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CASE STUDY #1

CASE STUDY #1. DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND. The Patient. 55 years old Female Married 5 children 22 grandchildren Non-smoker. CO-MORBIDITIES Diabetic Hypertension Coronary Artery Disease Hyperlipidemia Probable Sleep Apnea Obesity. Treatment Course.

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CASE STUDY #1

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  1. CASE STUDY #1 DEHISCED STERNAL MUSCLE FLAP, DEHISCED LEG, ABDOMINAL WOUND

  2. The Patient 55 years old Female Married 5 children 22 grandchildren Non-smoker

  3. CO-MORBIDITIES • Diabetic • Hypertension • Coronary Artery Disease • Hyperlipidemia • Probable Sleep Apnea • Obesity

  4. Treatment Course Bypass Surgery 10/01 Dismissed from hospital 10/04 Sternal Wound and Donor Site Infection- Readmitted 10/28 Incision and debridement of leg and sternum - sternum removal 11/06 Closure of chest with muscle flap Debridement of leg wound 11/14 Transferred to NHS Clarkson Hospital 12/05 Hyperbaric Oxygen Treatments Initiated 12/06 Debridement of Sternal/chest/leg wounds - VAC Therapy Initiated 12/12

  5. Treatment Course Debridement of sternal and leg wounds - abdominal wound 01/13 STSG to sternal and leg wounds with VAC therapy 1/20 Transferred from acute care to sub-acute rehab unit 02/05

  6. sternum leg rectus TRANSFERRED TO NHS 12/05 Sternal muscle flap and donor site are open Lower leg is dehisced and infected

  7. sternum leg rectus STERNAL, RECTUS AND LEG WOUNDS IMPROVE QUICKLY 12/12 Use of HBO and VAC therapy along with Multi-disciplinary approach

  8. leg rectus sternum abdomen STERNUM AND LEG GRANULATE ABDOMINAL WOUND DEBRIDED 01/13 Abdominal wound measures 15x10x4cm

  9. sternum leg abdomen SKIN GRAFT TO STERNUM AND LEG 1/20 VAC therapy replaced post skin graft for 5 days

  10. sternum leg COMPLETE TAKE ON SKIN GRAFTS TO LEG AND STERNUM 1/26 At first dressing change grafts have 100% take

  11. abdomen ABDOMEN CONTINUES TO HEAL 2/5 Patient is transferred to Sub-acute rehab floor

  12. INTERDISCIPLINARY PLAN OF CARE • Plastic Surgery • General Surgery • Infectious Disease • Cardiology • Pulmonary Medicine • Endocrinology • Nutrition • Nursing • Physical and Occupational Therapy

  13. STERNUMPHOTOGRAPHIC REVIEW 2 1 3 4 5

  14. RECTUSPHOTOGRAPHIC REVIEW 1 2 3 4

  15. LEGPHOTOGRAPHIC REVIEW 2 1 3 4 5

  16. ABDOMENPHOTOGRAPHIC REVIEW 2 1 3

  17. CASE STUDY #2 SHOULDER WOUND OSTEOMYLITIS REMOVAL OF HARDWARE

  18. THE PATINET • 39 Years Old • Male • 2 Children • Non-Smoker • In Nebraska visiting family

  19. CO-MORBIDITIES • Healthy Young Man • No co-morbidities • Wound occurred when dirt biking

  20. Treatment Course Accident occurred Closed, grossly displaced clavicle fracture 11/10 Presented at ER 11/15 Surgical reduction/fixation with plate and 6 screws 11/24 Released from hospital without any problems 11/25 Presented with signs and symptoms of infection 11/29 Staph cultured – plate and screws noted to be dislodged IV antibiotics initiated 12/01 Plate and screws surgically removed Systemic reaction to Nafcillin and oral dicloxacillin 12/12 Released to home 12/20

  21. Treatment Course Readmitted for further evaluation of non-healing wound 1/23 Surgical resection of mid third of clavicle with debridement of soft tissue infection Infectious disease consulted 1/30 Plastics called in – V.A.C. placed 2/2 Released with home care and V.A.C. 2/7 Clinic follow-up – V.A.C. discontinued-alginate initiated 2/14 IV antibiotics discontinued 2/21 Released from care-healed 2/28

  22. Resection of Clavicle with debridement VAC placed 2/02

  23. ABDOMEN First VAC dressing change 2/05

  24. ABDOMEN Released to home with Home Care 2/07 V.A.C. therapy IV antibiotics

  25. ABDOMEN First Clinic Follow Up 2/14 V.A.C. discontinued Alginate dressing applied

  26. Clinic Follow up 2/21 IV antibiotics discontinued

  27. ABDOMEN Wound is closed  2/28 Hypergranulation area in center Removed with silver nitrate stick

  28. INTERDISCIPLINARY PLAN OF CARE • Plastic Surgery • Orthopedic Surgery • Infectious Disease • Nutrition • Nursing • Home healthcare

  29. CLAVICLEPHOTOGRAPHIC REVIEW 3 1 2 4 5 6

  30. CASE STUDY #3 Perineal cyst Necrotizing Component Radical Surgical Debridement

  31. THE PATINET • 51 years old • Female • Single • Smoker

  32. CO-MORBIDITIES • Diabetic • Hypertension • Hyperlipidemia • Probable Sleep Apnea • Obesity

  33. Treatment Course Presented to Emergency Room with Perineal Cyst Infection Adult Onset Diabetes Mellitus Diagnosis Massive Infection with necrotizing features Emergency Surgery for debridement 1/16 Infectious Disease Consult 1/18 Plastic Surgery Consult V.A.C. Placement 1/24 Sub Acute Care Transfer 1/28 Released to Home 2/28 Healed 4/21

  34. 1/24 Vac placed 18cm – length 7cm – width 5cm tunnel @ 4:00 5cm tunnel @ 9:00

  35. 1/26 18cm length 5cm width 1cm undermining 0 tunnels

  36. 2/14 12cm length 5cm width

  37. 2/19 10cm length 4cm width

  38. Released to Home 2/28 9cm length 4cm width

  39. Clinic Follow-up 3/07 6cm length 4cm width

  40. Clinic Follow-up 3/14 6cm length 3cm width V.A.C. discontinued Normal Saline Moist dressings

  41. Clinic Follow-Up 03/21 6cm length 3cm width

  42. Clinic Follow-Up 03/28 5cm length 3cm width

  43. Clinic Follow-Up 4/05 2.5cm length 2cm width

  44. Clinic Follow-Up 4/13 2cm length 2cm width

  45. 4/21 Healed  Released from care

  46. INTERDISCIPLINARY PLAN OF CARE • Plastic Surgery • General Surgery • Infectious Disease • Endocrinology • Nutrition • Nursing • Home health care

  47. Photographic Review Groin/peri-rectal

  48. 4 2 1 3 8 5 6 7 9 11 10 12

  49. CASE STUDY #4 Perirectal Abscess Necrotizing Component Radical Debridement

  50. The Patient 62 year old Female Widow 2 Children

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