CASE

Cellulitis at Left Foot Thumb

Counselor:dr. E

by:D F, A A, D A, R B

Name : Galih Saputra No. RM : 00461307 Age : 10 years old Sex : Male Nationality : Indonesian Examination Date : April 15th 2013

IDENTITY

History of illness was taken at 15th April 2013

Patient came to surgery clinic to take care of his wound.

4 days ago, patient came to emergency unit because he had a wound on his left foot thumb after he stepped on the broken glass 30 minutes before he came to hospital. The doctor gave him Tetanus Toxoid injection, wound toilet, and hecting.

HISTORY OF ILLNESS

The pain in the wound area became worst since yesterday. The patient got fever and he couldn’t sleep. He took 1 tablet paracetamol.

HISTORY OF ILLNESS

General Appearance : Good GCS : 15 Illness : moderately sick Blood Pressure : 120/80 mmHg Heart rate : 120 bpm, equal,

regular, strong Respiration Rate : 25bpm Temperature : 36.50C Weight : 28 kg Height : 120 cm

Present Status

Skin : Pale (-), cyanotic (-) Head :

◦ Eyes : anemic conjunctiva -/-, icteric sclera -/-, round pupil, isocor diameter 3mm, direct and indirect light reflex +/+

Neck : no lymph node enlargement Chest : symmetry in shape and movement,

left = right◦ Lung : VBS +/+, rales -/-, Wheezing -/-◦ Heart : regular heart sound, murmur (-)

Physical Examination (15/04/2013)

Abdomen :◦ Inspection : flat◦ Auscultation : Bowel sound (+)◦ Percussion : tympani◦ Palpation : soepel

Genitalia : not examined Extremities

◦ Vulnus scissum post hecting at left foot thumb 3x3 cm Pain (+) Motoric (+) Sensoric (+) Crepitation (-)

Physical Examination (15/04/2013)

◦ Wound : Hyperemis (+) Swelling (+) Pus (+++)

Physical Examination (15/04/2013)

Cellulitis at left foot thumb

Diagnosis

Hematology

Hemoglobine 11.9 ↓ 14.0 – 17.5 g/dL

Hematocrite 35.5 ↓ 45 – 52%

Leukocyte 7,410 4,000 – 13,500 /mm3

Trombocyte 166,000 150,000 – 450,000/mm3

Eritrocyte 4,200,000 4,100,000 – 5,100,000 /mm3

MCV 84 80 – 100 fL

MCH 28 26 – 34 pg/mL

MCHC 34 32 – 36 g/dL

Laboratory Findings15/04/2013

Diff Count

Basophil 0.3 0.0 – 1.0

Eosinophil 3.1 1.0 – 5.0

Neutrophil Stab 0.0 ↓ 3.0 – 5.0

Neutrophil Segmen 61.6 ↑ 25.0 – 60.0

Lymphocyte 18.9 ↓ 25.0 – 40.0

Monocyte 16.1 ↑ 2.0 – 10.0

Laboratory Findings15/04/2013

Clinical Chemical

Blood Glucose 93 60 -100 mg/dL

Laboratory Findings15/04/2013

Vital Sign◦ BP : 120/80 mmHg◦ HR : 120 bpm◦ RR : 25 bpm◦ Temp : 36.50C

Intake : 2120.5 mL◦ Oral : 800 mL◦ IV : 1320.5 mL

Output : 600 mL◦ Urine : 600 mL

Follow Up15/04/2013

Clinic of Surgery◦ Wound toilet◦ Aff Hecting◦ Compress with betadine

Treatment

Abednego◦ Open treatment of the wound◦ Mebo ointment◦ RL 1500 cc/24 hr◦ Ceftriaxone 2x1 gram IV◦ Garamycin 2x20 mg IV◦ Kalmethasone 3x1 cc◦ Norages 3x1 cc

Treatment

Patient with post hecting vulnus scissum a/r digiti I pedis sinistra. He get the wound 4 days ago when he step on the broken glass. 30 minute later, he go to emergency unit and the doctor gave TT injection, wound toilet, and hecting.

Now, the patient feel the more pain on the wound. Yesterday he get fever and take PCT 1 tablet.

Resume

From physical examination, we found :◦ Vulnus scissum post wound toilet-hecting a/r digiti

I pedis sinistra 3x3 cm, pain (+), hyperemis (+), pus (+++), motoric (+), sensoric (+), crepitation (-)

From Laboratory examination on 15th April 2013, we found : Hemoglobine 11.9 g/dL, Hematocrite 35.5%, Diff Count 0.3/3.1/0.0/61.6/18.9/16.1

Resume

Diagnosis◦ Cellulitis post hecting vulnus scissum a/r

digiti I pedis sinistra

Resume

Quo ad vitam : ad bonam Quo ad functionam : ad bonam

Prognosis

DiscussionCellulitis

Cellulitis usually follows a breach in the skin, such as a fissure, cut, laceration, insect bite, or puncture wound. In this case, there is a wound in left foot thumb that can lead the invasion of certain bacteria. The vast majority of cases of cellulitis are likely caused by Streptococcus pyogenes and, to a lesser degree, by Staphylococcus aureus. Organisms on the skin and its appendages gain entrance to the dermis and multiply to cause cellulitis.

Cellulitis

The typical symptoms of cellulitis is an inflammation signs such as red, hot, swelling, and tender at the wound area.

Sign & Symptoms

In this patient: From the history obtained painful, swelling,

hot, and red in the left foot thumb. The pain in the wound area became worst.

The patient got fever yesterday, have yet took a paracetamol, going well

On examination there is Vulnus scissum post hecting at left foot thumb 3x3 cm with painful, good stimuli on sensory and motoric nerve and there is no crepitation. There are swelling, red skin, and a lot of pus in that wound.

The mainstay of therapy remains treatment with appropriate antibiotics, and recovery periods last from 48 hours to six months.

Treatment consists of resting the affected area, cutting away dead tissue, and antibiotics (either oral or intravenous). Pain relief is also often prescribed.

Treatment

In this patient:◦ When he come to surgery clinic, there’s a lot of

pus on his wound and has been hected 4 days ago.

◦ There’s tender, swelling, and red in the infected area.

◦ The doctor release the needlework, and make such as a small incision in addition to make a way out for the pus inside the wound. (from the principal treatment of the pus, ubi pus ibi evacua)

And then the doctor give ceftriaxone and garamycin as antibiotic to eradicate the bacteria, norages and mebo as analgetic to reduce the pain, and kalmethasone to reduce the inflammatory process.

Wim de jong, R. Sjamsuhidayat. 2004. Buku Ajar Ilmu Bedah. EGC edisi 2, hal-326.

Morris, A. 2003. Cellulitis and Erysipelas. Clin Evid 9, 1804-1809.

CREST. 2005. Guidelines on the Management of Cellulitis in Adults. 1-18

References

Thank You..