CHIEF COMPLAINT: 1. Retroperitoneal sepsis.
2. Duodenal cutaneous fistula.
3. Biliary obstruction.
4. Extensive adhesions of intraabdominal contents.

PRESENT ILLNESS: Mr. [**Name13 (STitle) **] is a 74-year-old
gentleman who has suffered a difficult problem over the last
6 to 8 months. He originally had a peptic ulcer which was
treated by embolization techniques of the gastroduodenal
artery. In the process of this, the pancreatic head was
necrosed. This led to a retroperitoneal sepsis which I had
ultimately took care of. He required a retroperitoneal
exploration and drainage originally. At that time, the head
of the pancreas and duodenum were found to be necrotic from
this process. He subsequently recovered from this, but over
the last 6 months suffered from recurrent bouts of
intraabdominal and retroperitoneal sepsis. These have been
treated by percutaneous tube decompressions. However, on each
occasion the sepsis has recurred. Accordingly, a fistulogram
was obtained in the last month and this indeed showed
communication of this retroperitoneal right upper quadrant
abscess collection with the duodenum. Based on this, we knew
that the source of this festering infection was in fact his
duodenum. A CAT scan was obtained and this suggested a
lateral tenting of the duodenum into the retroperitoneum
consistent with a fistula tract. Furthermore, he had
developed significant biliary dilation over this time with
the bile duct over 1.5 cm in diameter. This had contrast
within it and there was pneumoperitoneum indicated that there
was connection perhaps with the GI tract. Nonetheless, it was
significantly dilated indicative of downstream obstruction.
This would not be surprising given the fact that the head of
his pancreas literally was necrotic where I first encountered
him.

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: 1. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (4) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Folic Acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Sulfa (Sulfonamides) / Ciprofloxacin

PHYSICAL EXAM: AVSS
Gen: NAD, neck brace
HEENT: PERRLA, EOMI, OC/OP clear
Neck: brace; no LAD
CV: RRR, 2/6 SEM at LUSB, no gallops or rubs
Pulm: CTA B/L
Abd: +BS, nd, soft, tender to deep palpation throughought,
incisions are well healed; no CVA tenderness; percutaneous drain
in R flank, murky, yellow fluid
LE: no edema
Neuro: CN2-12 intact

FAMILY HISTORY: nc

SOCIAL HISTORY: Married, smokes 2 ppd, retired reader's digest editor
Other postoperative infection,Unspecified septicemia,Sepsis,Other retroperitoneal abscess,Fistula of stomach or duodenum,Obstruction of bile duct,Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Acute posthemorrhagic anemia,Unspecified essential hypertension,Gout, unspecified,Dermatitis due to drugs and medicines taken internally
Other postop infection,Septicemia NOS,Sepsis,Retroperiton abscess NEC,Gastric/duodenal fistula,Obstruction of bile duct,Intestinal adhes w obstr,Ac posthemorrhag anemia,Hypertension NOS,Gout NOS,Drug dermatitis NOS
Admission Date:  [**2201-1-21**]              Discharge Date:   [**2201-2-12**]

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

Service: SURGERY

Allergies:
Sulfa (Sulfonamides) / Ciprofloxacin

Attending:[**Known firstname 148**]
Chief Complaint:
1. Retroperitoneal sepsis.
2. Duodenal cutaneous fistula.
3. Biliary obstruction.
4. Extensive adhesions of intraabdominal contents.

Major Surgical or Invasive Procedure:
1. Exploratory laparotomy.
2. Extended adhesiolysis.
3. Duodenal cutaneous fistula takedown with primary closure
    of the duodenum.
4. Choledochojejunostomy (Roux-en-Y).
5. Gastroenterostomy.
6. J-tube placement.
7. Drainage of retroperitoneal sepsis.
8. Small-bowel resection.


History of Present Illness:
Mr. [**Name13 (STitle) **] is a 74-year-old
gentleman who has suffered a difficult problem over the last
6 to 8 months. He originally had a peptic ulcer which was
treated by embolization techniques of the gastroduodenal
artery. In the process of this, the pancreatic head was
necrosed. This led to a retroperitoneal sepsis which I had
ultimately took care of. He required a retroperitoneal
exploration and drainage originally. At that time, the head
of the pancreas and duodenum were found to be necrotic from
this process. He subsequently recovered from this, but over
the last 6 months suffered from recurrent bouts of
intraabdominal and retroperitoneal sepsis. These have been
treated by percutaneous tube decompressions. However, on each
occasion the sepsis has recurred. Accordingly, a fistulogram
was obtained in the last month and this indeed showed
communication of this retroperitoneal right upper quadrant
abscess collection with the duodenum. Based on this, we knew
that the source of this festering infection was in fact his
duodenum. A CAT scan was obtained and this suggested a
lateral tenting of the duodenum into the retroperitoneum
consistent with a fistula tract. Furthermore, he had
developed significant biliary dilation over this time with
the bile duct over 1.5 cm in diameter. This had contrast
within it and there was pneumoperitoneum indicated that there
was connection perhaps with the GI tract. Nonetheless, it was
significantly dilated indicative of downstream obstruction.
This would not be surprising given the fact that the head of
his pancreas literally was necrotic where I first encountered
him.

