CASE DISCUSSION
CASE DISCUSSION
醫學六 王家泰
醫學六 王家泰
History
History
•
Name :
陳 XX
•
Ward ： 11A 9-2
•
Date of Admission : 92/03/22
•
Age : 33 y/o
•
Sex : Female
History
History
•
Chief Complaint :
Wound infection after spinal surgery
‧Present illness :
This 33 y/o female patient is a case of hydrocephalus s/p V-P shunt 3 years ago in 萬芳醫院， She also had
ankylosing spondylitis with kyphotic deformity and received T12-L4 multiple level osteotomy without instrumentation on 92/03/03 and complete of
History
History
•
Wound infection was noted that she received
debridement and removal of implant on 92/03/12
and second debridement on 92/03/17.Body cast
was applied. Wound culture showed
Acinetobacter and Proteus mirabilis and Tienam
was used as antibiotics. She was then referred
to our hospital for further management.
•
Past History :
History
History
• Drug or food allergy : denied
• Previous OP history : hydrocephalus s/p V-P shunt 3 yrs ago , ankylosing spondylitis with kyphotic deformity s/p T12-L4 multiple level osteotomy , debridement for 2 times due to wound infection.
• Smoking(-) , alcohol drinking (-)
Physical Examination
Physical Examination
• Consciousness : clear JOMAC : intact E4M5V6
• Vital signs : stationary
• HEENT :
Conjunctiva : pink Sclera : non-icteric Pupil : isocoric Light reflex : L/R : +/+ JVE : nil LAP : nil
Goiter : nil ‧Chest :
Breathing sound : clear symmetric expansion Heart : RHB , no murmur was noted
Physical Examination
Physical Examination
• Abdomen
:
Bowel sound : normal active Liver/Spleen : impalpable No tenderness and rebounding pain was noted
OP marker : nil ‧Extremities :
No edema and ecchymosis was noted
Impression :
Lab Data
Lab Data
• C-reactive protein : WBC count : Seg.:‧ 03/22 6.89 03/22 23400 03/24 4.50 03/24 16540 84.4% 03/27 8.73 03/27 14380 79.8% 03/31 4.48 04/07 6650 70.3% 04/03 5.87 04/07 6.12 04/10 9.01
Wound Culture
Wound Culture
• 03/27 : Proteus mirabilis 3+
• 04/02 : Proteus mirabilis 2+ PDRAB 1+ 04/10 → 隔離室 （ 11B 22-1 ）
