CHIEF COMPLAINT: Septic
Unresponsive

PRESENT ILLNESS: This is a 38 year old male transfer to [**Hospital1 18**] from OSH on [**2128-7-13**].
He was found unresponsive at home back on [**2128-6-13**]. This followed
with a 2 month history of postprandial nausea, vomiting and
abdominal pain, for which he refused to seek medical attention.
He apparently had hemoptosisa t some point at home and was
brought to the hospital where he was found to be in profound
shock and circulatory collapse with a SBP in the 40's,
hypoglycemic and a HCT of 13.5. He was taken to the OR where
upon entering the abdomen, 3-liters of gastric contents were
drained. A perforation was identified at the distal antrum,
close to the pancreas with a 3 cm necrotic area eroding
posterior to the pancreas. He is POD 31, s/p distal gastrectomy
w/ Roux-en-Y gastrojejunostomy for perforated gastric/duodenal
ulcer. He is POD 20, s/p subtotal colectomy and end ileostomy
for sigmoid perforation and "atonic colon", as well as a
tracheostomy for respiratory failure. He is POD 17, s/p
exploratory laparotomy, revison of end ileostomy, small bowel
resection, cholecystectomy and T-Tube placement, now transferred
for sepsis w/ GPC in blood and WBC of 29. There is a concern for
a possible common bile duct injury and now he has multiple
enhancing intraabdominal collections (hepatic fluid collections)
as seen on a CT scan. He was found to have an Aortic clot at the
level of [**Female First Name (un) 899**] (infrarenal) and thought to be possibly infected. A
sump drain is putting out bile and a T-tube is close to the
pancreatic head.

MEDICAL HISTORY: Bipolar

MEDICATION ON ADMISSION: Morphine, Epogen 40,000 q weekly, Thiamine, ativan, Lovenox 40 q
daily, Protonix, Diflucan

ALLERGIES: Penicillins / Imipenem

PHYSICAL EXAM: VS: 102.9, 105, 98/38, 15, 100% Trach mask
Gen: Conversive, depressed mood
HEENT: trach
Chest: decreased breath sounds, coarse.
CV: RRR, bradycardic
Abd: soft, Nontender, nondistended, open abdomen with VAC in
place, T-tube in place with bile draining. Ileostomy RLQ, pink.
Ext: +2 edema

FAMILY HISTORY: 

SOCIAL HISTORY: History of substance abuse - cocaine and ETOH. Rehab x 3. +
Tobacco. Expelled from high school.
Fistula of intestine, excluding rectum and anus,Streptococcal septicemia,Sepsis,Other suppurative peritonitis,Accidental puncture or laceration during a procedure, not elsewhere classified,Pressure ulcer, heel,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Delusional disorder,Incisional hernia without mention of obstruction or gangrene,Peritoneal adhesions (postoperative) (postinfection),Pseudomonas infection in conditions classified elsewhere and of unspecified site,Bipolar disorder, unspecified,Tracheostomy status,Attention to ileostomy,Anemia, unspecified
Intestinal fistula,Streptococcal septicemia,Sepsis,Suppurat peritonitis NEC,Accidental op laceration,Pressure ulcer, heel,Urin tract infection NOS,Hyposmolality,Delusional disorder,Incisional hernia,Peritoneal adhesions,Pseudomonas infect NOS,Bipolar disorder NOS,Tracheostomy status,Atten to ileostomy,Anemia NOS
Admission Date:  [**2128-7-13**]              Discharge Date:   [**2128-12-16**]

Date of Birth:  [**2089-10-29**]             Sex:   M

Service: SURGERY

Allergies:
Penicillins / Imipenem

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Septic
Unresponsive

Major Surgical or Invasive Procedure:
T-tube Cholangiogram
Jejunal Feeding Tube Placement
Percutaneous Transhepatic Cholangiogram
Exploratory laparotomy with extensive adhesiolysis.
Enterocutaneous fistula takedown and repair.
Takedown of end ileostomy and direct anastomosis to sigmoid.
Repair of a iatrogenic bladder injury.
J tube placement.
Primary ventral hernia repair with component separation.


