-Dimer=0.87 GGT=81
MP -ve SGPT=53
MP ICT -ve ALP=348

Urine DR:
Dark yellow Protein +3, bil +3, Hb trace, rest normal

§ 24 hrs urinary protein was 7080 mg/24hrs

§ She was started on broad spectrum ABx, IV
hydration and supportive management initially

CXR
Rt. Lower lung consolidation with possible
consolidatory changes in the Lt lower lung field,
findings are suspicious for pneumonia.
she was already being treated for pneumonia.

US Abd:
Fatty infiltration of liver, sludge filled
Gallbladder, mild ascites.

Her CT Abd and Pelvis

with contrast was done considering
disseminated TB which showed mild B/L
pleural effusion with mild to moderate
ascites, no paraaortic lymphadenopathy

? Ascitic Fluid DR
Glu=70
prot=814
TLC=100
N=10
L=90
RBC +++

? During the hospital stay
? She became short of breath(14/06/2007)
? Her CXR showed Pulmonary edema

ABG
7.49/37.8/70.8/28.9/+5.9/95.3 on 6L Fio2

Trop I x2 were negative
She was treated with IV diuretics
Cardiology service was involved they
continued IV diuretics

Echo:
EF 60%, moderately dil. Lt Atrium
LVDD grade II
Mod-severe MR, mild TR
Mild PHTN, no vegetations/clots

Her Autoimmune profile was sent, and in the mean
while bone marrow was done to send TB CS and
cause for worsening Bicytopenia (dropping PLTs &
Hb) under cover of FFPs.

GI service was also involved for deranged LFTs
They suggested to send autoimmune workup
Which was already sent.

? 6-8 hrs after bone marrow Pt started having heavy bleeding from bone marrow procedure site and she was Tx with FFPs & platelets and with in next 12 hrs she started bleeding from every site (GI, oral cavity, Nose), Hematology was involved they suggested DIC workup Which was sent and which turned out to be negative
? Twice daily IV omeprazole was converted into infusion.

Bone marrow aspirate:
? hypocellular/dilute specimen
? Few erythroid and myeloid precursors.
? No megakaryocyte seen

Results of bone trephine (H&E) section:
? Erythroid hyperplasia with nuclear to cytoplasmic asynchrony.
? Few large cell seen ?early precursors. normal myeloid precursors.
? Adequate megakaryocytes. No metastatic infiltrate to granuloma seen.

Final Report:
§ Autoimmune hemolytic anemia ?cause.
§ megaloblastic features on bone trephine can be due to folate deficiency (secondary to hemolysis).

§ Pt was already kept on folic acid.

§ Her bleeding continued and ENT
service was involved for nasal packing

§ She was transfused with multiple
PRBC, FFPs, CryoPPT and was given factor VII (novoseven) on the advice of hematologist

? Multiple blood CS, Ascitic fluid CS, BM CS including AFB CS were sent which were negative.
? Her CCHF was sent which was also negative
? Her Ascitic fluid cytology was negative and so was autoimmune profile except AntiDsDNA which was 11.4 (n=0-6), Anti PLP & anticardiolipin Ab were negative
? C3=0.57 (n=0.88-2.01), C4=0.20 (n=0.16-0.47)
? She was started on pulse steroid
? After 3 days of bleeding and supportive transfusions she started dropping Spo2 on room air, able to maintain Spo2 at 96% on 15L Fio2 and her GCS dropped to 5/15, family was not agreed for intubation despite counseling.
? ABG=7.49/37.8/70.8/28.9/+5.9/95.3 on 15L Fio2
? She was maintaining blood pressures initially then she started having hypotension hence was started on inotropic support but on 25 June 2007 at 1430 hrs she had a sad demise.
Questions/Queries
? Whether she had SLE or something else?
? What was the cause of bleeding?
? Anything additional in the management of this patient which would have saved her life?
? What about her previous diagnosis of TB?
? If she would have been correctly diagnosed earlier would she able to survive?

SYSTEMIC LUPUS ERYTHROMETOSIS
(SLE)

DEFINITION

SLE is the prototype of a multisystem disease of autoimmune origin characterized clinically by acute/insidious onset chronic, remitting & relapsing in it?s course virtually affecting any organ of body & biochemically by presence of circulating autoantibodies against diversity of antigen.