After shepherding Mr. [**Name13 (STitle) **] through many months of
rehabilitation and increase improving nutritional status, I
posed to him that he is now suitably ready for definitive
operation to address this persistent infectious problem. [**Name (NI) **]
at this point had no forward progress being made because of
this. We continued to support him through an enteral feedings
through a J tube because his appetite was poor.

I had many long and detailed discussions with Mr. [**Name13 (STitle) **]
and his wife and daughter about this dilemma and the need for
definitive surgical intervention on this area. I described to
him the fact that I had hoped that this could be a limited
excision of the fistulous tract and bypass the biliary
system. On the other hand, I prepared him for a Whipple's
pancreaticoduodenectomy should there be evidence that the
whole duodenum and pancreatic head was destroyed by this
process and involved with the fistulous retroperitoneal
sepsis. We discussed the risks and benefits of this
operation, and his risks included poor wound healing,
bleeding and infection as well as the significant chance of
leaks or breakdowns in any of the connection. We also talked
about the other traditional risks of major abdominal surgery
including heart attack, stroke, pulmonary and renal failure
as well as cardiac problems. I did quote him a significant
chance of death from this operation on the terms of [**2-16**]%. He
and his wife understood these risks and he wished to proceed.

We went to the operating room on the morning of [**2201-1-21**]
with the intent of forming a duodenal cutaneous fistulas
takedown and debridement and drainage of retroperitoneal
sepsis as well as a biliary bypass.


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:
AVSS
Gen: NAD, neck brace
HEENT: PERRLA, EOMI, OC/OP clear
Neck: brace; no LAD
CV: RRR, 2/6 SEM at LUSB, no gallops or rubs
Pulm: CTA B/L
Abd: +BS, nd, soft, tender to deep palpation throughought,
incisions are well healed; no CVA tenderness; percutaneous drain
in R flank, murky, yellow fluid
LE: no edema
Neuro: CN2-12 intact


Pertinent Results:
[**2201-1-21**] 11:44AM   freeCa-1.33*
[**2201-1-21**] 11:44AM   HGB-9.0* calcHCT-27
[**2201-1-21**] 11:44AM   GLUCOSE-175* LACTATE-1.4 NA+-134* K+-4.6
CL--101
[**2201-1-21**] 11:44AM   TYPE-ART PO2-174* PCO2-37 PH-7.45 TOTAL
CO2-27 BASE XS-2 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-1-21**] 02:34PM   HGB-9.2* calcHCT-28
[**2201-1-21**] 02:34PM   LACTATE-1.9 K+-3.9
[**2201-1-21**] 02:34PM   TYPE-ART PO2-203* PCO2-34* PH-7.44 TOTAL
CO2-24 BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED
[**2201-1-21**] 04:36PM   freeCa-1.20
[**2201-1-21**] 04:36PM   HGB-9.7* calcHCT-29
[**2201-1-21**] 04:36PM   GLUCOSE-109* LACTATE-2.4* NA+-134* K+-4.2
CL--105
[**2201-1-21**] 04:36PM   TYPE-ART PO2-216* PCO2-36 PH-7.41 TOTAL
CO2-24 BASE XS-0 INTUBATED-INTUBATED
[**2201-1-21**] 07:17PM   PT-17.1* INR(PT)-1.5*
[**2201-1-21**] 07:17PM   PLT COUNT-239
[**2201-1-21**] 07:17PM   WBC-8.4 RBC-2.75* HGB-9.4* HCT-26.3* MCV-96
MCH-34.1* MCHC-35.7* RDW-14.3
[**2201-1-21**] 07:17PM   ALBUMIN-2.7*
[**2201-1-21**] 07:17PM   CK-MB-8 cTropnT-0.07*
[**2201-1-21**] 07:17PM   CK(CPK)-185*
[**2201-1-21**] 07:17PM   estGFR-Using this
[**2201-1-21**] 07:17PM   GLUCOSE-111* UREA N-31* CREAT-1.3* SODIUM-136
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-21* ANION GAP-13
[**2201-1-21**] 11:57PM   HCT-25.9*
.

