2.  IR  45 years old, female  Right handed  Manila  Chief complaint: purulent discharge from surgical wound

3.  Patient apparently well, good functional capacity and independent in his ADLs until…

4.  3 months PTA  Onset of jaundice  No other signs and symptoms  No medical advise sought for the jaundice

5.  1 month PTA  Admitted at PGH c/o GS3  A:> Obstructive jaundice 2' to choledochoithiasis  Scheduled for surgery c/o GS3 (may 2010)

6.  Intraoperatively  Noted (+) hard mass at distal common bile duct between portal and wall of duodenum; grossly normal liver; (+) hard nodule at anterior body of pancreas  OR done: Laparotomy, cholecystectomy intraoperative ultrasound,Pylorus preserving Pancreaticoduodenectomy, JP drain  Discharged on the 5 th post op day

7.  In the interim:  + surgical site pain  + erythema around surgical site  Noted yellowish foul smelling discharge from the incision site  (-) fever

8.  On follow-up at the OPD 10 days post op  Fever –Tmax 38.5  (+) purulent/foul smelling discharge on incision site and JP drains  (+) erythema on incision site

9.  (+) Cough productive of yellowish sputum 1 week  (+) decreased appetite  (-) abdominal pain  (-) nausea/vomiting  (-) hematochezia  (-) hematemesis  (-) melena  (-) hematuria  (-) dysuria

10.  (-) DM, HPN, PTB, BA, thyroid, kidney and liver diseases, seizures, CA  (-) Food and drug allergies

11.  (-) DM, HPN, PTB, BA, thyroid, kidney and liver diseases, seizures, CA

12.  Single  From Manila

13.  General Inspection: awake, alert, conscious, coherent, ambulatory and not in cardiorespiratory distress  Vital Signs: BP: 120/70 HR: 80 RR: 20 T 38 0C  HEENT: Pink palpebral conjunctivae, anicteric sclerae, (-) nasoaural discharge, (-) neck vein engorgement, (-) tonsillopharyngeal congestion, (-) anterior neck mass, (-) neck lymphadenopathy

14.  Chest and Lungs: (-) Deformities, equal chest expansion, clear breath sounds, (-) rales, (-) rhonchi, (-) wheezes  Cardiac: Adynamic precordium, distinct heart sounds, normal rate, regular rhythm, (-) heaves, (-) thrills, (-) murmurs

15.  Abdomen: Flabby, normoactive bowel sounds, tender, (near the area of -) masses, (-) organomegaly, generally tympanitic on all quadrants  (+) 20cm incision scar over the right upper quadrant of the abdomen. (+) erythema, (+) yellowish foul smelling fluid from the wound/incision sites and jp drain site. Staples in place

16.  SSSI s/p Whipple’s procedure (May 2010, PGH)

17.  6/3/10 A:> SSSI – admitted and started on piperacillin tazobactam 4.5g IV q 12  6/6/10 s/p VAC application  6/11/10 (-) charcoal test  6/12/10 histopath showed TB of the pancreas. Started on myrin P forte 4 tabs OD  6/13/10 wound gs/cs revealed Kliebsiella referred to IDS. Piperacillin tazobactam, and Myrin P forte continued.

18.  6/14/10 wound inspected, good granulation tissue, minimal purulent discharge, (-) visible fistula, (-) necrotic areas. still with febrile episodes t max 38 

19.  Removal of staples  Drainage of purulent material  CDW daily  VAC  Start piperacillin tazobactam, myrin P forte