CASE

REPORT
CLERK馮美鳳
01 基本資料 BASIC DATA

病歷號：28549419
NAME：詹O安

“ AGE&SEX：27y/o、Female
OCCUPATION：businessman
MARITAL STATUS：Cohabit with her girlfriend
ETHNIC ORIGIN：閩南
PLACE OF RESIDENCE：台中市北區
Source of information：Patient
”
02 主訴 CHIEF COMPLAINT

“ Right knee pain for 2 days

”
02
03 現病史
论文结构
PRESENT ILLNESS

8/20 squeezing zits on left knee with hands

left knee erythema and swelling

8/23 CMU ER • Vital sign: 135/78mmHg, 108bpm, 20cpm, 37.2->38℃
• Lab: WBC 13500 w/ seg. 78.5%, hsCRP 7.39
• EKG revealed NSR
Empiric Abx Curam 1.2g/Vial Q8H

pain worsening
• add Clindamycin 300mg Q6H
8/25
02
03 現病史
论文结构
PRESENT ILLNESS

direct smear of pus showed PMN 3+, GPC in cluster 2+,

8/27 with phagocytosis  Staphylococcus
• add Vancomycin 1000mg/Vial Q12H
• stop curam (8/23-27)

Deep pus culture showed S. aureus, MIC test showed

resistant to Clindamycin
• Stop Clindamycin (8/25-8/29)
8/29

Situation improved
Discharge (8th)
8/30 • Fusidate Sodium 500mg TID
Dx : Carbuncle with abscess formation, MRSA isolated
02
03 現病史
论文结构
PRESENT ILLNESS

• squeezing zits on right knee with hands

12/2
• Redness, mild tenderness

• furuncle over the erythematous area

• pain while standing and walking
12/3 • No fever, chills, trauma, overuse, exercise frequently, animal
bites, denied travel Hx, recreational drug use.
CMU ER
• Lab: WBC 12600 w/ seg. 75.8%, hsCRP 1.85
 Vancomycin 1000mg/Vial Q12H
02
03 現病史
论文结构
PRESENT ILLNESS
04 過去病史 PAST HISTORY

“ Nasal septum resection and Nasal polyp excision on MK100

•
•
Post nasal dripping
No specific postoperative sequelae

”
05 社會個人史 SOCIAL & PERSONAL HISTORY

Cigarette smoking：denied
“ Alcohol drinking：denied

Betel nut chewing：denied

Drug abuse：denied
”
06 過敏史 ALLERGIC HISTORY

Food allergy：denied
“ Drug allergy ：denied

Transfusion allergy ：denied

Contact allergy ：dust mites

”
07 家族史 FAMILY HISTORY
08 身體檢查 PHYSICAL EXAMINATION

General appearance
cooperative, well nourished

Consciousness
Clear (E4V5M6)

Vital signs
BP: 117/80 mmHg, T/P/R: 36.9/96/16, SpO2: 99% under room air
Perfusion and oxygenation status： warm limbs, no cyanosis

Integument
Skin：no jaundice, no erythematous change
08 身體檢查 PHYSICAL EXAMINATION

HEENT
Head：normal configuration.
Eyes：no pale conjunctiva, anicteric sclera, no hemorrhages, no petechiae.
Cornea：no scars, no ulcerations. Pupils：isocoric
Ears：no discharge.
Nose：no discharge, no epistaxis, no deformity.
Mouth and Throat
Lips: pink color, no cyanosis.
Mucous membranes/gingivae: no ulceration or pigmentation.
Tongue: no deviation, or ulceration. Pharynx: no tonsils enlargement.
Neck: supple, no motion limited.
Carotid pulses：normal amplitude, no bruits.
Jugular vein：no engorgement
Thyroid：no palpable nodules.
Trachea：central position.
Mass or nodes：not found.
08 身體檢查 PHYSICAL EXAMINATION

Chest
no bilateral coarse and decreased breathing sound, no wheezing or rhonchi

Heart
no tachycardia, no murmur, regular rhythm

Abdomen
soft, no tenderness, no rebounding pain, no muscle guarding
08 身體檢查 PHYSICAL EXAMINATION

Extremities
Upper：no deformity, fracture, atrophy, or weakness, no swelling, no ROM limitation
,
Lower：right pre-patellar region local swelling, erythematous change, tenderness
and one furuncle noted

Joints, Back and Spine

no joints tenderness

Lymphatic system
no palpable lymph nodes in neck, supraclavicular, axillary and inguinal region
09 系統回顧 REVIEW OF SYSTEM

General: no insomnia; no fever; no anorexia; no fatigue; no weakness

Integument: no hair loss; no rash; no pruritus; no change in color;
HEENT:
Head: no headache; no dizziness; no vertigo;
Eyes: normal visual acuity; no diplopia; no pain; normal color vision;
no corrective lenses; no photophobia
Nose: no epistaxis; no discharge; no stuffiness;
, normal sense of smell
Ears: no pain; no discharge; no hearing loss; no tinnitus
Throat: normal status of teeth; normal gums; no dentures; normal taste; no soreness;
no hoarseness; no lump
Respiatory: no wheezing; no hemoptysis; no sputum; no cough
CV: no palpitation; no chest distress/pain; no edema; no dyspnea; no intermittent claudication;
no cold limbs; no paroxysmal nocturnal dyspnea; no orthopnea
09 系統回顧 REVIEW OF SYSTEM