[**2201-2-9**] 01:10PM BLOOD WBC-12.6* RBC-2.90* Hgb-9.9* Hct-28.6*
MCV-99* MCH-34.3* MCHC-34.7 RDW-14.8 Plt Ct-421
[**2201-2-8**] 08:40AM BLOOD Glucose-114* UreaN-15 Creat-0.7 Na-133
K-5.0 Cl-103 HCO3-24 AnGap-11
[**2201-2-9**] 01:10PM BLOOD ALT-12 AST-16 AlkPhos-97 TotBili-0.6
[**2201-2-8**] 08:40AM BLOOD Calcium-9.4 Phos-2.1* Mg-1.6
.
Radiology Report UGI SGL CONTRAST W/ KUB Study Date of [**2201-1-29**]
10:07 AM
IMPRESSION:
1. Contrast in the stomach flows very slowly into the duodenum
and the
afferent and efferent loops of the gastrojejunostomy. It is
unclear whether
contrast passes through the efferent limb into more distal small
bowel.
Therefore, efferent loop obstruction or ileus cannot be
excluded. No definite
extravasation of contrast is seen, particularly in the region of
prior
duodenocutaneous fistula.
2. Increased density of left retrocardiac opacity, with now
obscuration of
the left hemidiaphragm. While this likely represents increased
atelectasis,
aspiration or infection cannot be excluded. Small left pleural
effusion also
cannot be excluded.
.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2201-2-2**]
3:04 PM
IMPRESSION:
1. No evidence of bowel obstruction.
2. Anterior abdominal wall defect with underlying ill- defined
collection
deep with multiple foci of gas.
3. Small rim-enhancing fluid collection with a focus of gas
within the left
abdomen.
4. Right upper quadrant catheter terminating medial to the liver
that does
not appear to be within a defined collection.
5. Moderate bilateral pleural effusions with underlying
atelectasis or
consolidation.
.
Radiology Report BAS/UGI AIR/SBFT Study Date of [**2201-2-9**] 2:59 PM

IMPRESSION: Patent gastrojejunal anastomosis with free passage
of contrast.
.
Radiology Report PORTABLE ABDOMEN Study Date of [**2201-2-10**] 5:10 AM

Preliminary Report !! PFI !!
No evidence of obstruction. Reflex of contrast in the biliary
tree, from
jejunal limb.
.
[**2201-1-21**] 12:56 pm SWAB      PERITONEAL ABSCESS.
   GRAM STAIN (Final [**2201-1-21**]):
      3+  (5-10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      2+   (1-5 per 1000X FIELD):   GRAM NEGATIVE ROD(S).
   WOUND CULTURE (Final [**2201-2-6**]):
      REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] @ 2:15 PM ON [**2201-1-27**].
      KLEBSIELLA PNEUMONIAE.    SPARSE GROWTH.
.


Brief Hospital Course:
This is a 74 yo male well know to the service. He went to the OR
for
1. Retroperitoneal sepsis.
2. Duodenal cutaneous fistula.
3. Biliary obstruction.
4. Extensive adhesions of intraabdominal contents.

NAME OF PROCEDURES:
1. Exploratory laparotomy.
2. Extended adhesiolysis.
3. Duodenal cutaneous fistula takedown with primary closure
of the duodenum.
4. Choledochojejunostomy (Roux-en-Y).
5. Gastroenterostomy.
6. J-tube placement.
7. Drainage of retroperitoneal sepsis.
8. Small-bowel resection.

Events:
[**1-21**]: 1U PRBC in PACU
[**1-22**]: Extubated, Unasyn D/Ced, LR decreased to 100cc/h
[**1-23**]: CK and Trop trending down, IV fluid changed to D5 1/2 NS
@ 75cc/h. Transfer to the floor
[**2108-1-24**]: Given albumin x 2, FeNa 0.09%, ID recs 2 weeks of
Meropenem [**Month/Day/Year 621**], NGT replaced for 1L> ? swelling to RUE. US showed
no clot.
[**1-27**]: Cx + for Carbapenamase producing Klebsiella from
abscess--> changed [**First Name9 (NamePattern2) **] [**Last Name (un) **]--> Tobra per ID recs.
[**1-28**]: stopped maintenance IVF, cont cc:cc replacement JP + NGT
losses, restarted Tube feeds (Peptamen); albumin and lasix given

