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Intern’s Hour

Intern’s Hour. IDENTIFYING DATA. IR 45 years old, female Right handed Manila Chief complaint: purulent discharge from surgical wound. HISTORY OF PRESENT ILLNESS. Patient apparently well, good functional capacity and independent in his ADLs until…. HISTORY OF PRESENT ILLNESS.

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Intern’s Hour

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  1. Intern’s Hour

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

  3. HISTORY OF PRESENT ILLNESS • Patient apparently well, good functional capacity and independent in his ADLs until…

  4. HISTORY OF PRESENT ILLNESS • 3 months PTA • Onset of jaundice • No other signs and symptoms • No medical advise sought for the jaundice

  5. HISTORY OF PRESENT ILLNESS • 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, cholecystectomyintraoperativeultrasound,Pyloruspreserving Pancreaticoduodenectomy, JP drain • Discharged on the 5th post op day

  7. HISTORY OF PRESENT ILLNESS • In the interim: • + surgical site pain • + erythema around surgical site • Noted yellowish foul smelling discharge from the incision site • (-) fever

  8. HISTORY OF PRESENT ILLNESS • 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. REVIEW OF SYSTEMS • (+) Cough productive of yellowish sputum 1 week • (+) decreased appetite • (-) abdominal pain • (-) nausea/vomiting • (-) hematochezia • (-) hematemesis • (-) melena • (-) hematuria • (-) dysuria

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

  11. FAMILY MEDICAL HISTORY • (-) DM, HPN, PTB, BA, thyroid, kidney and liver diseases, seizures, CA

  12. PERSONAL & SOCIAL HISTORY • Single • From Manila

  13. PHYSICAL EXAMINATION • General Inspection: awake, alert, conscious, coherent, ambulatory and not in cardiorespiratory distress • Vital Signs: BP: 120/70 HR: 80 RR: 20 T 380C • HEENT: Pink palpebral conjunctivae, anictericsclerae, (-) nasoaural discharge, (-) neck vein engorgement, (-) tonsillopharyngeal congestion, (-) anterior neck mass, (-) neck lymphadenopathy

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

  15. PHYSICAL EXAMINATION OPD • 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. ASSESSMENT at the OPD • SSSI s/p Whipple’s procedure (May 2010, PGH)

  17. COURSE • 6/3/10 A:> SSSI – admitted and started on piperacillintazobactam 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. Piperacillintazobactam, and Myrin P forte continued.

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

  19. INITIAL PLAN • Removal of staples • Drainage of purulent material • CDW daily • VAC • Start piperacillintazobactam, myrin P forte

  20. THANK YOU!

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