CHIEF COMPLAINT: Pancreatic head necrosis

PRESENT ILLNESS: 73M transferred from [**Hospital3 **] Hospital for necrosis of pancreas
seen on CT s/p emobolization of pancreaticoduodenal artery 2
days ago for upper GI bleed.  He was in usual health 4 days ago
when he had two episodes of bright red blood per rectum with
associated light headedness, no CP or SOB.  Was seen in ED
and admitted to medicine service.  Tagged RBC showed possible
bleeding proximal transverse colon but EGD 2 days ago revealed
"welling up" of blood in 2nd portion of duodenum with no
identification of source.  IR was consulted and embolization of
the duodenal portion of the pancreaticoduodenal artery was
performed the same day [**2200-5-23**].  Patient has not had any
subsequent episodes of BRBPR.  CT today was significant for
ileus and low attenuation of head of pancreas worrisome for
ischemia/necrosis and thickening of wall of duodenum. Patient
was tranferred to [**Hospital1 18**] for evaluation and care.

MEDICAL HISTORY: PMH: HTN, Dyslipidemia, EGD [**9-/2199**] with gastric/duodenal
ulcers, Gout, Neuropathy, Back pain, h/o carpal tunnel, cervical
radiculopathy

MEDICATION ON ADMISSION: atenolol 50', Cartia 120', Lisinopril 40', Prednisone 5'',
Naproyn 500'', Zocor 40', Nexium 40', Cochicine .6', ASA 81',
MVI', Vit B12, Vit D

ALLERGIES: Sulfa (Sulfonamides) / Ciprofloxacin

PHYSICAL EXAM: Vitals: 98.3, 76, 130/61, 24, 93RA
A&Ox3, NAD
NC/AT
NGT to low wall suction putting out thick light green fluid, no
blood
CV: RRR with 3/6 systolic murmur best heard LUSB
Pulm: lungs clear to auscultation bilaterally
GI: Distended, +BS, TTP in epigastrium and in RLQ. + tympany,
soft, no guarding or rebound tenderness, Rectal exam with
melanic
stool guiac +
GU: no foley
Ext: warm and dry

FAMILY HISTORY: nc

SOCIAL HISTORY: Married, smokes 2 ppd, retired reader's digest editor
Acute pancreatitis,Chronic or unspecified duodenal ulcer with perforation, with obstruction,Acute respiratory failure,Other retroperitoneal abscess,Infected hydrocele,Other postoperative infection,Delirium due to conditions classified elsewhere,Acute kidney failure, unspecified,Tobacco use disorder,Congestive heart failure, unspecified,Atrial fibrillation,Other inflammatory disorders of male genital organs,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic cholecystitis,Thrombocytopenia, unspecified
Acute pancreatitis,Chr duoden ulc perf-obst,Acute respiratry failure,Retroperiton abscess NEC,Infected hydrocele,Other postop infection,Delirium d/t other cond,Acute kidney failure NOS,Tobacco use disorder,CHF NOS,Atrial fibrillation,Male gen inflam dis NEC,Abn react-surg proc NEC,Chronic cholecystitis,Thrombocytopenia NOS
Admission Date:  [**2200-5-25**]              Discharge Date:   [**2200-7-10**]

Date of Birth:  [**2126-10-4**]             Sex:   M

Service: SURGERY

Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin

Attending:[**Known firstname 148**]
Chief Complaint:
Pancreatic head necrosis


Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Retroperitoneal exploration and drainage of abscess.
3. Open cholecystectomy.
4. Duodenostomy tube placement.
5. G-tube placement.
6. J-tube placement.
7.  Tracheostomy
8. Incision, drainage and debridement of right inguinal canal
and the suprapubic space.
9. Incision and drainage of scrotum.