History of Present Illness:
This is a 38 year old male transfer to [**Hospital1 18**] from OSH on [**2128-7-13**].
He was found unresponsive at home back on [**2128-6-13**]. This followed
with a 2 month history of postprandial nausea, vomiting and
abdominal pain, for which he refused to seek medical attention.
He apparently had hemoptosisa t some point at home and was
brought to the hospital where he was found to be in profound
shock and circulatory collapse with a SBP in the 40's,
hypoglycemic and a HCT of 13.5. He was taken to the OR where
upon entering the abdomen, 3-liters of gastric contents were
drained. A perforation was identified at the distal antrum,
close to the pancreas with a 3 cm necrotic area eroding
posterior to the pancreas. He is POD 31, s/p distal gastrectomy
w/ Roux-en-Y gastrojejunostomy for perforated gastric/duodenal
ulcer. He is POD 20, s/p subtotal colectomy and end ileostomy
for sigmoid perforation and "atonic colon", as well as a
tracheostomy for respiratory failure. He is POD 17, s/p
exploratory laparotomy, revison of end ileostomy, small bowel
resection, cholecystectomy and T-Tube placement, now transferred
for sepsis w/ GPC in blood and WBC of 29. There is a concern for
a possible common bile duct injury and now he has multiple
enhancing intraabdominal collections (hepatic fluid collections)
as seen on a CT scan. He was found to have an Aortic clot at the
level of [**Female First Name (un) 899**] (infrarenal) and thought to be possibly infected. A
sump drain is putting out bile and a T-tube is close to the
pancreatic head.

Past Medical History:
Bipolar

Social History:
History of substance abuse - cocaine and ETOH. Rehab x 3. +
Tobacco. Expelled from high school.

Physical Exam:
VS: 102.9, 105, 98/38, 15, 100% Trach mask
Gen: Conversive, depressed mood
HEENT: trach
Chest: decreased breath sounds, coarse.
CV: RRR, bradycardic
Abd: soft, Nontender, nondistended, open abdomen with VAC in
place, T-tube in place with bile draining. Ileostomy RLQ, pink.
Ext: +2 edema

Pertinent Results:
FISTULOGRAM/SINOGRAM

Reason: Please define anatomy of fistula

INDICATION: 39-year-old man with intracutaneous fistula.

FINDINGS: The patient was placed supine on the fluoroscopy
table. A preliminary scout radiograph again demonstrates
evidence of multiple prior surgeries, a surgically placed
jejunostomy catheter and the percutaneous biliary catheter
terminating in the jejunum. A 7 French catheter was gently
advanced slightly into the reported fistula site in the anterior
abdomen just to the left of midline within the known large
anterior open abdominal wound. Approximately 30 cc of Conray
contrast was gently infused under fluoroscopic guidance. There
was immediate opacification of a loop of small bowel just deep
to the fistula site. No other communication was seen.

IMPRESSION: Fistulogram demonstrate direct communication with a
loop of small bowel immediately deep to the reported fistula at
the patient's open abdominal wound.

COLON (BARIUM ENEMA)  [**2128-9-8**] 12:22 PM

COLON (BARIUM ENEMA); SMALL BOWEL ONLY (GASTROGRAF)

Reason: Define anatomy between ileostomy, fistula, and rectum.

IMPRESSION:

1. The [**Doctor Last Name 3379**] pouch ends at the mid sigmoid.

2. The fistula could not be demonstrated. If the fistula needs
to be demonstrated, a fistulogram, upper GI with barium or a CT
could be performed.

SMALL BOWEL ONLY (GASTROGRAF)  [**2128-9-8**] 12:22 PM

COLON (BARIUM ENEMA); SMALL BOWEL ONLY (GASTROGRAF)

Reason: Define anatomy between ileostomy, fistula, and rectum.

IMPRESSION:

1. The [**Doctor Last Name 3379**] pouch ends at the mid sigmoid.

2. The fistula could not be demonstrated. If the fistula needs
to be demonstrated, a fistulogram, upper GI with barium or a CT
could be performed.

RADIOLOGY  Final Report

SML BOWEL VIA ENTROCLYSIS TUBE  [**2128-9-7**] 2:37 PM

SML BOWEL VIA ENTROCLYSIS TUBE

Reason: Ileostomy contrast study (not fistula). Define anatomy
betw

IMPRESSION: Opacification of terminal loops of ileum and distal
jejunum without evidence of contrast extravasation or
visualization of enterocutaneous fistula. This suggests the
fistula is more proximal. Contrast did not definitely reach the
jejunal-jejunal anastamosis. For further delineation of anatomy
and evaluation of enterocutaneous fistula recommend fistulogram
or oral contrast study.

