Fracture shaft of Femur：股骨干骨折

1、Extern ConferenceOphthalmia NeonatorumA 17-day-old female term newbornCC: purulent discharge from Rt eye for 3 daysPI: 7 d PTA, Rt eye showed whitish-grey watery discharge and tear but no eyelid swelling was detected. 3 d PTA, Rt eyelids were red and swelled with occasional bloody-purulent discharge

2、.She was treated by topical ATB and eye irrigation with sterile water but these symptoms did not improve.She had no fever, no drowsiness, no URI symptoms. She was breast-fed well.Case presentationBirth history: G1P0A0, GA 38 wks, NL, Apgar 10,10 BW 3,090 g, length 50 cm, HC 33 cm There was no compli

3、cation after delivery.History of pregnancy: serology : neg no maternal history of STDamniotic membrane ruptured 7 hr before deliverymother had no fever or vaginal discharge. Family history: no genetic or contagious diseaseNo history of drug allergyVaccine: BCG, HBV1HistoryPhysical examinationBW 3,70

4、0 g (P50-75), length 54 cm (P75-90). HC 35 cm (P50)V/S: T 36.8C, P 168/min, R 40/min GA: active and non-toxic child, not irritable, not pale, no jx, no dyspnea, no signs of dehydrationHEENT: pharynx and tonsils are not injected Rt eye: red and mildly swollen eyelid, marked conjunctival injection wit

5、h purulent and bloody discharge, clear cornea, EOM and VA cannot be evaluated Lt eye : normal Physical examinationCVS: normal S1, S2, no murmur RS: normal breath sound, no adventitious soundAbd: soft, not tender, no hepatosplenomegalyNS: normal movement, Brudzinskis sign negativeProblem list1. Unila

6、teral purulent discharge (Rt eye)2. Mild eyelid swelling with marked conjunctival injection (Rt eye)Differential DiagnosisOphthalmia neonatorum (neonatal conjunctivitis)Neonatal dacryocystitisPeriorbital cellulitisOphthalmia neonatorum: in this patientPros Age of onset Clinical symptoms Most common

7、cause in newbornCons No history of maternal infection or vaginal discharge Differential Diagnosis-Schachter, J, Grossman, M. Chlamydia. In: Infectious Diseases of the Fetus and Newborn, 5th ed, Remington, JS, Klein, JO (Eds), WB Saunders, Philadelphia 2001. p.769. -de Toledo AR, Chandler JW: Conjunc

8、tivitis of the newborn. Infect Dis Clin North Am1992 Dec; 6:807-13Neonatal Dacryocystitis onset 2-4 wk Tenderness & swelling in medial canthal region Epiphora most prominent purulent D/C from puncta, cellulitis, conjunctivitis, Differential Diagnosis Epiphora was not eminent No tenderness & swelling

9、 in medial canthal regionIn this patientLang, Gerhard K., Ophthalmology: a short textbook, 2000 Georg Thieme Verlag, GermanyPeriorbital cellulitis Local spread (preceded with URI) Acute eyelid erythema and edema Pain, epiphora fever, conjunctivitis,Differential DiagnosisIn this patient Mild eyelid e

10、dema No Hx of URI, hordeolum, bug bite, trauma Discharge more prominent than swellingMalinow I, Powell KR: Periorbital cellulitis. Pediatr Ann 1993 Apr; 22:241-6 , leukocytosisCausesClinical symptomsAssociated findingsNeonatal conjunctivitisMaternal infectionDischarge, conjunctivitisMaternal STDNeon

11、atal dacryocystitisObstruction of lacrimal systemEpiphora, tenderness at epicanthal regionNasal diseasesPeriorbital cellulitisLocal spreadMarked eyelid edemaURIDifferential DiagnosisApproaching pediatric conjunctivitisHistory Maternal/paternal infection during pregnancy esp. STD Onset, severity, cha

12、racters of discharge Associated symptoms, preceding illness Possible causes of illness (trauma, bug bites)Physical examination eyelid eversion: hyperemia, follicles, papillae, membranes Characters and amount of discharge (purulent, mucoid, watery, bloody) Detailed eye exam if possible (EOM, VA, pupi

13、llary reaction, proptosis) Preauricular lymphadenopathy Systemic manifestation (fever, pneumonia, sinusitis, meningitis, arthritis)Approaching pediatric conjunctivitisOphthalmia neonatorumOphthalmia neonatorumNeonatal conjunctivitis during the first moAseptic chemical: silver nitrateSeptic bacteria,

14、 chlamydia, virusSeptic neonatal conjunctivitisNeisseria gonorrhoeae (GC) most seriousChlamydia trachomatis most commonNon-gonococcal, non-chlamydialAcquire during passing through the birth canalIncidenceOne of the most common eye disease in neonate Incidence ranging from 1.6-12.0%Weiss AH. Conjunct

15、ivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infectious disease, 2003, pp 486-89.Clinical presentationCommon findings:erythema and edema of the eyelidsconjunctival injectionchemosiswatery to purulent eye dischargeMore specific findings for