History of Present Illness:
73M transferred from [**Hospital3 **] Hospital for necrosis of pancreas
seen on CT s/p emobolization of pancreaticoduodenal artery 2
days ago for upper GI bleed.  He was in usual health 4 days ago
when he had two episodes of bright red blood per rectum with
associated light headedness, no CP or SOB.  Was seen in ED
and admitted to medicine service.  Tagged RBC showed possible
bleeding proximal transverse colon but EGD 2 days ago revealed
"welling up" of blood in 2nd portion of duodenum with no
identification of source.  IR was consulted and embolization of
the duodenal portion of the pancreaticoduodenal artery was
performed the same day [**2200-5-23**].  Patient has not had any
subsequent episodes of BRBPR.  CT today was significant for
ileus and low attenuation of head of pancreas worrisome for
ischemia/necrosis and thickening of wall of duodenum. Patient
was tranferred to [**Hospital1 18**] for evaluation and care.

During hospitalization patient received a total of 5 units PRBC
with 2 of those units being transfused overnight of [**5-24**].  He
had an NGT placed prior to transfer to [**Hospital1 18**].  Colonoscopy was
never performed to evaluate proximal transverse colon.

Past Medical History:
PMH: HTN, Dyslipidemia, EGD [**9-/2199**] with gastric/duodenal
ulcers, Gout, Neuropathy, Back pain, h/o carpal tunnel, cervical
radiculopathy


Social History:
Married, smokes 2 ppd, retired reader's digest editor

Family History:
nc

Physical Exam:
Vitals: 98.3, 76, 130/61, 24, 93RA
A&Ox3, NAD
NC/AT
NGT to low wall suction putting out thick light green fluid, no
blood
CV: RRR with 3/6 systolic murmur best heard LUSB
Pulm: lungs clear to auscultation bilaterally
GI: Distended, +BS, TTP in epigastrium and in RLQ. + tympany,
soft, no guarding or rebound tenderness, Rectal exam with
melanic
stool guiac +
GU: no foley
Ext: warm and dry