[**1-29**]: lasix given, clamped NG. Thin barium study. Nauseated. >
400 ml residual, reattached NG tube.
[**1-30**]: clamp trial. nauseous, NG reattached. rash per abdomen,
lower extremity - worsened, stopped repletion of ng and jp.
Patient's weight 168 lbs.
[**1-31**]: DC [**Month/Year (2) 621**], worsening rash to arms. ? allergy to flagyl. ID
consult agrees with allergy to antibiotics as cause
[**2-1**] - [**2-8**]: Failed multiple clamp trials. Patient averaged
about 4-5 hour of suction free period.
[**2-9**]: Febrile to 101.9 (HR119), started Vanc/Unasyn for new
retrocardiac opacity on CXR. Nauseated on clamp trial, NGT put
to suction.
Vanc and Unasyn stopped due to rash.
[**2-9**] UGI/SBI: Patent gastrojejunal anastomosis with free
passage of contrast.
[**2-10**] PEG placement.
[**2-11**]: G-tube capped, patient tolerating this.
[**2-12**]: Discharged home with tubefeedings and capped G-tube.

Pathology
I. Small bowel segment (A-B): Within normal limits.
II. Small bowel fistula site (C): Small bowel fragment with
chronic active inflammation and marked fibrosis.
III. Abscess bed (D-E): Fibroadipose tissue with foreign body
reaction and marked fibrosis.


Medications on Admission:
1. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (4) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Folic Acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).

3. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Day (4) **]: One (1)
Tablet PO BID (2 times a day).
4. Atorvastatin 40 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY
(Daily).
5. Lisinopril 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).

6. Metoprolol Tartrate 50 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO TID
(3 times a day).
7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Month/Day (4) **]: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
8. Trazodone 100 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO HS (at
bedtime).
9. Multivitamin     Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).

10. Senna 8.6 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
11. Oxycodone 5 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q6H (every 6
hours) as needed.
Disp:*40 Tablet(s)* Refills:*0*
12. KANGAROO PUMP
13. Jevity 1.2, 3 Cans daily
14. Doxycycline Hyclate 100 mg Capsule [**Month/Day (4) **]: One (1) Capsule PO
Q12H (every 12 hours): continue until surgery, as directed by
infectious disease.
Disp:*60 Capsule(s)* Refills:*1*


Discharge Medications:
1. Metoclopramide 10 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO Q6H (every
6 hours).
Disp:*120 Tablet(s)* Refills:*2*
2. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2*
3. Feeding Pump
Feeding Pump for J-tube feeds at home.
4. Tube feeding
Jevity 1.2.
Starting rate: 110 ml/hr; Goal rate: 110 ml/hr
Cycle?: Yes, starting now Cycle start: 1800 Cycle end: 1000

Flush w/ 30 ml water q8h
5. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: [**12-1**]  PO Q6H (every
6 hours) as needed for pain: Do not exceed 4000mg of tylenol in
24 hours. Feed via J-tube.
Disp:*600 mL* Refills:*0*
6. Oxycodone 5 mg/5 mL Solution [**Month/Year (2) **]: 5-10 mg PO every 4-6 hours
as needed for pain: Do not operate heavy machinery or consume
alcohol. [**Month (only) 116**] cause sedation. .
Disp:*500 mg* Refills:*0*
7. Docusate Sodium 50 mg/5 mL Liquid [**Month (only) **]: One Hundred (100) mg
PO BID (2 times a day): give Via J-tube.
take while using narcotics for pain control to help prevent
constipation.
Disp:*600 mL* Refills:*1*
8. Fentanyl 50 mcg/hr Patch 72 hr [**Month (only) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
Disp:*6 Patch 72 hr(s)* Refills:*0*

Testosterone patch


Discharge Disposition:
Home With Service

Facility:
VNA Assoc. of [**Hospital3 **]

Discharge Diagnosis:
1. Retroperitoneal sepsis.
2. Duodenal cutaneous fistula.
3. Biliary obstruction.
4. Extensive adhesions of intraabdominal contents.
5. Post-op Blood Loss anemia
6. KLEBSIELLA PNEUMONIAE.
7. Rash related to antibiotic allergy


Discharge Condition:
hemodynamically stable, tolerating tube feeds, ambulating, pain
controlled with an oral regimen


Discharge Instructions:
Incision Care: Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
You have been given teaching for your feeding jejunostomy tube
and G-tube. Please flush the tube as you have been taught &
please call our office or come to the ED if you notice
increasing swelling, redness or drainage around the insertion
site. You may return to your original feeding regimen with
Jevity 1.2.
.
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.
* Call you Doctors office for inability to tolerate G-tube
capping for >24 hours or >1.5 liter output over 24 hours. Please
also call if tolerating 24 hour capping for >1 week
* 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 ambulate several times per day.
* No heavy ([**11-26**] lbs) until your follow up appointment.

