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R4 王士豪 R4 王士豪 兒科急診 case conference 2016年6月23日 2016年6月23日 2016年6月23日.

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Presentation on theme: "R4 王士豪 R4 王士豪 兒科急診 case conference 2016年6月23日 2016年6月23日 2016年6月23日."— Presentation transcript:

1 R4 王士豪 R4 王士豪 兒科急診 case conference 2016年6月23日 2016年6月23日 2016年6月23日

2 檢傷紀錄 Date: 2008/04/09 T/P/R: 38.1/88/24 SBP/DBP: -/- E4V5M6 體重: 16 SPO2 : 98 病患來診為局部性腫脹 / 發紅,局部性蜂窩 性組織炎

3 General Data Chart No. 21164815 Name: 張 xx Birthday: 2003/03/10 Gender: male Age: 5-year-1-month-old Information source: his parents

4 Chief Complaint Intermittent fever with occipital wound pus formation for few days

5 Present illness-1 This 5-year-old boy was quite well before. He suffered from traffic accident on 3/23 and head injury hurt by his sister's teeth. The lesion site was on right occipital area. After that, the boy was brought to 怡仁 hospital for help. After primary suture of the occipital wound, the patient was discharged from ER. There was no discomfort, vomiting, seizure, nor ILOC at that time.

6 問題一? 這樣子的傷口可以縫合嗎?

7 Primary closure Whether or not to suture –Controversial Most open lacerations can be sutured within several hours of the injury after administration of adequate local care Leave these wounds open for drainage and possible delayed primary closure 72 hours after the injury Wounds to the face are usually closed promptly –Infection of these wounds is uncommon –Excellent blood supply to the face and scalp. Uptodate 2008

8 Not recommend suturing wound High risk for the development of infection –Crush injuries –Puncture wounds –Bites involving the hands –Dog bite wounds with delayed presentation (more than 6 to 12 hours for arm or leg bites or more than 12 to 24 hours for bites to the face) –Cat or human bites, except those to the face –Bite wounds in immunosuppressed hosts irrigated copiously, dressed, left open to drain, and examined daily to detect signs of infection Uptodate 2008

9 問題一的解答 如果他只有撕裂傷,看來是不可以縫合。然而?只有撕裂傷嗎?

10 Present illness-2 However, the patient had intermittent fever and headache since 3 days ago, and pus over prior occipital wound s/p suture was noted. Persistent headache occurred on 4/6 (2 weeks later after TA) and the headache was more severe on morning. There was no nausea, vomiting, diarrhea nor double vision. Therefore, he was brought to our emergency department on 4/9.

11 Past and personal history Systemic disease: denied Previous OP: nil NKA Smoking, Alcohol, Betel nut: denied

12 Physical examination T:38.5/ ℃ P:80/min R:20/min BP:98/51 mmHg General Appearance: lethargy Consciousness: clear, E4 V5 M6 HEENT: –Sclera: anicterus –Conjunctiva: not injected –Pus discharge over occipital wound s/p suture –Lips: no cyanosis NECK: –supple, no lymphadenopathy CHEST: –Breath pattern: smooth, bilateral symmetric expansion

13 Physical examination HEART: Heart sound: regular heart beat, no murmur, ABDOMEN: Tactile: soft and flat; no tenderness; no rebounding pain; no muscle guarding Percussion: dullness Bowel sound: normoactive BACK: No knocking pain over flank area EXTREMITIES: Freely movable SKIN: No rash; no petechiae or ecchymosis; no vesicle; no desquamation Intact without wound

14 Neurological examination Cranial nerves: no focal sign Muscle power: 5/5 DTR :++/++ Babinski sign: plantar flexion/plantar flexion Brudzinski sign: negative; Kernig sign: negative

15 小兒評估三角 外觀 Ill-looking, lethargy 循環 Skin and CRT not document 呼吸 正常

16 初步評估 兒童三角評估 : – 異常外觀, 正常呼吸, 循環狀態未記錄 生命徵象 : – 心跳 80, 呼吸 20, 血壓 98/51, – 體溫 38.5  C, 體重 16 kg, 血氧濃度 96%

17 初步評估 A: 氣道通暢 B: 呼吸不費力 C: 紅潤的膚色. 脈搏正常 微血管填充時間 < 2 sec. D: 嗜睡, E: 有頭皮外傷,且傷口化膿,且發燒

18 問題 在初步評估後, 你認為這位男童發生了什麼事 呢 ? 你的初步診斷為何 ?

19 初步診斷 中樞神經失能 – 異常外觀, 正常呼吸和循環狀態未記錄 ( 但正常 範圍血壓 )

20 接下來, 你該如何處置這位病 童 ? 你處置的優先順序為何 ?

21 處置的優先順序 評估 ABCs 血糖,脈動式血氧偵測 建立血管通路. 安排實驗室檢查及抽血. 你希望安排何種實驗室檢查 ? 可能造成此病童意識改變的原因 ?