16、different causative agentsClinical presentationSilver nitrateGCChlamydiaHerpesOnsetDay 1Day 3-5Day 5-14Day 6-14CharacterTransient, disappear in 2-4 daysHyperacute, purulentAcute, varying in severityCorneal epith defectsAffected eyeBilatBilatUni or bilatUni or bilatCorneal involvementNoEdema, ulcer,

17、perforationNo(eyelid scarring, pannus)Geographic ulcersExtraocularNoMaybeMaybe (pharyngeal colonization, pneumonitis, otitis)Vesicles on the skin or lid margin, othersAdapted from: Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediat

18、ric infectious disease, 2003, pp 486-89.InvestigationWhen to perform?Look more severePersist than 2-3 days or progressFirst appear after the first day of lifeCited from: Weiss AH. Conjunctivitis in neonatal period. In Long S, Pickening LK, Prober CG (eds): Principle and practice of pediatric infecti

19、ous disease, 2003, pp 486-89.Gram stainconjunctival exudateHistologic studyOphthalmia neonatorumChemical conjunctivitisBacterial conjunctivitisChlamydial conjunctivitisGram stainneutrophils, lymphocytesneutrophils, bacterianeutrophils, lymphocytes, plasma cellsProvisionaldiagnosisGonococcal infectio

20、nInvestigation for Chlamydial infectionConjunctival scraping for chlamydiaGiemsa stains from lower conjunctivaintracytoplasmic inclusion bodiesDo not collect from ocular discharge aloneCultureNon-culture methodDirect immunofluorescent antibody assayNucleic acid amplification tests (PCR)Chlamydial in

21、clusion bodyManagement1. If there are systemic symptoms, admit the patient for specific treatments and further investigation 2. Laboratory investigations include discharge G/S, cultures3. IV or IM third-generation cephalosporin should be given before laboratory results 4. Topical ATB is not necessar

22、y5. Consult ophthalmologistSpecific treatment1. Gonorrhea conjunctivitis (non-disseminated) Admit and separate patient from other babies Ceftriaxone 25-50 mg/kg/day IM single dose not to exceed 125 mg. Irrigated with NSS frequently until discharges disappear Treat parents 2. Chlamydia conjunctivitis

23、 Erythromycin oral 50 mg/kg/day qid for 14 days 0.5% erythromycin ointment tid/qid for 3 wks (unnecessary but may be adjunctive) Irrigated with NSS frequently until discharge disappear Treat parents Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed.ProphylaxisBaby that born from

24、 Gonorrhea-infected motherCeftriaxone 25-50 mg/kg/day (max 125 mg) IM single dose stat or aqueous pen-G 100,000 U IV single doseThe American Academy of Pediatrics and the U.S. Centers for Disease Control(CDC)1% silver nitrate solution0.5% erythromycin ointment1% tetracycline ointmentRed Book: 2006 R

25、eport of the Committee on Infectious Diseases. 27th ed.16/4/50 (Day 1)Admit (consult ophthalmologist: r/o orbital cellulitis)Observe clinical signs: sepsisRE: mild lid swelling, not tensed, erythema; conjunctival injection with chemosis; purulent bloody discharge wih pseudomembrane, full EOMProgress

26、ion16/4/50 (cont.) Investigation G/S of discharge: numerous PMN, no organism Giemsa staining of conjunctival scraping: pending Discharge culture for GC, bacteria, Chlamydia trachomatis: pending CBC: Hb 12.7 g/dL Hct 38.1% WBC 11640/mm3 N30.5% L 49.7% M16.2% E3.4% B0.2% plt 343000/mm3Progression16/4/

27、50 (cont.)Imp: Ophthalmia neonatorum, suspected C. trachomatis conjunctivitisStart ATB covering GC and ChlamydiaCeftriaxone 50 mg/kg/day iv over 30 min, single doseErythromycin Syr 50 mg/kg/day for 14 daysTopical ATB : erythromycin ed. (Tobrex ed. instead)Evaluate and treat mother OPD GynaeProgressi

28、on17/4/50 (Day 2)S: active child, afebrileO: RE: eyelid swelling, soft; conjunctival injection with chemosis; purulent bloody discharge; normal corneaA: not worseP: continue treatment18/4/50 (Day 3)Giemsa stain (16/4/50): not appropriate specimenRepeated conjunctival scaping for GiemsaZymar (Gatiflo

29、xacin) ed to RE q 2 hr (12.5 MKdose)Progression19/4/50 (Day 4) Afebrile RE: eyelid not swelling, conjunctiva-mildly injected, small amount of discharge, clear cornea Plan F/U OPD eye 1 week, with Giemsa stain resultProgressionNB with conjunctivitis are at risk of systemic infectionHx of mother (ANC, STD, perinatal Hx) and childComplete PETreat for GC if it cannot be ruled out and admit if there is evidence of systemic infection.Pres