CHIEF COMPLAINT: Right upper quadrant abdominal pain

PRESENT ILLNESS: The patient is an 85-year-old woman with a massive gallstone in
her gallbladder.  She is 2 months status post right upper
quadrant pain with a diagnosis of the large stone and acute
cholecystitis.  At that time due to a
transient troponin increased to 0.8 she was considered not to be
a candidate for surgery and she underwent a percutaneous
cholecystostomy.  Ultimately she did not rule in for myocardial
infarction.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Diastolic heart failure - likely NYHA II
-Atrial Fibrillation s/p AVJ ablation
- s/p Biotronik biventricular pacemaker placement at CSEMC [**8-13**]

MEDICATION ON ADMISSION: aspirin 325', atorvastatin 80', omeprazole 40', metoprolol
25", losartan 25', tramadol 50 prn, torsemide 10', metformin
500''', lorazepam 0.5", glipizide 5", cyclobenzaprine 5',
meclizine 12.5', ferrous sulfate 325', vit B-12

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 98.8  69  107/77  18  97% 4L NC
GEN: A&O, NAD, Russian speaking only
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no r/m/g
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender in RUQ/epigastrum. no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: 1+ LE edema, LE warm and well perfused

FAMILY HISTORY: Mother - died 79 ? cause
Father - died of old age
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: She lives alone with some assistance from nurses who come to her
home. She does not speak fluent English, her daughter has served
as a translator in past interactions.
Patient was a former technician doing mechanical drawings.
Lives alone. Patient walks with cane and also has walker.
-Tobacco history: Never smoked
-ETOH: None
-Illicit drugs: None
-Herbal Medications: None
Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute on chronic diastolic heart failure,Oliguria and anuria,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Unspecified transient cerebral ischemia,Hydrops of gallbladder,Unspecified transient mental disorder in conditions classified elsewhere,Umbilical hernia without mention of obstruction or gangrene,Urinary complications, not elsewhere classified,Other iatrogenic hypotension,Esophageal reflux,Unspecified essential hypertension,Laparoscopic surgical procedure converted to open procedure,Cardiac pacemaker in situ,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Cholelith w ac cholecyst,Ac on chr diast hrt fail,Oliguria & anuria,Chr pulmon heart dis NEC,DMII wo cmp nt st uncntr,Anemia NOS,Trans cereb ischemia NOS,Hydrops of gallbladder,Transient mental dis NOS,Umbilical hernia,Surg compl-urinary tract,Iatrogenc hypotnsion NEC,Esophageal reflux,Hypertension NOS,Lap surg convert to open,Status cardiac pacemaker,Abn reac-organ rem NEC
Admission Date:  [**2112-7-31**]              Discharge Date:   [**2112-8-6**]

Date of Birth:  [**2027-5-16**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
Right upper quadrant abdominal pain

Major Surgical or Invasive Procedure:
Laparoscopic, converted to open cholecystectomy
Umbilical hernia repair

History of Present Illness:
The patient is an 85-year-old woman with a massive gallstone in
her gallbladder.  She is 2 months status post right upper
quadrant pain with a diagnosis of the large stone and acute
cholecystitis.  At that time due to a
transient troponin increased to 0.8 she was considered not to be
a candidate for surgery and she underwent a percutaneous
cholecystostomy.  Ultimately she did not rule in for myocardial
infarction.

One month prior to this admission the tube was clamped.  She had
a drain study
which showed that there was flow of contrast injected through
the cholecystostomy tube into the cystic duct and common duct.
Three days PTA the drain was removed.  1 day PTA she experienced
right upper quadrant pain getting worse throughout the day.  She
presented to the emergency room with a white blood cell count of
11.6, alkaline phosphatase of 100, total bilirubin of 0.9.
Ultrasound showed less inflammation than was previously seen on
her ultrasound with a 4 cm stone in the gallbladder.  There was
no pericholecystic fluid or edema, but there was slight
stranding.


Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Diastolic heart failure - likely NYHA II
-Atrial Fibrillation s/p AVJ ablation
- s/p Biotronik biventricular pacemaker placement at CSEMC [**8-13**]

- not on warfarin because of life-threatening LGIB
3. OTHER PAST MEDICAL HISTORY:
-GERD
-Anxiety
-Anemia


Social History:
She lives alone with some assistance from nurses who come to her
home. She does not speak fluent English, her daughter has served
as a translator in past interactions.
Patient was a former technician doing mechanical drawings.
Lives alone. Patient walks with cane and also has walker.
-Tobacco history: Never smoked
-ETOH: None
-Illicit drugs: None
-Herbal Medications: None


Family History:
Mother - died 79 ? cause
Father - died of old age
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