22 意識改變的原因 Alcohol/Acidosis ( 酒精 / 酸中毒 ) Trauma ( 創傷 ) Epilepsy ( 癲癇 ) Insulin/Hypoglycemia ( 胰島素 / 低血糖 ) Ingestion ( 誤食 / 誤用 ) Poisoning/Psychogenic ( 中毒 / 心理因素 ) Opiates ( 鴉片類藥物 ) Shock ( 休克 ) Uremia ( 尿毒 )

23 這個病童可能之診斷 CNS dysfunction combine with –Fever –A complicated scalp wound –Previous head injury 可能之診斷 – 蜂窩性組織炎合併瀰漫性全身性感染 – 單純 CNS 感染 – 外傷性腦出血

24 Lab data WBC 23.3 1000/uL RBC 4.44 million/uL Hemoglobin 11.1 g/dL Hematocrit 34.0 % MCV 76.6 fL MCH 25.0 pg/Cell MCHC 32.6 g/dL RDW 12.6 % Platelets 578 1000/uL Segment 90.0 % Lymphocyte 4.0 % Monocyte 6.0 % BUN (B) 8 mg/dL Creatinine(B) 0.5 mg/dL AST (GOT) 24 U/L ALT/GPT 12 U/L Na 141 meq/L K 4.2 meq/L CRP 44.28 mg/L Sugar 87 mg/dl PH 7.315 PCO2 44.9 mmHG PO2 182.2 mmHG HCO3 22.3 mm/L SAT 99.1 %

25 下一步您會想做什麼? 會 NS? 住院? 做 CT?

26 NS consultation Compression fracture with pus Conscious drowsy Arrange CT enhancement to R/O abscess We will follow this case 家屬這時突然補充說他們有先去外院,外 院也懷疑腦部化膿

27 2008-04-09 Brain CT

28

29 2008-04-09 Brain CT (C+-) Depressed skull bone fracture at right occpital region with ill-defined low density lesions with marginal enhancement and perifocal white matter edema at right occipital lobe, c/w brain abscess. Mass effect with effacement of right lateral ventricle and minimal midline shift to left. No intracranial hemorrhage is noted. IMP: –Skull fracture and brain abscess with mass effect at right occipital region. –Suggest clinical correlation and MRI study.

30 Impression Occipital abscess right occipital bone fracture

31 Admission Empiric antibiotics: Vancomycin + Ceftriaxone + Metronidazole Mannitol

32 2008-04-09 Brain MRI_T1

33 2008-04-09 Brain MRI_FLAIR

34 2008-04-09 Brain MRI_T1_sagital

35 2008-04-09 Brain MRI evidence of brain abscess lesion located at right occipital lobe, about 5x3x4 cm in size, with the apperance of low on T1WI, high on T2WI and diffusion and low on ADC images, with perifocal edema and mass effect on right occipital horn;strong rim-like enhancement noted at the peripheral region. normal size and position of the ventricular system, except right occipoital horn. minimal posterior falx shifted to left side. IMP: c/w brain abscess, right occipital lobe.

36 2008-04-09 surgical intervention 手術說明 :remove brain abscess op procedure: –right occipital craniectomy –remove brai nabscess partially

37 2008-04-09 pathology report SNOMED –X2000-A-M43000 DX –SKULL, REMOVAL----CHRONIC INFLAMMATION GROSS D –THE SPECIMEN SUBMITTED CONSISTS OF SEVERAL PIECES OF TISSUE MEASURING 0.5 X 0.3 X 0.3 CM TO 2.5 X 2 X 0.6 CM. AMIE REPRESENTATIVE SECTIONS ARE TAKEN. MICRO D –SECTIONS SHOW BONY FRAGMENT AND CHRONIC INFLAMMATION.

38 2008-04-10 pathogen 鏡檢: PUS on 20080410 –GPC: rare –GNB: 2+ Anaerobic Cultue (TS) –Peptostrepto.micros Rare

39 2008-04-09~13 TPR

40 2008-04-14~18 TPR

41 2008-04-19~23 TPR

42 2008-04-21 Brain CT

43 Heterogeneous low attenuation lesion with fluid- fluid level over right occipital lobe, with perifocal edema and mass effect on adjacent occipital horn; variable-sized rim enhancement, the biggest one about 60x37 mm in size, brain abscesses are considered. Midline shift to left side, about 10 mm off midline. S/p change of right occipital craniotomy. IMP: Brain abscesses, right occiptal lobe.

44 2008-04-22 surgical intervention op procedure: 1. occipital large craniectomy 2. remove brain abscess op finding: 1. right occipital craniectomy 2. echo -guide corticotomy 3. awful smell, green pus gush out,about 30cc 4. after removed abscess brain mild slack and good pusitile 5. dura augmentation with fasia 6. wound closure layer by layer

45 2008-04-22 pathology report SNOMED –10101-B-M42100 DX –SKULL, OCCIPITAL, CRANIECTOMY----ABSCESS GROSS D –THE SPECIMEN SUBMITTED CONSISTS OF A PIECE OF TISSUE MEASURING 6.5 X 5.5 X 0.6 CM. (DECAL) CSC REPRESENTATIVE SECTION IS TAKEN. MICRO D –SECTIONS SHOW BONY TISSUE WITH NECROSIS, ACUTE AND CHRONIC INFLAMMATION.

46 2008-04-22 pathogen 鏡檢: PUS on 20080410 –GPB: 3+ –GNB: 3+ –Neutrophil: 2+ Anaerobic Culture (PUS) –Prevotella melaninogenica Light –Prevotella sp Light Aerobic Culture (PUS) –Viridans streptococcus Rare

47 2008-04-24~28 TPR

48 4/26 Change Vancomycin to Penicillin 5/6 DC Rocephin

49 2008-05-15 Brain MRI

50 Discharge on 5/23

51 Final Diagnosis Right occipital bone fracture and occipital brain abscess due to traumatic brain injury Status post craniotomy and drainage of abscess on 2008/04/09 and 04/22 Course of antibiotics treatment –Vancomycin (4/9~26, 17 days) –Penicillin (4/26~5/23, 28 days) –Rocephin (4/9~5/6, 28 days) –Metronidazole (4/9~5/23, 45 days)


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