Name No.

RM Age Sex Nationality Examination Date

: : : : : :

Galih Saputra 00461307 10 years old Male Indonesian April 15th 2013

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.

The pain in the wound area became worst since yesterday. The patient got fever and he couldnt sleep. He took 1 tablet paracetamol.

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

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 (-)

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 (-)

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

Cellulitis at left foot thumb

Hematology Hemoglobine
Hematocrite Leukocyte Trombocyte Eritrocyte MCV MCH MCHC

11.9
35.5 7,410 166,000 4,200,000 84 28 34

14.0 17.5 g/dL

45 52% 4,000 13,500 /mm3 150,000 450,000/mm3 4,100,000 5,100,000 /mm3 80 100 fL 26 34 pg/mL 32 36 g/dL

Diff Count Basophil

Eosinophil Neutrophil Stab Neutrophil Segmen Lymphocyte Monocyte

0.3
3.1 0.0 61.6 18.9 16.1

0.0 1.0
1.0 5.0 3.0 5.0 25.0 60.0 25.0 40.0 2.0 10.0

Clinical Chemical Blood Glucose 93 60 -100 mg/dL

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

Clinic of Surgery
Wound toilet Aff Hecting Compress with betadine

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

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.

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

Diagnosis
Cellulitis post hecting vulnus scissum a/r digiti I pedis sinistra

Quo ad vitam Quo ad functionam

: ad bonam : ad bonam

Cellulitis

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.

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

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.

In this patient:
When he come to surgery clinic, theres a lot of pus on his wound and has been hected 4 days ago. Theres 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