**FINAL REPORT [**2128-8-17**]**

   URINE CULTURE (Final [**2128-8-17**]):
      PSEUDOMONAS AERUGINOSA.    >100,000 ORGANISMS/ML..
         AZTREONAM sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].

         AT THE REQUEST OF DR. [**Last Name (STitle) **]. #[**Numeric Identifier 67543**].  INTERMEDIATE TO
AZTREONAM.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------    16 I
CEFTAZIDIME-----------    16 I
CIPROFLOXACIN---------   =>4 R
GENTAMICIN------------  =>16 R
IMIPENEM--------------     4 S
MEROPENEM-------------     4 S
PIPERACILLIN---------- =>128 R
PIPERACILLIN/TAZO-----    64 S
TOBRAMYCIN------------  =>16 R

**FINAL REPORT [**2128-7-18**]**

   WOUND CULTURE (Final [**2128-7-18**]):
      ENTEROCOCCUS SP..    >15 colonies.
      STAPHYLOCOCCUS, COAGULASE NEGATIVE.    >15 colonies.
         COAG NEG STAPH does NOT require contact precautions,
regardless of
         resistance.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |          STAPHYLOCOCCUS,
COAGULASE NEGATIVE
                             |          |
AMPICILLIN------------   <=2 S
CLINDAMYCIN-----------           <=0.25 S
ERYTHROMYCIN----------           <=0.25 S
GENTAMICIN------------                1 S
LEVOFLOXACIN----------              =>8 R
OXACILLIN-------------              =>4 R
PENICILLIN------------     8 S    =>0.5 R
RIFAMPIN--------------            <=0.5 S
TETRACYCLINE----------                2 S
VANCOMYCIN------------   <=1 S        2 S

BLOOD/FUNGAL CULTURE (Final [**2128-7-25**]):
      DUE TO OVERGROWTH OF BACTERIA, UNABLE TO CONTINUE
MONITORING FOR
      FUNGUS.
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**2128-7-21**] 13:24.
      ENTEROCOCCUS FAECALIS.    FINAL SENSITIVITIES.
         HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
         gentamicin. Screen predicts possible synergy with
selected
         penicillins or vancomycin. Consult ID for details.
         HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
         streptomycin. Screen predicts NO synergy with
penicillins or
         vancomycin.  Consult ID for treatment options.  .
      ENTEROCOCCUS FAECALIS.    FINAL SENSITIVITIES.
         HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml
of
         gentamicin. Screen predicts possible synergy with
selected
         penicillins or vancomycin. Consult ID for details.
         HIGH LEVEL STREPTOMYCIN SCREEN: Resistant to 1000mcg/ml
of
         streptomycin. Screen predicts NO synergy with
penicillins or
         vancomycin.  Consult ID for treatment options.  .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS FAECALIS
                             |          ENTEROCOCCUS FAECALIS
                             |          |
AMPICILLIN------------   <=2 S      <=2 S
PENICILLIN------------     8 S        4 S
VANCOMYCIN------------   <=1 S      <=1 S

GRAM STAIN (Final [**2128-7-14**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
      SMEAR REVIEWED; RESULTS CONFIRMED.

   FLUID CULTURE (Final [**2128-7-17**]):
      ENTEROCOCCUS SP..    MODERATE GROWTH.
      STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA.    SPARSE
GROWTH.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |          STENOTROPHOMONAS
(XANTHOMONAS) MALTOPH
                             |          |
AMPICILLIN------------   <=2 S
PENICILLIN------------     4 S
TRIMETHOPRIM/SULFA----              <=1 S
VANCOMYCIN------------   <=1 S

   ANAEROBIC CULTURE (Final [**2128-7-18**]):    NO ANAEROBES ISOLATED.


   FUNGAL CULTURE (Final [**2128-7-29**]):    NO FUNGUS ISOLATED.

   ACID FAST SMEAR (Final [**2128-7-16**]):
      NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.

   ACID FAST CULTURE (Preliminary):    NO MYCOBACTERIA ISOLATED

RADIOLOGY  Final Report

[**Numeric Identifier 23562**] CHANGE PERC BILIARY DRAINAGE CATHETER  [**2128-8-30**] 7:40 AM

Reason: Please perform cholangiogram through existing PTC tube.
Contrast: OPTIRAY

IMPRESSION: Prompt biliary drainage into bowel via a tract that
may represent the distal CBD. An 8 French drain is now capped to
internal drainage. Findings discussed by Dr. [**Last Name (STitle) 19420**] with Dr.
[**Last Name (STitle) **] on day of image acquisition.