Pertinent Results:
[**2200-5-26**] 12:18AM BLOOD WBC-13.5* RBC-3.84* Hgb-12.5* Hct-34.7*
MCV-90 MCH-32.6* MCHC-36.0* RDW-17.4* Plt Ct-160
[**2200-5-26**] 08:30AM BLOOD WBC-11.5* RBC-3.53* Hgb-11.1* Hct-32.0*
MCV-91 MCH-31.6 MCHC-34.8 RDW-17.3* Plt Ct-143*
[**2200-5-26**] 12:18AM BLOOD Glucose-83 UreaN-15 Creat-0.9 Na-136
K-3.9 Cl-104 HCO3-20* AnGap-16
[**2200-5-26**] 12:18AM BLOOD ALT-29 AST-37 LD(LDH)-290* AlkPhos-64
Amylase-158* TotBili-1.9*
[**2200-5-26**] 12:18AM BLOOD Lipase-92*
[**2200-5-26**] 12:18AM BLOOD Albumin-3.0* Calcium-9.9 Phos-1.9*
Mg-1.2*
.
CT HEAD W/O CONTRAST  [**2200-5-26**] 4:17 AM
IMPRESSION: No acute intracranial process.
.
CTA ABD W&W/O C & RECONS  [**2200-5-29**] 2:01 AM
IMPRESSION:
1. Large gas- and fluid-containing retroperitoneal collection
extending from the region of the second portion of the duodenum
and pancreatic head, along the right flank, through the right
inguinal canal into the right scrotum. The findings are
consistent with duodenal perforation, likely related to reported
recent embolization.
2. Necrosis of the pancreatic head, largely replaced by a gas-
and fluid- containing collection. No pancreatic ductal dilation.
3. 11-mm cystic lesion in the uncinate process of the pancreas.
This could possibly relate to the patient's acute syndrome, as
in the case of focal pancreatic necrosis, versus a primary
cystic lesion of the pancreas or dilation of the uncinate
process duct. If this lesion is not resected, further followup
will be required after the patient's acute process has resolved.
4. Massive scrotal edema and right-sided hydrocele directly
extending from the retroperitoneal collection. The marked
enhancement about the periphery of the collection and marked
scrotal edema are consistent with inflammatory process.
5. Bilateral hypodense renal lesions, too small to characterize.
6. Probable gallbladder adenomyomatosis.
.
SCROTAL U.S.  [**2200-5-29**] 1:58 PM
TESTICULAR ULTRASOUND: Comparison was made with the CT scan
performed on the same day dated [**2200-5-29**]. Right testicle
measures 2.8 x 2.6 x 3.6 cm. Left testicle measures 2.8 x 2.2 x
3.5 cm. The vascularity to the testicles is preserved without
evidence of focal lesion. Echotexture of the testicles is
normal. Within the bilateral scrotum in extratesticular
location, there is markedly heterogeneous and echogenic complex
fluid, due to extension of the pancreatic fluid tracking down in
the retroperitoneum as seen on the CT study. The skin is
thickened; however, there is no evidence of subcutaneous air.
IMPRESSION: Heterogeneous complex material and fluid within the
scrotum bilaterally in extratesticular location, due to tracking
and accumulation of the pancreatic fluid seen on CT study.
Normal testicles with preserved flow without focal lesion. The
findings were discussed with the referring physician.
.
ECHO
Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF 70%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. An eccentric,
posteriorly directed jet of mild to moderate ([**2-12**]+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
CT ABDOMEN W/O CONTRAST  [**2200-6-1**] 10:23 AM
CONCLUSION:
1. Interval improvement in the patient's right flank
retroperitoneal collection, status post surgery. Multiple drains
are identified in situ. No evidence of intraperiotneal spillage
of contrast pd connection with the residual collection .
2. There has been dramatic interval worsening in the patient's
pulmonary status and consideration towards a formal chest CT to
further evaluate these is made. There is a wide differential
including pulmonary edema, infection and ARDS.
.
CHEST (PORTABLE AP)  [**2200-6-5**] 4:24 AM
FINDINGS: As compared to the previous radiograph, there is a
slight improvement. The extent of the left-sided pleural
effusion has decreased, the right lung has increased in
transparency. There are still moderate opacities at the right
lung base and extensive retrocardiac atelectasis. The size of
the cardiac silhouette is unchanged. Also unchanged are the
positions of the monitoring and support devices. There is no
evidence of newly occurred parenchymal opacities.
.
CT PELVIS W/CONTRAST  [**2200-6-13**] 1:01 PM
IMPRESSION:
1. Interval development of large amount of air and fluid within
the right scrotum, which extends into the right lower anterior
abdominal wall. A catheter is identified extending from the
right retroperitoneal flank into the right inguinal canal.
2. Splenic hypodensity and renal hypodensities, too small to
characterize.
3. Interval improvement in bilateral patchy opacities at the
lung bases.
4. Unchanged appearance of bilateral pleural effusions.
.
CHEST (PORTABLE AP)  [**2200-6-25**] 3:51 PM
As compared to the previous radiograph, the intrathoracic tube
has been exchanged for a tracheal tube. The left-sided central
venous access line has been removed. Increase in extent of the
left-sided pleural effusion. Unchanged extent of the
retrocardiac atelectasis. Unchanged extent of moderate pulmonary
edema, there is no evidence of newly occurred focal parenchymal
opacities suggestive of pneumonia.
.
CT ABDOMEN W/CONTRAST  [**2200-7-3**] 2:46 PM
IMPRESSION:
1. Interval decrease in large amount of air and fluid collection
within the right lower anterior abdominal wall extending to the
right scrotum.
2.Catheter is identified near the medial portion of the duodenum
at the site of perforation. Small fluid collection measuring 1.5
cm is noted near the third portion of the duodenum.
3. Bilateral pleural effusions.
.
CHEST (PORTABLE AP)  [**2200-7-5**] 4:22 AM
Tracheostomy tube and right subclavian catheter remains in
place. A small right and moderate left pleural effusion have
increased in the left side. There has been mild interval
worsening of moderate-to-severe pulmonary edema. There has been
interval increase in left lower lobe retrocardiac atelectasis.
The left cardiac border is obscured by the pleuroparenchymal
opacities.
.


