SOAP NOTES ON TB MENINGITIS. COMPLETE CASE PRESENTATION FROM PHARM D DEPARTMENT INCLUDES TREATMENT AND ASSESSMENT

1. TB MENINGITIS
AYESHA FAREED
PHARM D.

2. Age 30yr
Gender female
Ip 184693
Weight 67kg
Height 162.5cm
BMI 24
2

3. Chief complaint : a 30year old female admitted in hospital
with chief complaint of severe headache, vomiting ,stroke.
Past medical history : wedgner’s granuloma
Surgical history: none
Allergies: no known drug allergies
3

4. Medication reconciliation:
Inj.Mannitol 100ml IV QID
Inj. Optineuron 1 amp IV OD
Inj.Dexamethasone 8mg IVTID
Physical examination:
Height: 162.5cms
Weight:67kg
BMI:24
Vitals:
Pulse : 98/min
B.P. : 120/80MmHg
RR : 22/min
Temp : 100º
4

5. Provisional Diagnosis :
TB MENINGITIS with multiple tuberculoma
5

6. Labs:
Parameter Normal Day
Hb 13-18mg/dl 12.2
TLC 4.5-11 15.3
sodium 136-145mmol/lt 134
Uric acid 2.2-6.0 8.8
platelets 1.5-4.5lac 2.98lac
LDH 81-234 533
6
ANCA: positive
CSF: ↓glucose,↑protein.
MRI: ischemic infract (Rt.Thalamic region)

7. Pharmaceutical care plan
Subjective evidences:
•Headache
•Vomitings
•Left leg parasthesias
Objective evidences:
ANCA:positive
CSF: ↓glucose,↑protein.
MRI:mild lesions
7

8. Final diagnosis:TB MENINGITIS
8

9. •Day:1
•c/o severe headache, vomitings,
Stroke.
•Past:fever treated for dengue
in outside hospital.
•Later admitted in yashodha with
↑headache and numbness in thumb.
•Skin biopsy revealed neutrophilic
leukocytosis and vasculitis and treated
with omnacortil.
•Later she was admitted to apollo and
diagnosed with TB meningitis from the
following reports.
ANCA: positive
CSF: ↓glucose,↑protein.
Plan: Rifampicin sensitivity
•Inj.pantoprazole 40mg IV OD
•T.Pyrazinamide 750mg PO BD
•T.Pyridoxine 40mg PO OD
•T.Ethambutol 1g PO OD
•Inj.Enoxaparin 40mg SC OD
•T.Aspirin 150mg PO OD
•T.Isoniazid 300mg PO OD
•T.Tayo 60k PO once a week
•Inj.Levofloxacin 750mg IV OD
•T.Flunarazine 10mg PO HS
•Syp.Lactulose 15ml RT HS
•Inj.Streptomycin 750mg IM OD
•Inj.Tramadol 50mg IV BD
•Naproxin 500mg PO BD
•Inj.ondansetron 4mg IV BD
•T.Dexamethasone 8mg POTID after food
•Inj.leviteracetam 500mg IV BD

10. Day:2
•Re evaluation of vasculitis
•MRI: leision, acute ischemic brain
infarct.
•Rifampicin is resistent
Day :3
•Pallor and presented with joint pains
in fingers and knees
•hallucinations
•CBC and uric acid tests were done
•Hb:8g/gl
•Uric acid -8.8
•Transfused 1 pint of PRBC
•T.Febuxostat 80mg PO OD
•T.Alprazolam 0.25mg PO HS
•Stop pyrazinamide
•CST
•T.Acetazolamide 250mg POTID
•Naturiax fibre powder 1 tsp
•CST

11. Day:4
•Melena was seen
drop in hb-?UGI bleed
•Plan:DVT Stockings
•PhysiotherapyTID
•Head ache mild
Day:5
Patient stable
No headache
Plan to discharege with ATT
Stop acetazolamide
Tramadol
Naproxin
CST
CST

12. Sno Drug Dose Rout
e
Frequenc
y
Indication Start
date
Stop
date
1
Inj.pantoprazole 40mg IV OD Ulcer Px 1
2 T.Pyrazinamide 750mg PO BD ATT 1 3
3 T.Pyridoxine 40mg PO OD Vit supp 1
4 T.Ethambutol 1g PO OD ATT 1
5 Inj.Enoxaparin 40mg SC OD DVT Px 1
6 T.Aspirin 150mg PO OD Stroke 1
7 T.Isoniazid 300mg PO OD ATT 1
8 T.Tayo 60k 1tab PO Once a
week
Vit D 1
12
DRUG CHART:

13. Sno Drug Dose Rout
e
Frequenc
y
Indication Start
date
Stop
date
9
Inj.Levofloxacin 750mg IV OD ATT 1
10 T.Flunarazine 10mg PO HS Head ache 1
11 Syp.Lactulose 15ml RT HS Constipation
12 Inj.Streptomycin 750mg IM OD ATT 1
13 Inj.Tramadol 50mg IV BD Head ache 1
14 Inj.ondansetron 4mg IV BD Vomitings 1
15 T.Dexamethasone 8mg PO TID vasculitis 1
16 T.Acetazolamide 250mg PO TID headache 2
17 Naturiax fibre 1 tsp PO BD Protein supp 2
13
DRUG CHART:

14. Sno Drug Dose Rout
e
Freque
ncy
Indication Start
dose
Stop
dose
18 T.Febuxostat 80mg PO OD Uric acid 3
19 T.Alprazolam 0.25mg PO HS hallucinatio
ns
3
20 Naproxin 500mg PO BD headache 1
21 Leviteracetam 500mg IV BD Seizure Px 1
DRUG CHART

15. Assessment:
•A 30year old female admitted in hospital with chief complaint of severe
headache associated with vomitings and high grade fever (T max-104˚) at night
times.
•previously she was admitted in yashodha with severe headache, stroke,
numbness of thumb, skin biopsy revealed neutrophilic leukocytosis , vasculitis,
and was on omnacortil.
•later she was admitted in apollo and diagnosed with TB Meningitis
•On day3 she complained with pain in the fingers joints and knees. uric acid test
was done and revealed ,high uric acid levels(8.8)and stopped pyrazinamide.
•On day 4 she was pallor and experienced with melena .CBC revelaed drop in Hb.
They Suspected UGI? bleed and stooped pain killers. Acetazolamide was stopped
due to melena
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16. TB Meningitis:
•T.Pyrazinamide 750mg PO BD
•T.Pyridoxine 40mg PO OD
•T.Ethambutol 1g PO OD
•T.Isoniazid 300mg PO OD
•Inj.Levofloxacin 750mg IV OD
•Inj.Streptomycin 750mg IM OD
Head ache:
•T.Flunarazine 10mg PO HS
•Inj.Tramadol 50mg iv bd
•T.Acetazolamide 250mg POTID
•Naproxin 500mg PO BD

17. Supportive care:
•Inj.Pantoprazole 40mg IV OD ulcer prophylaxis
•T.Aspirin 150mg PO OD for stroke
•T.Tayo 60k PO once a week for vit-D
•Naturiax fibre powder 1 tsp for protein
•T.Alprazolam 0.25mg PO HS for hallucinations
•Inj.leviteracetam 500mg IV BD for seizure prophylaxis
Hyperurecemia :
T.Febuxostat 80mg PO OD

18. Plan:
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Recommendations:
• Pyrazinamide is recommended along with febuxostat as the uric acid levels
decreased to low level if used alone.
•As there is no effective treatment forTB Meningitis pyrazinamide can be
given along with febuxostat with close uric acid monitiring.

19. Disease monitoring parameters:
TB Meningitis:
•Hyponatremia
•Stroke
•Exacerbation of chronic diseases
•Hypoxemia
•CBC
Stroke:
•Bloodpressure
•CBC

20. Drug monitoring parameters:
Pantoprazole: weight changes, mild diarrhea, gas, stomachpain
Pyrazinamide: gout, anorexia, sideroblastic anemia, utricaria, porphyria
Ethambutol : headache, loss of appetite, worsening gout
Enoxaparin: bleeding gums, hemoptysis, nose bleed, red or brown urine
Aspirin : vertigo, itchy rash, worsening of asthama, tinitis
Isoniazid: yellow skin, dark urine, numbness, seizers,confusion
Tayo 60k : loss of appetite, bone or muscle pain
Levofloxacin : constipation, dizziness, abdominal pain, abdominalgas
Flunarazine : weight gain, extra pyramidal effects, depression
Lactulose : diarrhea, bloating gas, stomach pain
Streptomycin: parasthesia of face, utricaria, esinophilia
Tramadol : convulsions, itching, flushing
Ondansetron: lightheadedness, blurred vision, muscle spasms
Dexamethasone : swelling, weight gain, insomnia, mood changes
Acetazolamide : melena, frequent urination
Leviteracetam: hallucinations, weakness,irregular heart beats
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21. Patient counseling:
•We have to support the patient that none of theTB medications
are harmful and does not cause any intestinal obstruction.
•Psycologically support the patient that stroke can be managed
with physiotherapy and supportive care
•Alprazolam which is prescribed for hallucinations should not be
taken regularly .
•The duration of treatment for tb meningitis is for 9 months,and
the medications are to be take regularly without any failure.
•Wash your hands properly
•Maintain good hygeine
•Lots of water and vegetables with unrefined sea salt
•Physiotherapy
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22. DISCHARGE MEDICATIONS:
•T.Pyrazinamide 750mg PO BD for 9 months
•T.Pyridoxine 40mg PO OD for 9 months
•T.Ethambutol 1g PO OD for 9 months
•T.Isoniazid 300mg PO OD should be taken on empty stomach
•Inj.Levofloxacin 750mg IV OD for 9 months
•Inj.Streptomycin 750mg IM OD for 9 months
T.Febuxostat 80mg PO OD for 15 days
•T.Pantoprazole 40mg IV OD ulcer prophylaxis for 3 days
•T.Aspirin 150mg PO OD for stroke at night time every day
•T.Tayo 60k PO once a week for vit-D
•Naturiax fibre powder 1 tsp for protein suppliment X 10days
•T.leviteracetam 500mg IV OD for seizure prophylaxis