EPIDEMIOLOGY

? 1:2500 in general population
? 1:700 in women
? 9:1 Female to male ratio
? 2:1 Female to male ratio in childhood & in age group above 65
? More common in African-American women.

Clinical Features
Constitutional Symptoms - Fatique, Fever
Arthralgia, Myalgia, Weight Loss

Cutaneous
Acute Skin Lesions - Generalized, Erythema, Bullous, Butterfly Rash
Subacute - Erythematous Palpable Plaques Associated With Ro/Ssa
Chronic Discoid
Alopecia
Raynaud

Clinical Features
1. Renal - Acute Renal Failure
Chronic Renal Failure
Nephrotic Syndrome
Nephritis
Pyelonephritis

Clinical Features?..
3. Pulmonary - Pneumonitis
Pleurisy
Pleural Effusion
Pulmonary Embolism
Pulmonary Fibrosis
Alveolar Hemorrhage

4. G.I.T. Dysphagia
- Mouth Ulcers
- Peritonitis
- Pancreatitis
- Mesenteric Vasculitis
- Bowel Infarction

Clinical Features..
5. Cardiac - Pericarditis
- Endocarditis (Libman-Sachs)
- Myocarditis
- Coronary Artery Disease

6. Reticulo-Endothelial
- Lymphadenopathy
- Splenomegaly

Diagnostic Criteria

Diagnosis - Acr Criteria
1. Malar Rash
2. Discoid Rash
3. Skin Photosensitivity
4. Painless Oral Or Nasopharnygeal Ulcers
5. Non Erosive Arthritis Or Arthralgia
6. Serositis (Pleurisy, Pericarditis)
7. Renal Involvement
8. Neurologic Disorders
9. Haematologic Disorders
10.Immunologic Disorder (Le Cells, Anti-Dna, Anti-Smith, False + Ve Vdrl, Aca
11. Ana

Any Four Out Of The Above Criteria

Labs
Laboratory
1. Leucopenia < 4,000
2. Thrombocytopenia
3. Anaemia - Hemolytic, Normochromic, Normocytic
4. Markedly Elevated Esr > 100
5. Usually Normal Crp
6. Ana - Present In 95% Homogeneous, Speckled
7. Anti Ds-Dna -Specific But Not Sensitive Suggest Severe Or Lupus Nephritis
8. Anti- Sm-Specific
9. Anti Ro/Ssa, La/Ssb - Neonatal Lupus, Congenital Heart Block
10.Anti Ribosomal P-Lupus Cerebritis
Labs..
11. Anti-Phospholipid (Igg Or Igm) - Aps
12. False Positive Vdrl

Lupus Nephritis
1. Albuminuria > 0.5g/24 Hrs Or Dipstick 3+
2. Casts (Rbc, Granular, Tubular, Mixed)
3. Haematuria (> 5rbc/Hpf)
4. Elevated Creatinine

Treatment

Simple Analgesics
Nsaids
Steroids
Hydroxychloroquine

Dmards - Methotrexate, Azathioprine,
- Cyclosporin, Cyclophosphamide,
- Mycophenolate Mofetil

Complications
- Opportunistic Infection
- Avascular Necrosis
- Premature Atherosclerosis - Myocardial Infarction
- RECURRENT ABORTION
- NEONATAL LUPUS

Prognosis
? Overall five years survival is more than 90 %

? Early mortality is due to organ failure or sepsis

? Late mortality is due to CVS complications

About Author:
Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Nephrology Fellow in AKUH, Pakistan. He has written many articles on Thyroid, Hyponatremia, Tuberculosis and Viral Hemorrhagic Fever, for more articles by Dr. D.S. Merchant visit www.text2read.com

Clinical Presentation, Demographic And Pathological Pattern Of Primary Thyroid Carcinoma Discussion