G-Tube use:
You recently had a G-tube placed to assist with managment of
your nausea and vomiting. The G-tube should remain capped unless
you feel nauseous or your abdomen becomes distended and
uncomfortable. If you feel nauseous, remove the cap and attach
the G-tube to a drainage bag as you have been taught. The bag
will help to remove the contents of your stomach and decrease
the nausea. Please use care when capping and uncapping the
G-tube so you do not accidentally pull it out. It is sutured in
place, but care should be exercised. If you develop increasing
redness/pain/swelling at the site of the G-tube call the office
or come to the ED for evaluation.

Diet:
You may take sips of clear liquid throughout the day for
comfort. If you become nauseous uncap the G-tube and attach to a
bag for drainage. If you are able to tolerate a capped G-tube
for 24 hours you may cautiously increase your dietary intake of
clear liquids and food (jello, clear broth etc.). DO NOT advance
diet beyond clears. You are recieving all the necessary calories
and nutrition via your nightly tube feeds into your J-tube.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) **] in 3 weeks. Call his office at
([**Telephone/Fax (1) 2363**].



Completed by:[**2201-2-12**]
{'Other postoperative infection,Unspecified septicemia,Sepsis,Other retroperitoneal abscess,Fistula of stomach or duodenum,Obstruction of bile duct,Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Acute posthemorrhagic anemia,Unspecified essential hypertension,Gout, unspecified,Dermatitis due to drugs and medicines taken internally'}


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: 1. Retroperitoneal sepsis.
2. Duodenal cutaneous fistula.
3. Biliary obstruction.
4. Extensive adhesions of intraabdominal contents.

PRESENT ILLNESS: Mr. [**Name13 (STitle) **] is a 74-year-old
gentleman who has suffered a difficult problem over the last
6 to 8 months. He originally had a peptic ulcer which was
treated by embolization techniques of the gastroduodenal
artery. In the process of this, the pancreatic head was
necrosed. This led to a retroperitoneal sepsis which I had
ultimately took care of. He required a retroperitoneal
exploration and drainage originally. At that time, the head
of the pancreas and duodenum were found to be necrotic from
this process. He subsequently recovered from this, but over
the last 6 months suffered from recurrent bouts of
intraabdominal and retroperitoneal sepsis. These have been
treated by percutaneous tube decompressions. However, on each
occasion the sepsis has recurred. Accordingly, a fistulogram
was obtained in the last month and this indeed showed
communication of this retroperitoneal right upper quadrant
abscess collection with the duodenum. Based on this, we knew
that the source of this festering infection was in fact his
duodenum. A CAT scan was obtained and this suggested a
lateral tenting of the duodenum into the retroperitoneum
consistent with a fistula tract. Furthermore, he had
developed significant biliary dilation over this time with
the bile duct over 1.5 cm in diameter. This had contrast
within it and there was pneumoperitoneum indicated that there
was connection perhaps with the GI tract. Nonetheless, it was
significantly dilated indicative of downstream obstruction.
This would not be surprising given the fact that the head of
his pancreas literally was necrotic where I first encountered
him.

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: 1. Fentanyl 50 mcg/hr Patch 72 hr [**Month/Day (4) **]: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. Folic Acid 1 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily).

ALLERGIES: Sulfa (Sulfonamides) / Ciprofloxacin

PHYSICAL EXAM: AVSS
Gen: NAD, neck brace
HEENT: PERRLA, EOMI, OC/OP clear
Neck: brace; no LAD
CV: RRR, 2/6 SEM at LUSB, no gallops or rubs
Pulm: CTA B/L
Abd: +BS, nd, soft, tender to deep palpation throughought,
incisions are well healed; no CVA tenderness; percutaneous drain
in R flank, murky, yellow fluid
LE: no edema
Neuro: CN2-12 intact

FAMILY HISTORY: nc

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

### Response:
{'Other postoperative infection,Unspecified septicemia,Sepsis,Other retroperitoneal abscess,Fistula of stomach or duodenum,Obstruction of bile duct,Intestinal or peritoneal adhesions with obstruction (postoperative) (postinfection),Acute posthemorrhagic anemia,Unspecified essential hypertension,Gout, unspecified,Dermatitis due to drugs and medicines taken internally'}