Physical Exam:
Vitals: 98.8  69  107/77  18  97% 4L NC
GEN: A&O, NAD, Russian speaking only
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no r/m/g
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender in RUQ/epigastrum. no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: 1+ LE edema, LE warm and well perfused


Pertinent Results:
CBC - 11.6 > 37.2 < 185
N:85.6 L:9.8 M:4.2 E:0.3 Bas:0.1

134 | 95 |  12
---------------< 188
3.3 | 27 | 1.0

AST: 36  ALT: 19  AP: 100  Tbili: 0.9  Lip: 16
PT: 14.0  PTT: 25.5  INR: 1.2

EKG: biventricular pacing, unchanged from prior. Recent
interrogation of her Biotronik device shows 13 months of battery
life left. She is [**Age over 90 **]% V-paced with underlying AF with slow VR.

RUQ U/S: Large gallstone (3-4 cm) partially impacted at GB neck.
GB distended w/ wall edema, + [**Doctor Last Name **]. No free fluid. Shadowing
limits eval of CBD.



Brief Hospital Course:
Ms. [**Known lastname 28613**] was taken the operating room on [**2112-7-31**] for a lap
converted to open cholecystectomy, largely due to the size of
stone and difficulties associated with body habitus.  Please
refer to Dr.[**Name (NI) 6218**] operative note for additional details.

Post-operatively, she was admitted to the ICU for further care
due to severe pain and low urine output requiring heavy fluid
resuscitation in the setting of her multiple comorbidities and
pulmonary hypertension.  Overall, her neuro status wasw normal.
She had some post-op agitation into POD [**1-10**] which was treated
with haloperidol and ultimately resolved.  She remained with
normal mental status throughout the rest of her course.  Her
pain was managed with an epidural placed by the acute pain
service team and was subsequently removed on POD 4 without
incident; she tolerated a dilaudid PCA then oral pain when
appropriate.

She required pressors intermittently into POD 2 and remained HD
stable thereafter.  From a pulmonary perspective, CXRs were
routinely monitored for fluid overload and she was dosed with IV
lasix a couple times in order to manage her fluid balance.
Urine output improved gradually.  From a renal perspective, her
Cr did increase immediately post-operatively, peaking on [**8-3**] to
1.8 before trending downwards.  This was attributed to fluid
resuscitation issues post-op as well as lasix therapy.

From a GI perspective she was NPO initially and advanced to a
regular diet over the course of her hospitalization.  She
tolerated regular diet without incident.

She was kept on ciprofloxacin/flagyl for antibiotic coverage
until POD #3.

Of note, patient was noted to have decreased movement in her
left side during an episode of hypotension in the post-operative
period while in the ICU.  A carotid ultrasound was performed and
did not show plaque at the bifurcation but did show some flow
abnormalities including reversal of flow indicative of a
proximal lesion.  This is to be followed up as an outpatient
with further imaging potentially required.  Due to the symptoms
resolving and its overall lack of acuity this was not
readdressed during this hospitalization.

Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.

At the time of discharge on POD#6, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.


Medications on Admission:
aspirin 325', atorvastatin 80', omeprazole 40', metoprolol
25", losartan 25', tramadol 50 prn, torsemide 10', metformin
500''', lorazepam 0.5", glipizide 5", cyclobenzaprine 5',
meclizine 12.5', ferrous sulfate 325', vit B-12


Discharge Medications:
1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain for 14 days.
Disp:*120 Tablet(s)* Refills:*0*
2. glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. cyclobenzaprine 10 mg Tablet Sig: Five (5) Tablet PO DAILY
(Daily).
5. ciclopirox 0.77 % Suspension Sig: Two (2)  Topical once a
day: to right thumb nail and between fingers.
6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day.
7. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day.
8. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO once a day as
needed for dizziness.
9. metformin 500 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. sucralfate 1 gram Tablet Sig: One (1) Tablet PO at bedtime.

12. torsemide 10 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Home With Service

Facility:
CityWide Home Care Inc

Discharge Diagnosis:
Cholecystitis and umbilical hernia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the general surgery service for a hernia
repair and cholecystectomy.

Please call your doctor or go to the emergency department if:
*You experience new chest pain, pressure, squeezing or
tightness.
*You develop new or worsening cough, shortness of breath, or
wheeze.
*You are vomiting and cannot keep down 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.
*You experience burning when you urinate, have blood in your
urine, or experience an unusual discharge.
*Your pain is not improving within 12 hours or is not under
control within 24 hours.
*Your pain worsens or changes location.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*You develop any concerning symptoms.

General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any new
medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 20
lbs., until you follow-up with your surgeon, who will instruct
you further regarding activity restrictions. Please also
follow-up with your primary care physician.