Discussion:
The demographic characteristics of our patients are comparable to western literature, however clinical presentation is somewhat different and more aggressive. Thyroid Carcinoma is prevalent in females with the male to female ratio of 1:2.2 which is comparable to the study conducted by L.M Zuberi and et al with male to female ratio of 1:2.5 reported from USA20 and the study conducted by Sajid H. Shah and et al18 which is in contrast with the study by Ahmed et al which revealed relatively low male to femaleratio of 1.01:1.08108 the highest female to male ratio of 9:1 to 13:1 has been reported in the series published from Japan109,110. Age of the patients with thyroid carcinoma ranged from 15-75 years with the mean age of 42 years which is in comparison with study conducted by S Akhtar and et al30 and Tariq Sarfraz and his colleagues from Army Medical College, Rawalpindi in which average age of presentation was 42.2 years with the overall range of age was 16 years to 70 years111

In this study the highest prevalence of thyroid carcinoma was obseved in 2nd, 3rd and 4th decade which is comparable to the study conducted by Ahmed et al and Sajid and his colleagues at Aga Khan University Hospital, Karachi18 which showed highest prevalence in 3rd, 4th and 5th decade of life112
In this study most of the patients with thyroid carcinoma belonged to urdu speaking 34.5% followed by sindhi (18.2%) and punjabi (16.4%) speaking patients while pathan (3.6%) and balochi (5.5%) have lowest number of thyroid carcinoma patients while the rest (21%) of the thyroid carcinoma patients belonged to other class including Northern areas and Afghanistan.

In the present study papillary thyroid carcinoma was the most frequent histological type of thyroid tumor in both males and females and it comprises 80% of all thyroid malignant tumors which is comparable to USA where 90% of all thyroid carcinomas are papillary thyroid carcinoma112,113,114. Ahmed et al from Saudi Arabia also reported 80% of papillary thyroid carcinoma in their series112 while in another local series by Khan et al from Rawalpindi reported 60% of papillary thyroid carcinoma115. In the present study, follicular thyroid carcinoma constitute 10.9% which can be compared with the study done by Sajid H et al Karachi in which follicular carcinoma is second most common type of thyroid carcinoma contituting 11.6%18 this was also shown by the study done in Rawalpindi by Tariq Sarfraz and his colleagues but the percentage was higher 23.8% for follicular thyroid carcinoma29. Medullary thyroid carcinoma constitute 3.6% compared to the study conducted by Sajid H et al Karachi18. The medullary thyroid carcinoma comprised about 1.8% in this study in contrast to the study conducted by Tariq Sarfraz and his colleagues at Rawalpindi which showed 4.8% of medullary thyroid carcinoma29 and the study conducted by Sajid and his colleagues at Karachi which showed 9.7% of thyroid medullary carcinoma18.

The most common presentation of our patients was neck swelling/mass which was present in 54 (98.2%) of patients which was also true for the study conducted by Zuberi and her colleagues at AKUH Karachi3. A series from Riyadh, Saudi Arabia reports similar findings of mass/goitre as the most frequent presentation in patients with thyroid cancer. It was present in three-quarters of their patients116. Goitre is common, occurring in 3.2-6.5% of western population26,117,118

Histological Type Shah?s Study% Our Study %
Papillary Carcinoma 69 80
Follicular Carcinoma 11.6 10.9
Medullary Carcinoma 9.7 3.6
Anaplastic Carcinoma 5.9 1.8

Presentation Zuberi?s Study % Our Study %
Mass in Neck 31 98.2
Weight Loss - 61.8
dysphagia <5 16.4
Hoarseness/ Recent Change of voice <5 20
Cervical Lymphadenopathy 33.3 50.9
Shortness of Breath <5 21.8

Presentation Sarfraz?s Study % Our Study %
Mass in Neck(Solitary Nodule/ Multinodular mass 90.4 98.2
Cervical Lymphadenopathy 14.2 50.9
Breathing difficulty 4.7 21.8

Conclusions:
Thyroid carcinoma was more common in females. Papillary carcinoma was the most common histological type of thyroid carcinoma in females as well as in males. Thyroid carcinoma was more prevalent in third and fourth decades of life and it is more common in urdu speaking followed by sindhi, Punjabi and balochi and pushto speaking (Pathan) population. The most common presentation was the mass in anterior neck and weight loss and cervical lymphadenopathy, dyspnea and dysphagia