RADIOLOGY  Final Report

CTA ABD W&W/O C & RECONS  [**2128-8-23**] 11:04 AM

CTA ABD W&W/O C & RECONS; CT PELVIS W&W/O C

Reason: Please assess for patency of infrarenal aorta, iliacs.
Inclu
Contrast: OPTIRAY

[**Hospital 93**] MEDICAL CONDITION:
38 year old man with multiple medical problems, thrombus in
infrarenal aorta.

IMPRESSION:
1. Resolution of multiple fluid collections as described above.
Small subcentimeter resolving fluid collection in the
gallbladder fossa remains.
2. No infrarenal aortic or iliac thrombus identified.

RADIOLOGY  Final Report

[**Numeric Identifier 23562**] CHANGE PERC BILIARY DRAINAGE CATHETER  [**2128-8-5**] 9:24 AM

IMPRESSION:

1. Pullback percutaneous transhepatic cholangiogram performed
which showed no evidence of leak. Good drainage of contrast is
identified from the intrahepatic bile ducts through the CBD into
the bowel.

2. Replacement of a 6 French nephroureteral-type catheter with
the pigtail coiled within the common bile duct and the tip
within the small bowel. The catheter was capped at this time and
left for internal drainage.

CATHETER, DRAINAGE  [**2128-7-27**] 7:41 AM

IMPRESSION:
1. Percutaneous cholangiogram demonstrated no dilatation of the
intrahepatic biliary ducts or common bile duct. Contrast
extravasation was noted in the region of the proximal common
bile duct consistent with bile leak. 8-French percutaneous
biliary drain with distal pigtail and middle interlocking loops
was placed via the right intrahepatic bile duct into the common
bile duct and into the bowel. The sideholes were positioned
within the confluence of the right and left intrahepatic bile
ducts and at the distal end. No sideholes were present
throughout the common bile duct.
2. In situ T-tube was replaced with jejunostomy feeding tube.
The catheter can be used immediately for feeding.

[**Numeric Identifier 23564**] CHALNAGIOGRAPHY VIA EXISTING CATHETER  [**2128-7-15**] 8:50 AM

Reason: Please assess for biliary leak/anastomotic breakdown
Contrast: OPTIRAY

CONCLUSION: Draining of bile as described. I do not know exactly
how much bile drains into the T tube; however, it may be
possible to percutaneously place a catheter in the biliary tree
and negotiate moving the Glidewire down the path into the
duodenum to establish internal biliary drainage. There was
definitely no contrast material that entered the pancreatic duct
however.
.
CT 150CC NONIONIC CONTRAST  [**2128-7-14**] 5:32 AM

CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST

REASON FOR THIS EXAMINATION:
Please perform w/ PO/IV contrast to assess for leak from
anastomosis site(s), biliary leak, etc
CONTRAINDICATIONS for IV CONTRAST: None.

IMPRESSION:
1. Gallbladder fossa fluid collection after cholecystectomy;
this could be an infected collection or biloma. Multiple
irregular hepatic lesions are suspicious for abscesses.

2. Unusual placement of T tube in the right upper quadrant with
question of whether the one limb is within the common bile duct
or outside it. T tube cholangiogram would be helpful to further
evaluate.

3. Open abdominal wound with subtotal colectomy and small bowel
resection with right lower quadrant ostomy. Diffuse small bowel
wall thickening may be post-surgical, however, ischemia is a
consideration. Multiple rim-enhancing fluid collections
throughout the abdomen could be infected.

4. Thrombus within the infrarenal aorta at the origin of the [**Female First Name (un) 899**]
and distal to it raises concern for traumatic or coagulopathic
cause. The [**Female First Name (un) 899**] has contrast within it, however, it is uncertain
whether this is retrograde or anterograde filling.

5. Bilateral hypodense renal lesions could represent
pyelonephritis or perfusion abnormalities. Renal arteries and
veins are patent.

Findings were called to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on the morning of
[**2128-7-14**].

[**Numeric Identifier 67544**] INTRO PERC TRNASHEPATIC STENT  [**2128-7-27**] 7:41 AM

HISTORY: 38-year-old man status post gastrectomy with Roux-en-Y
gastrojejunostomy with the postoperative course complicated with
biliary leak and enterocutaneous fistula.