Brief Hospital Course:
This is a 73 yo M with pancreas necrosis based on CT finding
from [**Hospital3 **]
hospital related to embolization of Pancreaticoduodenal artery
on [**5-23**].  Since then his GI bleed has stabilized without any
additional events of BRBPR or melena.  However a colonoscopy to
evaluate tagged RBC scan findings of proximal transverse colon
was not done.  He was transferred to the ICU on [**5-30**] for CHF,
respiratory distress.

CV: Murmur, on cardizem at home, will give IV metop. He had an
episode of A-fib on HD 5. This was a transient episode that
resolved with IV Lopressor.
ON HD 6, he had an episode of CHF, Respiratory distress and was
transferred to the ICU. His BNP was 1072.  [**6-23**] Echo: EF>65%, 2+
MR (eccentric), stable c/w [**2200-5-30**].  On [**6-24**] he another bout of
AFIB.  Upon discharge, the patient is in normal sinus rhythm.

GI: GI bleed/necrosis pancreas/ileus - NGT to suction, NPO,
Protonix [**Hospital1 **], serial abdominal exams. T-bili was slightly
elevated at 1.9 on admission. Amylase and Lipase were also
elevated.

His CAT scan revealed a gross amount of retroperitoneal air and
this tracked down into the right testicular region and was
entirely consistent with pancreatic necrosis gone afoul. The
patient suffered signs of sepsis including atrial fibrillation
and respiratory distress in the day prior to this operation and
he underwent exploration for management.

He went to the OR on [**2200-5-30**] for:
1. Exploratory laparotomy.
2. Retroperitoneal exploration and drainage of abscess.
3. Open cholecystectomy.
4. Duodenostomy tube placement.
5. G-tube placement.
6. J-tube placement.

He went to the OR on [**2200-6-16**] for:
1. Incision, drainage and debridement of right inguinal canal
and the suprapubic space.
2. Incision and drainage of scrotum.

He went for EGD on PPD 5 and this showed a single ulcer large
ulcer was found in the duodenum on the medial wall extending
from the duodenal bulb to the second portion of the duodenum.
The ulcer was partially obscured by debris and necrotic material
but there was a suggestion of ischemia with no obvious mass and
no bleeding.

He was also complaining of right inguinal pain. An US showed no
evidence of pseudoaneurysm. Loops of bowel corresponding to
point of patient's maximal tenderness.  He was noted to have
progressive scrotal swelling. A CT the next day showed a right
hydrocele. A repeat CT scan demonstrated evidence of fluid
tracking through the inguinal canal from a retroperitoneal
collection into the scrotum. It was determined that he needed to
go to OR for washout and drainage.  The wound was packed with
WTD dressings and we intermittently used a wound vac to help
with healing.

Repeat Abd CT on [**7-3**] showed gastric contrast appears to have
traversed duodenum with a decrease collection w/in R abd
wall-->R scrotum.

Upon discharge, the patient's wound is healing very nicely, and
we are continuing with [**Hospital1 **] WTD dressing changes.

H.pylori was negative.

Delerium: Possibly related to EtOH withdrawl. He had one
unwitnessed fall when trying to get out of bed. He had family at
the bedside during the day for reorientation and sitter at
night. Geriatrics was consulted for the delirium and
recommendations followed

FEN: A PICC was placed on [**5-27**] and TPN initiated.  TPN was
discontinued [**6-11**] and the patient's tube feeds were advanced to
65cc/hr.  Upon discharge, the patient's tube feeds were Replete
with fiber full strength at a rate of 70cc/hr with q4h 30cc
water flushes.

