OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology Name: De Los Santos, John Rex Age/Sex: 4/M Address: 5921 Halamanan Area, Commonwealth , Quezon City Date of Admission: August 13, 2007 Date of Discharge: September 12, 2007 Admitting Diagnosis: t/c Orbital cellulitis with osteomyelitis, OD Final Diagnosis: Orbital cellulitis with osteomyelitis, OD Physicians-in-charge: Drs. Reyes/Santiago/Mateo/Brucelas/Samaniego Hospital No: 1454642
PATIENT DISCHARGE SUMMARY This is a case of a 4 year old child, who came in due to a palpable mass located in his lateral canthal area, OD History of Present Illness: One year prior to consult, the patient was noted to have a palpable small mass similar to a size of playing marble which gradually enlarged almost every month. 8 weeks prior to consult, the patient sought consult with a private MD, with an impression of cancer. Advised for an unrecalled surgery but he was lost to follow-up. 1 week prior to consult, the patient sought consult at East Avenue hospital and FNAB was done. The result was: upper lid wall, right , no malignant cells seen, cytomorphologic features consistent with marked chronic inflammation with multiple bacterial colonies. The patient was advised to have CT-scan. Diagnosis was to consider lymphoma but it was lost to follow-up. Medication given was Cloxacillin for 1 week . Persistence of the mass prompted consult. Past Medical History: No previous hospitalizations Family Medical History: No known familial diseases Previous Eye History: Denies any eye illness and has no previous eye operation Personal/Social History: Non- smoker and non- alcoholic beverage drinker Review of Systems: Constitutional: no weight loss, no loss of appetite, no chills, no fever Skin: no pigmentation, no itchiness HEENT: no headache, no dizziness, no tinnitus, no epistaxis, no neckpain, no dysphagia, no hoarseness Respiratory: no difficulty of breathing, no cough, no colds, no hemoptysis Cardiovascular: no chest pains, no orthopnea GIT: no abdominal pain, no change in bowel movements, no melena, no hematochezia GUT: no dysuria, no oliguria, no hematuria Endocrinology: no polydipsia, polyphagia, polyuria Hematology: no bleeding tendencies, no easy bruisability Neurology: no seizure, no tremors, no loss of consciousness Physical Examination: General: conscious, coherent, ambulatory, not in cardiorespiratory distress Vital Signs: HR=87 RR=20 T=37C HEENT: normocephalic, anicteric sclerae, no tonsillopharyngeal congestion, no cervical lymphadenopathy, no neck vein distention, no neck mass, (+) wound on the lateral aspect of the supraorbital and infraorbital area. Visual Acuity: OD: Central, steady, maintained corneal reflex OS: Central, steady, maintained corneal reflex
External Eye Exam
Anicteric sclerae EOM Full and equal
Funduscopy OD: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E OS: (+) ROR, CM, DDB, CDR 0.3, AVR 2:3, (-) H/E Slit Lamp Clear (-) uptake no opacity clear (-) uptake
-CHEST and LUNGS: symmetrical chest expansion, clear breath sounds HEART: no precordial bulge, normal rate, regular rhythm ABDOMEN: flat, soft, non-tender, normoactive bowel sounds EXTREMITIES: no pallor, no cyanosis, full and equal pulses Assessment: t/c Orbital cellulitis with osteomyelitis, OD Course in the wards: Patient was admitted under the service of Drs. Reyes/ Santiago/ Mateo/Daffon/Samaniego. The patient was maintained on diet appropriate for his age. IVF was started D5MB 1L maintained under KVO. Vital signs monitoring was done q4. Medications given were Ampicillin Sodium + Sulbactam Sodium 350mg QID TIV and Fusidic acid (Fucithalmic) E/S, instill to OD BID. The Department of Pediatrics was informed about this admission for co-management, clearance for possible incision and drainage under seation and suggest appropriate sedative. Recorrect dosage of Ampi-sulbactam (full dose) via IV. On the first hospital day, patient’ vital signs were stable. He was seen and examined by a pediatrician & and was prescribed with Amicillin-Sulbactam 500mg/IV q 6. He had CBCwith PC examination and CXR-PA/L views and CTscan of the head and orbits was revealed. The patient was for PPD. Other previous managements were continued. On the 2nd hospital day, the following drugs were given: Amikacin 100mg TIV q8 hours and Paracetamol 250mg/5ml 8ml for T>38C and Paracetamol Aeknil for T> 38.5C. Other previous managements were continued. On the 3rd hospital day, the patient was seen by an anesthesiologist. Consent for