RADIOLOGISTS: Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 19420**] who was present and
supervising throughout the procedure.

IMPRESSION:
1. Percutaneous cholangiogram demonstrated no dilatation of the
intrahepatic biliary ducts or common bile duct. Contrast
extravasation was noted in the region of the proximal common
bile duct consistent with bile leak. 8-French percutaneous
biliary drain with distal pigtail and middle interlocking loops
was placed via the right intrahepatic bile duct into the common
bile duct and into the bowel. The sideholes were positioned
within the confluence of the right and left intrahepatic bile
ducts and at the distal end. No sideholes were present
throughout the common bile duct.
2. In situ T-tube was replaced with jejunostomy feeding tube.
The catheter can be used immediately for feeding.

[**Numeric Identifier 27731**] PERC TRANSHEPATIC CHOLANGIOGRAPHY  [**2128-8-5**] 9:24 AM

REASON FOR THIS EXAMINATION:
Increased percutaneous transhepatic biliary drainage for 48
hours. Please perform a tube cholangiogram to assess the biliary
tree.
INDICATION: Status post gastrectomy, Roux-en-Y gastrojejunostomy
with hepaticojejunostomy. Previous biliary leak with T-tube in
place.

IMPRESSION:

1. Pullback percutaneous transhepatic cholangiogram performed
which showed no evidence of leak. Good drainage of contrast is
identified from the intrahepatic bile ducts through the CBD into
the bowel.

2. Replacement of a 6 French nephroureteral-type catheter with
the pigtail coiled within the common bile duct and the tip
within the small bowel. The catheter was capped at this time and
left for internal drainage.

[**Numeric Identifier 67545**] PERC TRANSHEPATIC CHOLANGIOGRAPHY  [**2128-8-30**] 7:40 AM

[**Hospital 93**] MEDICAL CONDITION:
38 year old man with s/p gastrectomy, roux-en-y
gastrojejeunostomy with subsequent T-tube placement and
percutaneous transhepatic biliary drainage tube placement. There
is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] drain in the subhepatic fossa near the CBD.
IMPRESSION: Prompt biliary drainage into bowel via a tract that
may represent the distal CBD. An 8 French drain is now capped to
internal drainage. Findings discussed by Dr. [**Last Name (STitle) 19420**] with Dr.
[**Last Name (STitle) **] on day of image acquisition.

FISTULOGRAM/SINOGRAM  [**2128-11-26**] 10:35 AM

INDICATION: 39-year-old man with intracutaneous fistula.

IMPRESSION: Fistulogram demonstrate direct communication with a
loop of small bowel immediately deep to the reported fistula at
the patient's open abdominal wound.


Brief Hospital Course:
He had a lengthy & complicated hospital course. Original surgery
was done [**6-13**] for perforated gastric ulcer resulting in distal
gastrectomy with Roux-en-Y. On [**6-24**] it was noted that he has
stool draining from his JP drain. He went back to surgery for a
subtotal colectomy and ielostomy. He again returned to surgery
on [**6-28**] for Cholecyctectomy, small bowel resection and
ileostomy revision.

#Radiology: An abdominal CT showed an unusual placement of T
tube in the right upper quadrant with question of whether the
one limb is within the common bile duct or outside it.  A T-tube
study on [**2128-7-15**] showed a communication of the proximal ascending
limb of the T-tube, which either lies in a remnant of the
previous common bile duct or in the surrounding cavity; however,
a short portion of the CBD does fill and there is reflux into
the right and left hepatic ducts, and separately to the distal
limb duodenum.
On [**2128-7-27**], a percutaneous cholangiogram demonstrated no
dilatation of the intrahepatic biliary ducts or common bile
duct. Contrast extravasation was noted in the region of the
proximal common bile duct consistent with bile leak. 8-French
percutaneous biliary drain with distal pigtail and middle
interlocking loops was placed via the right intrahepatic bile
duct into the common bile duct and into the bowel. The sideholes
were positioned within the confluence of the right and left
intrahepatic bile ducts and at the distal end. No sideholes were
present throughout the common bile duct.
On [**2128-8-5**], the radiologists pulled back the percutaneous
transhepatic cholangiogram performed which showed no evidence of
leak. Good drainage of contrast was identified from the
intrahepatic bile ducts through the CBD into the bowel. There
was replacement of a 6 French nephroureteral-type catheter with
the pigtail coiled within the common bile duct and the tip
within the small bowel. The catheter was capped at this time and
left for internal drainage.
On [**2128-8-13**] the [**Doctor Last Name 406**] drain was D/C'd.
On [**2128-8-30**] a cholangiogram showed prompt biliary drainage into
bowel via a tract that may represent the distal CBD.
He had additional studies to establish his anatomy.

