DISCHARGE
SUMMARY
A.D, 58 YEARS, MALE,
Diagnosis: spine
infection 3 months post PLIF
Treatment:
Non operative (antibiotics)
Background
Presenting Information:
The above-named patient is a known patient of this facility;
He had a L5/S1 posterior lumbar interbody fusion on account of L5/S1
degenerative disc disease about 3 months ago. He subsequently developed
surgical site collection of hematoma and serosanguinous fluid which required
wound washout twice before complete wound healing. He has enjoyed a relatively
uneventful recuperation following discharge 2 months ago.
However, he represented on the 13/01/2023 with
complains of sudden onset radicular low
back pains, following some domestic exertion, and associated with fever,
headache, generalized weakness and difficulty in walking. He describes the pain
as sharp, constant, aggravated by sitting and walking. Pain was severe - VAS
score of 9.
Admitting
vital signs: PR: 104B/M BP: 150/100mmhg, RR: 24C/M,
Spo2:94%RA
On
examination: in moderate painful distress, not pale,
anicteric, febrile (39.0), previous scar seen on midline of the back. Full power
in lower limbs, normal bowel and bladder functions. Previous midline lumbar
spine scar was noted to have healed completely, with no evidence of discharge
or swelling but exquisitely tender on deep palpation and differential warmth.
Blood Investigations on admission - 14/01/2023 suggest
clearly an inflammatory process on going
·
FBC – WBC- 15.12, PCV-38 %, PLT- 313.
·
MP: positive
·
CRP: > 200
Imaging – L/S CT scan done (14/01/2023) showed L5/S1 screws and intervening cage in place with no evidence of instability(See image below)
MRI(L/S) 16/01/2023 below did not show any convincing
evidence of paraspinal abscess but obvious post surgical changes
Based on the above clinical, laboratory and imaging
findings, a late onset paraspinal inflammation was suspected but to rule out
any infection. And he was placed on the following medications immediately
·
IM emal 150mg dly for 3 days
·
IV rocephin 1G 12hrly for 2 weeks
·
IV vancomycin 750mg 8hrly for 2 weeks
·
IV tramadol 50mg 12hrly x 72hrs
·
IV PCM 600mg 8hrly x 72hrs
·
Supp diclofenac 100mg 12hrly x 1 week
·
Tab Omeprazole 20mg bd x 1/52
·
IV pentidine 50mg PRN
·
Tabs lyrica 75mg 12hrly
Follow up Lab Investigations: 16/01/2023 reveals that
CRP is still significantly high but the WBC was on decline. He was to continue
the IV antibiotics for at least two weeks and then to switch over to oral
antibiotics for another 4 weeks.
FBC: WBC: 11.25, PCV: 38% PLT: 198
CRP: > 200Mg/l
EUCR: Na: 136.7, K: 3.8, CL: 108 Urea: 21, Creatinine:
0.36
Lab Investigations : 20/01/2023
CRP: > 200 mg/l
Lab Investigations: 23/01/2023
FBC: WBC: 12.1 PCV: 38.9 PLT: 470
CRP: 127 Mg/l
EUCR: Na: 140 K: 4.92 CL: 107.8 CR: 0.61 Urea: 39.75
Update
30/01/2023
Following the completion of 14days of IV Vancomycin
and IV Rocephin today his clinical condition improved although was still having
mild intermittent fever. Inflammatory markers showed reduction from previously
elevated values. CRP was noted on the down ward trend. He was not quite
ambulant and tolerating physiotherapy much better. He will continue tab Zinnat
500mg bd for another 4 weeks
Lab Investigations: 30/01/2023
FBC: WBC: 6.71 PCV: 40.02 PLT: 282
EUCR: Na: 139 K: 4.46 CL: 107.2 Urea:19.37 Cr: 0.72
CRP: 107mg/l
A check L/S MRI 30/01/2023 still did not reveal any evidence of paraspinal abscess
MRI L/S done revealed no ring enhancing lesion on the
contrasted T1 SAG view
Update (01/02/2023)
Clinically, he has improved significantly as low back
pain has reduced and he is currently walking without much difficulty.
MRI L/S showed reducing inflammation compared to
previous MRI done on the 16/01/2023 and no obvious sign of abscess collection.
CRP, FBC, inflammatory markers which were previous
elevated has been on the downward trend.
He is to continue Tab Zinnat 500mg bd for the next 4 weeks,
serial blood test and for possible discharge. It is however recommended that he
should not return to Makurdi just yet due to probable uncomfortable bad roads,
long journey time and the overwhelming need for him to stay closer to the
hospital for ease of access to follow up visits until the expiry of his
treatments in about 4 weeks. A nearby apartment or Hotel is highly recommended
for your considerations and please
contact us again for any further clarifications.
Discharge medications:
·
Tabs Zinnat 500mg twice daily for 3 weeks
·
Tabs lyrica 150mg dly
·
Tabs chymoral 2 tablets three times daily
for 3 days
·
Tabs vitamin c 1000mg twice daily for 9
days
Discharge instructions
·
Should have adequate rest and avoid
strenuous activities
·
Regular light exercises
·
Healthy lifestyle and drink about 3 liters
of water in a day.
UPDATE (6/04/2023)
Continued to have back and leg pain. Shocking in
nature and marginal relieve with neuropathic medications. Seal dose of
gabapentin. Still has low back and waist pains but normal full power both upper
and lower limbs. Normal bowel and bladder functions.
Check CT lumbosacral spine shows implant in place but
S1 implant (pedicle screws) seen to have a halo around the distal half. Most
importantly, the healing and fusion progess is satisfactory but it appears as
though he is reacting to or not tolerating the implant. Therefore, need to
review with a view to remove the implant when healing is very satisfactory and
discuss with the patient.
Plan:
·
Tabs Zinnat 500mg bd x 1/12
·
To see in four weeks time.
Dr
Oseni Somina MD
For Team Wellington Clinics Abuja
----------electronically signed to prevent delay in transmission.