OSPITAL NG MAYNILA MEDICAL CENTER Department of Ophthalmology
Name: De Los Santos, John Rex Hospital No: 1454642 Age/Sex: 4/M Address: 5921 Halamanan Area, Commonwealth , Quezon City Date of Admission: August 13, 2007 Admitting Diagnosis: t/c Orbital cellulitis with osteomyelitis, OD Physicians-in-charge: Drs. Reyes/Santiago/Mateo/Daffon/Samaniego
CLINICAL ABSTRACT 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 started to have a palpable small mass similar to a size of playing marble which gradually enlarges almost every month. 8 weeks prior to consult, the patient sought consult to 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 and the result was upper lid wall, right , no malignant cells seen, cytomorphologic features consistent with marked chronic inflammation with multiple bacterial colonies, patient was advised to have CT-scan. Diagnosis was to consider lymphoma but it was lost to followup. 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 PERTL 2-3mm
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
Hyperemic TM, AS
Tragal tenderness, AD Impacted cerumen, AD
(-) intranasal mass, (-)discharge
Uvula at midline (+) CLAD
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
Plan Please refer to ENT-HNS for definitive management of the cellulitis and osteomyelitis.
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. nd On the 2 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. rd On the 3 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. th On the 4 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 n eeded for pain, Penicillin 20mg TIV q8. Patient was transferred to the wards when vital signs were stable. th On the 5 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. th On the 6 hospital day, the mother was advised to place warm compress to OD. Other previous managements were continued. th On the 7 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. th th On the 8 – 9 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. th On the 10 , the IVF was shifted to heplock. Daily wound care was advised, meds were continued. th On the 11 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.