#Abdomen/GI: An NGT tube was in place and he was NPO. His
abdomen was open with a wound VAC in place. A sump drain to low
wall suction was putting out large amounts of bilious drainage.
A T-tube to gravity was draining small amounts of bilious
drainage. He will need to continue the suction on the sump drain
in order to avoid ostomy maceration. See "Ostomy Nurse Notes".

#Vascular:
A CT showed an Aortic thrombosis at the origin of the [**Female First Name (un) 899**]. A HIT
panel was checked and a TTE performed. The TEE showed an EF
>55%.
An Argatroban drip was started and then switched to a Heparin
drip for an Aortic clot. Coumadin was dosed and his INR was
closely monitored. He was receiving 7.5 to 10 mg daily. The
Coumadin was D/C'd prior to his Or date on [**2128-12-2**].

#ID: He was placed on broad spectrum antibiotics. Vancomycin,
Levofloxacin, and  Flagyl were started.
Pertinent Microbiology includes:
[**7-13**] blood: Enterococcus (VSE), Staphylcoccus, (MRSE).
Sputum: neg; Bactrim ([**Date range (1) 67546**])
[**7-14**] blood fungal culture: ENTEROCOCCUS FAECALIS.
Peritoneal: enterococcus & xanthomas[bactrim],
Blood Culture: Enterococcus and coag neg staph.
[**7-17**] cath tip: enterococcus, Staphylcoccus, Coagulase Negative.
Blood Cultures were negative x 2.
[**7-19**], [**7-26**], [**8-2**]: MRSA and VRE negative.
[**7-19**] Stool: C.diff neg
[**8-12**] UA: Leuk Mod Blood Sm WBC [**12-27**] Epi <1; started Levo
[**8-13**] Urine Culture: P. aeruginosa, [**Last Name (un) 36**] to Zosyn, imipenem,
meropenem.
[**9-2**] Urine Culture: Pseudomonas Aeruginosa.

#Psychiatry:
The patient has a long history of Bipolar disorder vs.
Schizoaffective d/o, chronic paranoia, ETOH abuse. He seems
cognitively intact and at his baseline. His current exam is
notable for low level agitation, auditory hallucination and
?paranoia. Recommendations were for Haldol for agitation if
needed. Haldol was D/C'd and Ativan, Olanzapine were added. He
was psychiatrically stable on Celexa and Klonopin.

#Respiratory:
He required routine suctioning of thick white secretions. He was
able to tolerate a Passy Muir valve and had a strong productive
cough. On [**2128-8-23**] his trach was decannulated and his was
respiratory status was stable.

#Ostomy Care: The ostomy nurse performed routine ileostomy
changes. On [**2128-7-15**] a fistula is noted on the left lateral
portion of the wound. The wound undermines on each side and the
drainage is green with a pungent odor. By [**2128-8-30**] the wound
has decreased in size with healthy granulation tissue. The
fistula is still putting out loose to thick brown/green stool.
There is only mucous draining from the ileostomy. Ileostomy
pouched with [**Last Name (un) **] seal and ConvaTec Active Life pouch. The
fistula was pouched with ConvaTec's large wound manager pouch
with [**Last Name (un) **] seals. the inside seal was sealed with Coloplast
paste strips. A 33 Fr cath was exited thru the pouch and
stabilized with a Nu Hope Catheter holder Peri-wound and
peristomal skin are intact.

Over the next months, he was stable and continued with wound
care every 2 to 3 days. The Ostomy nurses did an excellent job
at closing his abdomen with serial ostomy changes that are well
documented. On [**2128-11-29**] - repouched him using ConvaTec medium
fistula pouch and two piece Natura system with [**First Name8 (NamePattern2) **] [**Last Name (un) **] seal for
the ileostomy.
Have placed a 30 fr cath into the wound bed brought it out
through the pouch using a Coloplast drain port to secure the
cath through the pouch. The cath was placed to suction set at
60, use the 16 gage Intracath as a vent in the catheter. Have
protected the wound bed and fistula with Adaptic.

