CASE STUDY

PATIENTS NAME : CLAUDINE

AGE : 58 years old SEX : Female BIRTHDAY : May 14, 1946 BIRTHDAY PLACE : Boracay

CHIEF COMPLAINT:

Difficulty opening mouth & Jaw discomfort

One month prior to consult, patient tried to pull an ingrown toe nail by herself with an old, rusty nipper as described by the patients relatives, causing injury to the patients left foot. She was cleaning her toenails when she accidentally got cut at the peri-ungal area on the 1st digit of her left foot. No medications were taken and no consult was done. No other symptoms noted at that time.

Several days after the incident, while the patient was gardening barefooted; one of the patients grandson, accidentally stepped on her injured toenail. The patient noticed the open wound was soiled accidentally; she then rubbed off the soil particles off her toes.

About 3weeks prior to consult, patient complained of recurrent ear pain with minimal discharge. She consulted with an ENT who gave her antibiotic ottic drops. No manipulation of the ear was done. Patient did not complain of any other signs and symptoms.

 One

week prior to consult, patient experienced muscular spasm and cramp like pain on her lower extremities. Patient disregarded the symptoms and did not seek consult. No medications to relieve the pain and spasm were taken.

 Hypertensive

for unknown years Range of BP: 160/100 150/90 mmHg History of Surgical Operations: - Head surgery (1970. 2x)

 She

had received her primary tetanus series in childhood And her last booster was definitely more than 10 years ago.

 125/70 mm Hg Temperature 37C

BP

 Patient

unable to open her jaw wider than 1

inch Muscular spasm and cramp like pain on her lower extremities Stiffness of the neck Lung sounds were clear. Heart sounds were within limits. No murmurs Left big toe shows a raise 5cm erythematous circumferential lesion with a centrally granulated wound.

 Doctors

diagnose tetanus base on the clinical signs and symptoms only. diagnosis is not useful as the C. tetani bacteria usually cannot be recovered from the wound of an individual who has tetanus

Laboratory

 Hydrogen

peroxide was applied to the area and 3ml of 1% lidocaine was injected around the lession. The wound was surgically debrided of all necrotic tissues and debris with a scapel & copiously irrigated with normal saline. A wick was inserted for drainage, and the wound was allowed to drain and to close by secondary intention

 The

patient was counseled about the diagnosis of tetanus with secondary infection and the need for hospital admission. The patient refused, so he was advised about all the possible sequelae of the disease including death. Still the patient requested to be treated as an outpatient with admission on if symptoms worsened

Two doses of human anti tetanus immunoglobulin (hyper-tet 250 u) was injected in the upper outer quadrant of each buttocks. Patient was given a 0.5mg tetanus-diphtheria booster into the left deltoid muscle. Mentronidazole, 500mg orally 4times per day was prescribed for 10days. Patient was instructed to go to hospital if jaw stiffness worsened or a temperature ensued or if ability of swallowing or any other spasm or symptom occurred.

 Patient

was free of symptoms. Afebrile, no progression of symptoms Trismus had resolved completely

 Patient

was totally asymptomatic Wound had stopped draining Erythematous circumferential lesion was fading But temperature was 37.5C The wick was removed Wound was copiously irrigated with normal saline and left open to heal Wound was dressed

 Patient

to continue with the metronidazole four times a day. Ciprofloxacin, 250mg orally two times a day, was added for secondary infection of the wound from staphylococcus or sterptococcus organism Mupirocin to apply to the wound after peroxide dabs and told to return for follow up visit in 4days.

 Patient

asymptomatic Afebrile Wound was clean, dry, granulated without erythema Patient was told to finish 10day supply of metronidazole and ciprofloxacin And return if symptoms reappreared.