GI: no abdominal distress pain; no vomiting; no nausea; no change in bowel habit;

no hematemesis; no melena; no blood in stools; no dysphagia
Metabolic and endocrine: no nervousness; no heat/cold intolerance; no weight change;
no growth and development; no sweating; no polydipsia
GU: no dribbling; no urgency; no hesitancy; no incontinence; no dysuria; no hematuria;
no nocturia; no polyuria; no urinary frequency;
Hematotologic: no easy brusity or bleeding; no
, lymphadenopathy; no anemia
Neuropsychiatry: no dizziness; no paresthesia; no depression; no irritablility; no ataxia;
no syncope; no speech disturbance; no weakness or paralysis; no seizures;
no tremor; no loss of sensation; no anxiety
Musculoskeletal: Joint pain;right knee local swelling and pain; no wasting; no stiffness;
no limitation of motion; no muscular weakness
02
10 住院
论文结构
AFTER ADMISSION

• check superficial pus culture & Deep pus culture

12/4
Keep Vancomycin 1000mg/Vial Q12H

• Vancomycin trough level: 8.2

12/6  Vancomycin 1250mg/Vial Q12H

discharge
Doxycycline and Fusidate Sodium
Dx: Prepatellar bursitis, right knee
12/9
02
10 住院
论文结构
AFTER ADMISSION

• check superficial pus culture & Deep pus culture

12/4
Keep Vancomycin 1000mg/Vial Q12H

• 報告內容:
嗜氧報告：Staphylococcus aureus(MRSA)
Antimicrobial MIC (ug/ml)
• R :Penicillin(P) >1
• Vancomycin trough level: 8.2
12/6 • R :Oxacillin(OX) >4

•
Vancomycin 1250mg/Vial Q12H
R :Erythromycin(E) >4
• R :Clindamycin(CC) >2
• S :Vancomycin(Va) <=1
• S :Teicoplanin(TEC) <=1
• S :Linezolid(LZD) <=1
• S :Daptomycin(DAP) <=1
• S :Tetracycline(TE) <=0.5
• S :Doxycycline(D) <=0.5
•discharge
S :Trimethoprim/Sulfamethoxazole(SXT) <=1/19
•Doxycycline and Fusidate
R :Ciprofloxacin(CIP) >2 Sodium
•Dx:SPrepatellar
:Fusidic Acid(FA) <=1right knee
bursitis,
12/9 • Gram's stain:Gram Positive Coccus
• 厭氧報告：
• 參考值：No growth
02
10 住院
论文结构
AFTER ADMISSION

• check superficial pus culture & Deep pus culture

12/4
Keep Vancomycin 1000mg/Vial Q12H

• Vancomycin trough level: 8.2

 Vancomycin 1250mg/Vial Q12H
12/6
• Glucose AC: 100mg/dL

檢驗項目 報告內容 單位 參考值

WBC: 7.0 x10^3/ul (3.6-11.2)
Hb: 13.1 g/dL (男:13.7-17.0
女:11.1-15.0) 檢驗項目 報告值 單位 參考值
Platelet: 252 x10^3/ul (130-400) SGPT(ALT): 18 IU/L (5-40)
Diff. Count Total Bilirubin: 0.4 mg/dL (0.2-1.3)
Neutrophilic Segment: 59.7 % (43.3-76.6) BUN: 10 mg/dL (5-26)
Lymphocytes: 25.4 % (16-43.5) Creatinine: 0.56 mg/dL (男性:0.6-1.3；女性0.4-1.1)
Monocytes: 7.3 % (4.5-12.5)
discharge GFR: 129 mL/min/1.73㎡ (>90)
Eosinophils: 6.3 % (0.6-7.9)
Doxycycline andhsCRP:
Fusidate Sodium 0.49 mg/dL (<0.8(-))
Basophils: 1.3 % (0.2-1.4) Sodium(Na): 138 mmol/L (135-147)
N.Bands: % Dx: Prepatellar bursitis, right knee
12/9 Potassium(K): 3.8 mmol/L (3.5-4.9)
Metamyelocytes: %
Myelocytes: %
Promyelocytes: %
Blasts: %
02
10 住院
论文结构
AFTER ADMISSION

• check superficial pus culture & Deep pus culture

12/4
Keep Vancomycin 1000mg/Vial Q12H

• Vancomycin trough level: 8.2

12/6  Vancomycin 1250mg/Vial Q12H

• discharge
Doxycycline and Fusidate Sodium
Dx: Prepatellar bursitis, right knee
12/9
• Rheumatoid factor (RF)
CELLULTIS
CLERK馮美鳳
01 概述
INTRODUCTION
01 概述 INTRODUCTION

• acute inflammatory condition of the skin

• Cellulitis, abscess, or both are among the most common skin and soft
tissue infections
• manifests as an area of skin erythema, edema, and warmth
• nearly always unilateral, and the lower extremities are the most
common site of involvement
01 概述 INTRODUCTION

may be caused by
• indigenous flora colonizing the skin and appendages
(e.g., S. aureus and S. pyogenes)
• by a wide variety of exogenous bacteria
02 流行病學
EPIDEMIOLOGY
02 流行病學 EPIDEMIOLOGY

• most frequently among middle-aged individuals and older adults.