#Nutrition:
He was started on TPN for nutritional support upon admission to
[**Hospital1 18**]. On [**2128-7-21**], there was successful placement of Dobhoff
feeding tube within the stomach. On [**2128-7-27**] the In situ T-tube
was replaced with jejunostomy feeding tube. Tube feedings were
slowly advanced depending on the drainage output. His Albumin
was slowly increasing from 2.2 on [**8-10**] to 2.9 on [**8-30**]. His tube
feeds were being cycled 1/2 strength TPN at 90cc/hr and Boost
shakes were ordered [**Hospital1 **].

------Fe-----------TIBC------[**Last Name (un) **]-----TRF-------Alb
[**9-13**]---28------------319------44-------245-------3.1
[**9-19**]--28------------328------35-------252-------2.9
[**9-27**]--30------------361------30-------278-------3.0
[**10-4**]--33------------367------18-------282-------3.1
[**10-18**]--34------------400------12-------308-------3.1
[**10-25**]--33------------429------12-------330-------3.5
[**11-1**]--47------------434------12-------334-------3.5
[**11-8**]--31------------439------11-------338-------3.4
[**11-15**]--35------------458------10-------337-------3.4
[**2059-11-22**]------------438------9.1------352-------3.5
[**2058-11-28**]------------460------9--------354-------3.4

#Physical Therapy: The physical therapist worked with him on a
regular basis using exercise bands and transferring him out of
bed to chair. He eventually was walking the halls and had
improved his strength dramatically.

#Foot
A foot ulcer was noted from his prolonged hospital stay.
Multipodis boots were ordered and his heel was kept elevated.
This improved as he became more mobile and resolved.
After a prolonged hospitalization, he went to the OR on [**2128-12-2**]
with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 957**]. The following was performed:
1.  Exploratory laparotomy with extensive adhesiolysis.
2.  Enterocutaneous fistula takedown and repair.
3.  Takedown of end ileostomy and direct anastomosis to sigmoid.
4.  Repair of a iatrogenic bladder injury.
5.  J tube placement.
6.  Primary ventral hernia repair with component separation.

Post-operatively, he did well.

Pain: His post-op pain was controlled with epidural and PCA. He
was transitioned to PO Percocet and had excellent pain control
prior to discharge.

GI: He was NPO with a NGT. He complained on loose stool on POD 6
after his tube feedings were increased. He was started on
Imodium and the diarrhea began to resolve.
.
Abd: He had 3 drains that were placed to low wall suction. These
were then put to a JP bulb suction. He subsequently had the
drains removed as the output decreased. The last drain was
removed the day of discharge. His staples were removed on his
discharge day. His abdomen was well healed without signs of
infection. The T-tube in the Right Flank was secured to his side
and will remain in place for now.
.
GU: The Foley remained in place for 10 days due to the bladder
injury while intraop. This was D/C'd and he was voiding without
incident.
.
FEN: He continued with his TPN. The J-tube was to gravity.
J-tube feedings were started on POD 4. These were slowly
increased. He started on [**2-9**] strength Impact and ramped up as
tolerated. The TPN was stopped and his PO diet was increased
slowly. He had calorie counts which showed an intake of
~2000kcal and ~100gm of protein. He was tolerating a regular
diet and the tube feedings were discontinued.
.
Activity: He was ambulating the halls and moving independently.


Medications on Admission:
Morphine, Epogen 40,000 q weekly, Thiamine, ativan, Lovenox 40 q
daily, Protonix, Diflucan

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
Disp:*qs Tablet(s)* Refills:*0*
2. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QHS (once a day (at bedtime)).
Disp:*qs Tablet, Rapid Dissolve(s)* Refills:*2*
3. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO QAM (once a day (in the morning)).
Disp:*qs Tablet, Rapid Dissolve(s)* Refills:*2*
4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*qs Tablet(s)* Refills:*2*
5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*qs Tablet(s)* Refills:*2*
6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 1 months.
Disp:*60 Tablet(s)* Refills:*0*
7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
8. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*qs Tablet(s)* Refills:*2*
9. Loperamide 1 mg/5 mL Liquid Sig: [**6-16**] ML PO every eight (8)
hours as needed for diarrhea.
Disp:*qs ML* Refills:*0*
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) **] AND SOUTHERN NH VNA

Discharge Diagnosis:
Sepsis
Pancreaticobiliary injury with a major biliary leak.
Open abdominal wall with exposed jejunum
Ventral hernia wound
End ileostomy
Entercutaneous Fistula


Discharge Condition:
Good


Discharge Instructions:
You may resume your regular diet.