Incision Care:
*Please call your surgeon or go to the emergency department if
you have increased pain, swelling, redness, or drainage from the
incision site.
*Avoid swimming and baths until cleared by your surgeon.
*You may shower and wash incisions with a mild soap and warm
water. Gently pat the area dry.
*You have staples. Please have them removed at your follow up
appointment at the general surgery clinic.

HOW YOU [**Month (only) **] FEEL:
You may feel weak or ??????washed out?????? for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All these feelings and reactions are normal and should go away
in a short time. If they do not, tell your surgeon.

YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that, it??????s OK.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.

YOUR BOWELS:

Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as Milk
of Magnesia, 1 tablespoon) twice a day. You can get both of
these medicines without a prescription.

If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.

After some operations, diarrhea can occur. If you get diarrhea,
[**Male First Name (un) **]??????t take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your surgeon.

Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more
than 3 lbs.

Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] upon discharge to
arrange a follow up appointment in [**1-10**] weeks. Office is located
at [**Hospital1 18**], [**Hospital 2577**] Medical Office Building, [**Location (un) **].

Please follow up with your PCP regarding your carotid artery
study and the need for an MRA or CTA of the arch, neck and
intracranial vessels.

Please follow up with a physical therapist in your area.



Completed by:[**2112-8-6**]

Name:  [**Known lastname 14733**], [**First Name3 (LF) 6371**]
Unit No: [**Unit Number 14734**]
Admission Date: [**2112-7-31**]
Discharge Date: [**2112-8-6**]
Date of Birth: [**2027-5-16**]
Sex: F
Service: SURGERY


ADDENDUM:  The pulmonary edema that she has experienced
during this admission was acute and indeed was diastolic CHF
or cardiogenic in etiology.



                        [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(1) 846**]

Dictated By:[**Last Name (NamePattern4) 6631**]
MEDQUIST36
D:  [**2112-9-16**] 13:36:13
T:  [**2112-9-16**] 14:10:53
Job#:  [**Job Number 14735**]
{'Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute on chronic diastolic heart failure,Oliguria and anuria,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Unspecified transient cerebral ischemia,Hydrops of gallbladder,Unspecified transient mental disorder in conditions classified elsewhere,Umbilical hernia without mention of obstruction or gangrene,Urinary complications, not elsewhere classified,Other iatrogenic hypotension,Esophageal reflux,Unspecified essential hypertension,Laparoscopic surgical procedure converted to open procedure,Cardiac pacemaker in situ,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


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: Right upper quadrant abdominal pain

PRESENT ILLNESS: The patient is an 85-year-old woman with a massive gallstone in
her gallbladder.  She is 2 months status post right upper
quadrant pain with a diagnosis of the large stone and acute
cholecystitis.  At that time due to a
transient troponin increased to 0.8 she was considered not to be
a candidate for surgery and she underwent a percutaneous
cholecystostomy.  Ultimately she did not rule in for myocardial
infarction.

MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- Diastolic heart failure - likely NYHA II
-Atrial Fibrillation s/p AVJ ablation
- s/p Biotronik biventricular pacemaker placement at CSEMC [**8-13**]

MEDICATION ON ADMISSION: aspirin 325', atorvastatin 80', omeprazole 40', metoprolol
25", losartan 25', tramadol 50 prn, torsemide 10', metformin
500''', lorazepam 0.5", glipizide 5", cyclobenzaprine 5',
meclizine 12.5', ferrous sulfate 325', vit B-12

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals: 98.8  69  107/77  18  97% 4L NC
GEN: A&O, NAD, Russian speaking only
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, no r/m/g
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, tender in RUQ/epigastrum. no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: 1+ LE edema, LE warm and well perfused

FAMILY HISTORY: Mother - died 79 ? cause
Father - died of old age
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.

SOCIAL HISTORY: She lives alone with some assistance from nurses who come to her
home. She does not speak fluent English, her daughter has served
as a translator in past interactions.
Patient was a former technician doing mechanical drawings.
Lives alone. Patient walks with cane and also has walker.
-Tobacco history: Never smoked
-ETOH: None
-Illicit drugs: None
-Herbal Medications: None 

### Response:
{'Calculus of gallbladder with acute cholecystitis, without mention of obstruction,Acute on chronic diastolic heart failure,Oliguria and anuria,Other chronic pulmonary heart diseases,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Anemia, unspecified,Unspecified transient cerebral ischemia,Hydrops of gallbladder,Unspecified transient mental disorder in conditions classified elsewhere,Umbilical hernia without mention of obstruction or gangrene,Urinary complications, not elsewhere classified,Other iatrogenic hypotension,Esophageal reflux,Unspecified essential hypertension,Laparoscopic surgical procedure converted to open procedure,Cardiac pacemaker in situ,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