• Erysipelas occurs in young children and older adults
• The incidence of cellulitis is about 200 cases per 100,000 patient-years
• Skin abscess may occur in healthy individuals with no predisposing
conditions.
02 流行病學 EPIDEMIOLOGY

Predisposing factors
• trauma (such as abrasion, penetrating wound, pressure ulcer, venous
leg ulcer, insect bite, injection drug use)
• Skin inflammation (such as eczema, radiation therapy)
• Edema due to impaired lymphatic drainage, venous insufficiency
• Obesity
• Immunosuppression (such as diabetes or HIV infection)
• toe web intertrigo
• Preexisting skin infection (such as tinea pedis, impetigo, varicella)
03 微生物學
MICROBIOLOGY
03 微生物學 MICROBIOLOGY

• Access including cracks in the skin, abrasions, cuts, burns, insect bites,
surgical incisions, and IV catheters.
• most commonly
 group A Streptococcus ; Streptococcus pyogenes
 S. aureus (including methicillin-resistant strains)
• Minority: Gram-negative aerobic bacilli
03 微生物學 MICROBIOLOGY

• Staphylococcus aureus
 focal infection
(such as a furuncle, a carbuncle, a surgical wound, or an abscess)
 purulent cellulitis
• group A Streptococcus ; Streptococcus pyogenes
 more rapidly spreading
 frequently associated with lymphangitis and fever
 nonpurulent cellulitis
03 微生物學 MICROBIOLOGY

• Pathogens implicated in special clinical circumstances

 cat bites : Pasteurella multocida
 dog bites and human bites : Capnocytophaga canimorsus, anaerobic
streptococci, Staphylococcus intermedius
 human bites : Eikenella corrodens
 Penetrating trauma (EX. nails) : Pseudomonas
 Salt water : Vibrio vulnificus
 freshwater : Aeromonas hydrophila
 fish and domestic swine : Erysipelothrix rhusiopathiae
03 微生物學 MICROBIOLOGY

• Streptococcus agalactiae occurs primarily in elderly patients and those

with diabetes mellitus or peripheral vascular disease
• Haemophilus influenzae typically causes periorbital cellulitis in children
in association with sinusitis, otitis media, or epiglottitis.
04 臨床表現
CLINICAL MANIFESTATIONS
04 臨床表現 CLINICAL MANIFESTATIONS

• skin erythema, edema, and warmth

• Fever may be present
• nearly always unilateral, and the lower extremities are the most
common site of involvement
• bilateral involvement should prompt consideration of alternative
causes
05 診斷
DIAGNOSIS
05 診斷 DIAGNOSIS

• Based upon morphologic features of the lesion and clinical

manifestation
• Gram’s stain and culture provide a definitive diagnosis
• needle aspiration or a punch biopsy, cultures are positive in only 20%
of cases.
• Radiographic examination can be useful to determine whether a skin
abscess is present and for distinguishing cellulitis from osteomyelitis
06 治療
TREATMENT
06 治療 TREATMENT

• nonpurulent infection : empiric antibiotic therapy

• drainable abscess : undergo incision and drainage. In addition,
antibiotic therapy is warranted if clinical criteria are met
• purulent cellulitis : antibiotic therapy
 復發性蜂窩組織炎
07 RECURRENT CELLULITIS
07 復發性蜂窩組織炎 RECURRENT CELLULITIS

Staphylococcal
• eosinophilia and elevated serum levels of IgE (Job’s syndrome)
07 復發性蜂窩組織炎 RECURRENT CELLULITIS

Streptococcal
• may be caused by organisms of group A, C, or G with chronic venous
stasis or with saphenous venectomy for coronary artery bypass surgery.
• chronic lymphedema resulting from elephantiasis, lymph node
dissection, or Milroy’s disease
07 復發性蜂窩組織炎 RECURRENT CELLULITIS

Recurrent Abscess
• Anatomic defect
• Crohn disease
• Acquired immunosuppressive conditions (such as diabetes or HIV
infection)
• drug abuse
• CA-MRSA
 回顧
08 REVIEW
08 回顧 REVIEW

27y/o female denied any systemic disease

Denied drug use, TOCC Hx,
• 8/23-8/30 discharge
 Carbuncle with abscess formation,
Surgery Hx (exc. Nasal surgery)
MRSA isolated
 Under Curam (8/23-27), Glucose AC: 100mg/dL
Clindamycin(8/25-29),  Rule out Diabetes
Vancomycin(8/27-30)
• 12/3-12/9 discharge
 Prepatellar bursitis, right knee Knee sono, RF factor
 Under Vancomycin(12/3-12/8)
06 參考資料
REFERENCE

• Harrisons Principles of Internal Medicine, 19th Edition

• …
THANKS!