You may shower.  Allow water to run over the wound and pat dry.
No baths for 4 weeks.

* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Other symptoms concerning to you

Take all new medications as directed.  Do not drive while taking
narcotic pain medication.

Continue to walk several times/day

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**],
MD Phone:[**Telephone/Fax (1) 2833**] Date/Time:[**2129-1-7**] 9:30



Completed by:[**2128-12-16**]
{'Fistula of intestine, excluding rectum and anus,Streptococcal septicemia,Sepsis,Other suppurative peritonitis,Accidental puncture or laceration during a procedure, not elsewhere classified,Pressure ulcer, heel,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Delusional disorder,Incisional hernia without mention of obstruction or gangrene,Peritoneal adhesions (postoperative) (postinfection),Pseudomonas infection in conditions classified elsewhere and of unspecified site,Bipolar disorder, unspecified,Tracheostomy status,Attention to ileostomy,Anemia, unspecified'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Septic
Unresponsive

PRESENT ILLNESS: This is a 38 year old male transfer to [**Hospital1 18**] from OSH on [**2128-7-13**].
He was found unresponsive at home back on [**2128-6-13**]. This followed
with a 2 month history of postprandial nausea, vomiting and
abdominal pain, for which he refused to seek medical attention.
He apparently had hemoptosisa t some point at home and was
brought to the hospital where he was found to be in profound
shock and circulatory collapse with a SBP in the 40's,
hypoglycemic and a HCT of 13.5. He was taken to the OR where
upon entering the abdomen, 3-liters of gastric contents were
drained. A perforation was identified at the distal antrum,
close to the pancreas with a 3 cm necrotic area eroding
posterior to the pancreas. He is POD 31, s/p distal gastrectomy
w/ Roux-en-Y gastrojejunostomy for perforated gastric/duodenal
ulcer. He is POD 20, s/p subtotal colectomy and end ileostomy
for sigmoid perforation and "atonic colon", as well as a
tracheostomy for respiratory failure. He is POD 17, s/p
exploratory laparotomy, revison of end ileostomy, small bowel
resection, cholecystectomy and T-Tube placement, now transferred
for sepsis w/ GPC in blood and WBC of 29. There is a concern for
a possible common bile duct injury and now he has multiple
enhancing intraabdominal collections (hepatic fluid collections)
as seen on a CT scan. He was found to have an Aortic clot at the
level of [**Female First Name (un) 899**] (infrarenal) and thought to be possibly infected. A
sump drain is putting out bile and a T-tube is close to the
pancreatic head.

MEDICAL HISTORY: Bipolar

MEDICATION ON ADMISSION: Morphine, Epogen 40,000 q weekly, Thiamine, ativan, Lovenox 40 q
daily, Protonix, Diflucan

ALLERGIES: Penicillins / Imipenem

PHYSICAL EXAM: VS: 102.9, 105, 98/38, 15, 100% Trach mask
Gen: Conversive, depressed mood
HEENT: trach
Chest: decreased breath sounds, coarse.
CV: RRR, bradycardic
Abd: soft, Nontender, nondistended, open abdomen with VAC in
place, T-tube in place with bile draining. Ileostomy RLQ, pink.
Ext: +2 edema

FAMILY HISTORY: 

SOCIAL HISTORY: History of substance abuse - cocaine and ETOH. Rehab x 3. +
Tobacco. Expelled from high school. 

### Response:
{'Fistula of intestine, excluding rectum and anus,Streptococcal septicemia,Sepsis,Other suppurative peritonitis,Accidental puncture or laceration during a procedure, not elsewhere classified,Pressure ulcer, heel,Urinary tract infection, site not specified,Hyposmolality and/or hyponatremia,Delusional disorder,Incisional hernia without mention of obstruction or gangrene,Peritoneal adhesions (postoperative) (postinfection),Pseudomonas infection in conditions classified elsewhere and of unspecified site,Bipolar disorder, unspecified,Tracheostomy status,Attention to ileostomy,Anemia, unspecified'}