Respiratory: On [**2200-6-12**]: He received a tracheosotmy.  On [**6-26**] the
trach was downsized.  The patient was on and off of the vent and
required a continued stay in the ICU.  Upon discharge, the
patient had been off of the vent for ~4-5 days without signs of
respiratory distress.

Infectious diseases:
MICRO:
[**6-29**]:C diff neg
[**6-29**] BAL: NG
[**6-20**] Peritoneal Cx: Enterobacter x2
[**6-16**] Inguinal Canal OR swab : Enterobacter x2
[**6-9**] Sp Cx: enterobacter cloacae
[**5-30**] RP tissue: Prevotella Beta lactam neg. and Strep Viridans
[**5-30**] RP fluid: GNR, GPC, strep viridans
[**5-26**] Hpylori: Neg

Upon discharge, the patient is in stable condition, has been off
of the vent for > 4 days, is afebrile with all vitals stable,
tolerating tube feeds well, and with pain controlled.


Medications on Admission:
atenolol 50', Cartia 120', Lisinopril 40', Prednisone 5'',
Naproyn 500'', Zocor 40', Nexium 40', Cochicine .6', ASA 81',
MVI', Vit B12, Vit D

Discharge Medications:
1. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Month/Year (2) **]: One (1)
Appl Ophthalmic PRN (as needed).
2. Metoprolol Tartrate 50 mg Tablet [**Month/Year (2) **]: 2.5 Tablets PO TID (3
times a day).
3. Lisinopril 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily).

4. Quetiapine 25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H (every 12
hours) as needed for agitation, insomnia.
5. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
6. Folic Acid 1 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily).

7. Insulin Regular Human 100 unit/mL Solution [**Last Name (STitle) **]: One (1) unit
Injection ASDIR (AS DIRECTED): Fingerstick QACHS, Q6HInsulin SC
Fixed Dose Orders
Breakfast Dinner
NPH      5  Units NPH      5  Units
Insulin SC Sliding Scale
  Breakfast Lunch Dinner Bedtime Q6H
Regular Regular Regular Regular Regular
Glucose Insulin Dose Insulin Dose Insulin Dose Insulin Dose
Insulin Dose
0-60   mg/dL [**2-12**] amp D50 [**2-12**] amp D50 [**2-12**] amp D50 [**2-12**] amp D50 [**2-12**]
amp D50
61-120   mg/dL 0   Units 0   Units 0   Units 0   Units 0   Units

121-160   mg/dL 2   Units 2   Units 2   Units 2   Units 2
Units
161-200   mg/dL 4   Units 4   Units 4   Units 4   Units 4
Units
201-240   mg/dL 6   Units 6   Units 6   Units 6   Units 6
Units
241-280   mg/dL 8   Units 8   Units 8   Units 8   Units 8
Units
281-320   mg/dL 10   Units 10   Units 10   Units 10   Units 10
Units
321-360   mg/dL 12   Units 12   Units 12   Units 12   Units 12
Units
361-400   mg/dL 14   Units 14   Units 14   Units 14   Units 14
Units
Notify M.D.

.
8. Miconazole Nitrate 2 % Powder [**Month/Day (2) **]: One (1) Appl Topical QID
(4 times a day) as needed.
9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Month/Day (2) **]: 4-8 Puffs
Inhalation Q4-6H () as needed.
10. Albuterol 90 mcg/Actuation Aerosol [**Month/Day (2) **]: 4-8 Puffs Inhalation
Q6H (every 6 hours) as needed.
11. Octreotide Acetate 100 mcg/mL Solution [**Month/Day (2) **]: One Hundred
(100) mcg Injection Q8H (every 8 hours).
12. Zolpidem 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO HS (at bedtime).