the anesthesia was secured. ECG show sinus bradycardia. Patient was placed NPO post midnight. On the 4th hospital day, the patient was given clearance by the operation by the pediatrician. The patient underwent I&D, OD under GETN-Mask SEVO+O2. O2 inhalation at 3-4lpm via face mask. IVF were 3 D5LR 500cc to run for 8 hours each at 61gtts/min. The specimen was for GS/CS and cell cytology. Medications given were Paracetamol 210 mg TIV q4 as needed for pain, Penicillin 20mg TIV q8. Patient was transferred to the wards when vital signs were stable. On the 5th hospital day, the previous medications were continued and daily wound care was advised. VA was OD and OS = central, steady,maintained with 2-3 mm PERTL. Vital signs monitoring was done every 4 hours. On the 6th hospital day, the mother was advised to place warm compress to OD. Other previous managements were continued. On the 7th hospital day, Amicillin-Sulbactam 500mg/IV q 6 hours, Amikacin 100mg TIV q8 hours, Fusidic acid (Fucithalmic) E/S, instill to OD BID, and Paracetamol 250mg/5ml 8ml for T>38C were given to the patient. Dialy wound care was advised. . Vital signs monitoring was done every 4 hours. Other previous managements were continued. On the 8th – 9th hospital day, other previous managements were continued. The drain was noted to be on placed. The OD was noted to have decrease swelling, discharge and erythema.
On the 10th, the IVF was shifted to heplock. Daily wound care was advised, mediications were continued. On the 11th hospital day, the IV meds were shifted to oral Amipisulbactam was shifted to Cefuroxime 250mg/ml syrup, 2ml TID for 4 days. Cefuroxime was not available, Co-amoxilclav 250/62.5/5ml syrup was given 7ml TIDx 4 days. The patient was allowed to go home by the Pediatrician. On the 12th hospital day, the MGH order was deferred. Ampisulbactam 500mg IV every 6 hours was continued. The patient was started on Oxacillin 500mg IV every 6 hours (100mkd) and was ordered to continue antibiotics for 1 week. The patient was referred to Pedia-Ortho Surgery for co-management. Laboratories requested were ESR, CRP after 10 days of antibiotics. On the 13th -14th hospital day, daily wound care was done. Folllow-up ESR, CRP and GS/CS results. Medications were: Ampisulbactam 500mg evey 6 hours thru heplock and Oxacillin 500 mg IV every 6 hours. All IV meds to continue for 4-6 weeks. On the 15th -17th hospital day, daily wound care was done. The patient was for CBC. Other previous managements were continued. On the 18th hospital day, the patient was seen by the Surgery department and suggested to do Debridement and curettage at the lateral wall of orbit. The patient was referred to ENT-HNS for definitive management. On the 19th hospital day, patient’s vital signs were stable. Daily wound cleaning was carried out. Heplock was reinserted. He was seen by ENT – HNS and gave impression of: t/c osteomyelitis, lateral orbit wall, right, and request was carried out for PNS and lateral orbit x-ray. Present management continued. On the 20th – 23rd hospital day, patient’s vital signs were stable. Heplock was shifted to IVF D5 0.3 NaCl to run at KVO. present medications continued. On the 23rd hospital day, patient vital signs were stable. The patient was planned for open biopsy under GA to rule out histiocytosis. On the 24th hospital day, patient was febrile and was referred to the Pediatrics department. Phlebitis was diagnosed and Paracetamol 250 mg/ml 5 ml was given every 4 hours for the fever. Warm compress was applied to the phlebitis site. On the 25th hospital day, the patient still had high-grade fever and infection was considered. Repeat CBC with PC was carried out. Paracetamol was given round-the-clock and antibiotics were shifted to Piperacillin-Tazobactam 1,000 mg TIV Q 6 (200 mkd) and Amikacin 110 mg TIV q 8 (15 mkd). The patient’s mother signed a statement that they refused to have a biopsy done. On the 26th to 29th hospital day, patient’s vital signs were stable. Medications were continued. The patient’s mother still refuses the required biopsy. Ophthalmologic intervention were no longer needed by the patient, hence he was put to MGH Ophtha-wise. The patient was planned to be transferred to Pediatrics for care. On the 30th hospital day, the patient’s vital signs were stable. Patient seen by Pediatrics and was advised may go home pedia – wise. Home medications given include: Co-amoxiclav 250mg/5ml 6 ml every 6 hours for 10 days, and Multivitamins 10ml once a day.