CASE PROTOCOL WOUND DEHISCENCE SECONDARY TO SURGICAL SITE INFECTION, S/P LSCS II

GENERAL DATA This is a case of Y.D.., a 31-year old female, Buddhist, Filipino, married, from Novaliches Quezon City, born on November 27, 1980 who was admitted at our institution last April 28, 2012.

CHIEF COMPLAINT: Hypogastric pain

HISTORY OF PRESENT ILLNESS: Two weeks prior to admission, patient underwent LSCS II (April 13, 2012). Patient had an unremarkable stay at the hospital. Patient was discharged stable with no subjective complaints. 11 days prior to admission, patient experienced hypogastric pain, nonradiating, not associated to food intake. Patient also complained of pain at the post-op site and undocumented fever, Patient consulted her AMD and was given unrecalled antibiotic twice daily for 7 days. One day prior to admission, patient noted persistence of the above symptoms. Patient consulted her AMD for removal of sutures. Pus was noted from the incision site. No medications were given. Few hours prior to admission, due to persistence of the above symptoms, patient consulted her AMD and was advised admission

PAST MEDICAL HISTORY: (-) Hypertension, diabetes mellitus II, bronchial asthma (-) Allergies (+) s/p LSCS II (April 13, 2012)

FAMILY HISTORY (-) Hypertension, DM, bronchial asthma, thyroid disease

OB HISTORY G3P3 (3-0-0-3) s/p LSCS II (1x due to malpresentation)

PHYSICAL EXAMINATION: Conscious, coherent, ambulatory, not in cardiorespiratory distress BP: 110/70 mmHg CR: 74/min RR: 20 /min T: 36. 5

Pink palpebral conjunctivae, anicteric sclerae Supple neck, no palpable cervical lymph nodes Symmetrical chest expansion, no retractions, clear breath sounds Adynamic precordium, normal rate, regular rhythm, no murmurs Flabby, midline vertical incision on hypogastric area, NABS, soft, no tenderness No gross deformities, full and equal pulses

ADMITTING DIAGNOSIS: Wound dehiscence secondary to surgical site infection, rule out intraabdominal infection s/p LSCS II (April 13, 2012)

COURSE IN THE WARD: Upon admission, patient was placed on NPO temporarily and venoclysed with PLR 1L to run for 8 hours. The following work-ups were done: CBC with platelet count, urinalysis, serum electrolytes, BUN, creatinine, FBS, HbA1c. The following medications were started: Co-Amoxiclav 600mg IVT (Bactin) every 6 hours, Ranitidine 50 mg IVT (Ulcin) every 8 hours, Tramal 50 mg IVT every 12 hours. Daily change of dressing with fucidin ointment was done. On the 3rd hospital day, wound culture with ARD was requested and done. Previos IVF was decreased to run for 16 hours. Previous medications were continued, Patient was referred to the service of Ob-Gyn for further evaluation and management. On the 5th hospital day, patient underwent wound debridement under local anesthesia with IV sedation. Intraoperatively, abscess was noted at the subcutaneous tissue down to the muscle and granulation tissue. Patient tolerated the procedure well. Patient was clinically stable and vital signs were normal. Post-operatively, tramal 50 mg was incorporated to D5LR 1L and regulated to run for 12 hours. Previous medications were continued. Patient was also given Nubain 1 mL + 2 cc PNSS, 1 mL IVT every 6 hours and diazepam (valium) 5 mg/tab STAT. Daily change of dressing with fucidin ointment was done. Patient was then placed on diet as tolerated. On the 9th hospital day, patient complained of minimal to moderate post-op site pain. Vital signs were stable and normal. D5LR 1L + Tramal 50 mg was decreased to run at KVO rate. Co-Amoxiclav 600mg IVT (Bactin) every 6 hours was continued. Ranitidine, Tramal 50 mg IVT and Nubain were discontinued. On the 11th hospital day, drainage catheter was removed. IVF was shifted to PLR IL + 50 mg Tramal to run at KVO rate. The rest of the hospital stay was unremarkable. Patient was discharged stable and improved on the 13th hospital day.

FINAL DIAGNOSIS: Wound dehiscence secondary to surgical site infection s/p LSCS II

OPERATIVE PROCEDURE: Wound debridement LABORATORIES CBC 04/28/12 Hgb HCT RBC Platelet WBC Segmenters Lymphocytes Monocytes Eosinophils 127 0.37 4.04 508 7.0 0.51 0.37 0.09 0.03 Ref. Range 120-160 0.37-0.54 4.0-5.4 150-400 5.0-10.0 0.55-0.70 0.25-0.40 0.02-0.08 0.01-0.06

Blood Chemistry 04/29/12 FBS HbA1c BUN Creatinine Sodium Potassium 77.63 5.82 19.66 0.59 139 4.50 Reference range 70.7-116.0 4.80-5.90 7.79-21.40 0.48-1.17 138-145 3.80-5.50

Wound Culture and Sensitivity (5/3/12) No growth after 3 days of incubation

Urinalysis 05/02/12 Color: Transparency: Reaction: Sp Gr: Protein: Sugar : RBC : Pus : Bacteria : Hyaline Casts : 04/28/12 Yellow Turbid 5.0 1.015 Negative Negative 4-8 30-35 moderate none 05/02/12 Light yellow Clear 7.0 1.010 negative negative 0-2/HPF 0-4/HPF few none

PATHOLOGY 05/02/12 Patho No. 2012-1341 Diagnosis: Skin with ulceration, acute and chronic inflammation, foreign body type reaction involving up to subcutaneous tissue.