13. Amlodipine 5 mg Tablet [**Month/Day (2) **]: Two (2) Tablet PO DAILY (Daily).

14. Ferrous Sulfate 300 mg/5 mL Liquid [**Month/Day (2) **]: Three [**Age over 90 1230**]y
(350) mg PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Location (un) 86**]

Discharge Diagnosis:
Ischemic pancreatic head
Retroperitoneal ulcer with duodenal ulcer and perforation.
Sepsis.
Delerium
Acute CHF
Respiratory Failure
Inguinal and scrotal sepsis on the right side.


Discharge Condition:
Stable off vent
Continue drain care
Continue wound care
PT


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting, diarrhea
or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* No heavy lifting (>[**11-26**] lbs) for 6 weeks.

You have a right groin wound that will be changed twice a day
with wet to dry gauze packings


Followup Instructions:
Provider: [**Name10 (NameIs) **],[**Known firstname **] [**Name Initial (NameIs) **].  [**Telephone/Fax (1) 1231**]  Call to schedule
appointment
{'Acute pancreatitis,Chronic or unspecified duodenal ulcer with perforation, with obstruction,Acute respiratory failure,Other retroperitoneal abscess,Infected hydrocele,Other postoperative infection,Delirium due to conditions classified elsewhere,Acute kidney failure, unspecified,Tobacco use disorder,Congestive heart failure, unspecified,Atrial fibrillation,Other inflammatory disorders of male genital organs,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic cholecystitis,Thrombocytopenia, 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: Pancreatic head necrosis

PRESENT ILLNESS: 73M transferred from [**Hospital3 **] Hospital for necrosis of pancreas
seen on CT s/p emobolization of pancreaticoduodenal artery 2
days ago for upper GI bleed.  He was in usual health 4 days ago
when he had two episodes of bright red blood per rectum with
associated light headedness, no CP or SOB.  Was seen in ED
and admitted to medicine service.  Tagged RBC showed possible
bleeding proximal transverse colon but EGD 2 days ago revealed
"welling up" of blood in 2nd portion of duodenum with no
identification of source.  IR was consulted and embolization of
the duodenal portion of the pancreaticoduodenal artery was
performed the same day [**2200-5-23**].  Patient has not had any
subsequent episodes of BRBPR.  CT today was significant for
ileus and low attenuation of head of pancreas worrisome for
ischemia/necrosis and thickening of wall of duodenum. Patient
was tranferred to [**Hospital1 18**] for evaluation and care.

MEDICAL HISTORY: PMH: HTN, Dyslipidemia, EGD [**9-/2199**] with gastric/duodenal
ulcers, Gout, Neuropathy, Back pain, h/o carpal tunnel, cervical
radiculopathy

MEDICATION ON ADMISSION: atenolol 50', Cartia 120', Lisinopril 40', Prednisone 5'',
Naproyn 500'', Zocor 40', Nexium 40', Cochicine .6', ASA 81',
MVI', Vit B12, Vit D

ALLERGIES: Sulfa (Sulfonamides) / Ciprofloxacin

PHYSICAL EXAM: Vitals: 98.3, 76, 130/61, 24, 93RA
A&Ox3, NAD
NC/AT
NGT to low wall suction putting out thick light green fluid, no
blood
CV: RRR with 3/6 systolic murmur best heard LUSB
Pulm: lungs clear to auscultation bilaterally
GI: Distended, +BS, TTP in epigastrium and in RLQ. + tympany,
soft, no guarding or rebound tenderness, Rectal exam with
melanic
stool guiac +
GU: no foley
Ext: warm and dry

FAMILY HISTORY: nc

SOCIAL HISTORY: Married, smokes 2 ppd, retired reader's digest editor 

### Response:
{'Acute pancreatitis,Chronic or unspecified duodenal ulcer with perforation, with obstruction,Acute respiratory failure,Other retroperitoneal abscess,Infected hydrocele,Other postoperative infection,Delirium due to conditions classified elsewhere,Acute kidney failure, unspecified,Tobacco use disorder,Congestive heart failure, unspecified,Atrial fibrillation,Other inflammatory disorders of male genital organs,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic cholecystitis,Thrombocytopenia, unspecified'}
