CHIEF COMPLAINT: Obstructive jaundice
Reason for MICU transfer: AF with RVR

PRESENT ILLNESS: Ms. [**Known lastname 30380**] is a 73 year old woman with history of HTN and
recurrent UTIs was brought in to OSH ED by EMS with confusion
and jaundice.  At the OSH she was found to have a UA suggestive
of UTI with WBC "too numerous to count".  RUQ US and CT were
performed showing bile duct dilation to over 2 cm with the
presence of stones, sludge and debris. Labs were significant for
WBC 17, T bili 16.7, Alk phos 234, ast/alt 112/150, cr 0.7. She
was given Zosyn 4.5 g IV empirically for her UTI and concern for
biliary infection.  She remained afebrile and hemodynamically
stable throughout. She was then transferred to [**Hospital1 18**] for
definitive treatment with ERCP.  En route to [**Hospital1 18**] patient
developed an irregular tachycardia with rates to 150s.  She was
asymptomatic and denied chest pain or shortness of breath.
73-year-old female who was being transferred from outside
hospital here for ERCP, en route developed tachycardia to 170s,
by EMS found to be in atrial fibrillation. She states she was at
another hospital yesterday the 2 abdominal pain and jaundice,
was supposed to have ERCP done today. Currently she says she
feels chills, no pain.

MEDICAL HISTORY: HTN
Spinal stenosis
Osteoarthritis s/p R hip replacement
Recurrent UTIs
Anxiety
Fluid retention
Hyponatremia in the setting of HCTZ use

MEDICATION ON ADMISSION: (per OSH records):
Lasix 20 mg daily
Prempro 0.45/1.5 one tablet daily
Potassium 10 meq [**Hospital1 **]
Trazodone 12.5 mg qhs
Atorvastatin 20 mg daily
Ibuprofen 600 mg tid
Polyethylene glycol 17 g daily
Docusate 100 mg po bid
Cozaar 100 mg daily
Nexium 40 mg daily
Zyrtec 10 mg daily
Omega 3 1200 mg [**Hospital1 **]
Vitamin E 400 IU daily
Calcium carbonate 600 Vitamin D one daily
MV daily
Cymbalta 60 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 99.4 BP: 119/65 HR: 140 RR: 21 O2sat 95% RA
GEN: pleasant, jaundiced, drowsy comfortable, NAD
HEENT: PERRL, disconjugate gaze, icteric, very dry MM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
JVD difficult to assess
RESP: poor inspiratory effort, good air movement throughout
CV: distant heart sounds, tachycardic, irregular, no m/r/g
ABD: obese, no ascites, nd, +b/s, soft, nt
EXT: no c/c/e , 2+ distal pulses
SKIN: diffusely juandiced, no rashes
NEURO: awake but drowsy, oriented to person x 2. Cn II-XII
intact. Strength difficult to assess given inattentiveness, and
drowsiness.  Moving all four extremities, + tremor with exertion
vs asterixis, No sensory deficits to light touch appreciated.

FAMILY HISTORY: Unable to obtain as patient confused.

SOCIAL HISTORY: Patient lives alone and is independent of all ADLs. She denies
any history of tobacco use.  She reports a history of social
alcohol use but denies any alcohol use in months.  She denies
use of illicit drugs and herbal medications.
Calculus of bile duct without mention of cholecystitis, with obstruction,Hyperosmolality and/or hypernatremia,Cholangitis,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension
Choledochlith NOS w obst,Hyperosmolality,Cholangitis,Urin tract infection NOS,Atrial fibrillation,Hypertension NOS
Admission Date:  [**2185-11-8**]              Discharge Date:   [**2185-11-10**]

Date of Birth:  [**2111-12-12**]             Sex:   F

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
Obstructive jaundice
Reason for MICU transfer: AF with RVR

Major Surgical or Invasive Procedure:
ERCP


History of Present Illness:
Ms. [**Known lastname 30380**] is a 73 year old woman with history of HTN and
recurrent UTIs was brought in to OSH ED by EMS with confusion
and jaundice.  At the OSH she was found to have a UA suggestive
of UTI with WBC "too numerous to count".  RUQ US and CT were
performed showing bile duct dilation to over 2 cm with the
presence of stones, sludge and debris. Labs were significant for
WBC 17, T bili 16.7, Alk phos 234, ast/alt 112/150, cr 0.7. She
was given Zosyn 4.5 g IV empirically for her UTI and concern for
biliary infection.  She remained afebrile and hemodynamically
stable throughout. She was then transferred to [**Hospital1 18**] for
definitive treatment with ERCP.  En route to [**Hospital1 18**] patient
developed an irregular tachycardia with rates to 150s.  She was
asymptomatic and denied chest pain or shortness of breath.
73-year-old female who was being transferred from outside
hospital here for ERCP, en route developed tachycardia to 170s,
by EMS found to be in atrial fibrillation. She states she was at
another hospital yesterday the 2 abdominal pain and jaundice,
was supposed to have ERCP done today. Currently she says she
feels chills, no pain.

In the ED initial vital signs were, T 98.9 BP 120/86 HR 170 RR
20 SpO2 98%.  She was found to be in atrial fibrillation with
rates reaching 180s. She was given diltiazem 15 mg IV x 2 with
minimal response. She was started on a diltiazem gtt which was
titrated up to 15mg/hr.  With addition of small metoprolol
boluses of 5 mg IV x 3 her heart rate was in 120s to 130s.  She
had no documented episodes of hypotension and did not report
chest pain or shortness of breath. She received 4 L NS, Zosyn
4.5 g IV, and magnesium 2 g IV prior to transfer to the ICU.
.
On arrival to the ICU, patient was drowsy but able to speak in
full sentences. On questioning she denied any localizing
complaints.  She reported that she had abdominal pain for almost
a week.  She was uncertain when she started to become jaundiced.
She was confused and unable to give reliable history regarding
associated symptoms.


Past Medical History:
HTN
Spinal stenosis
Osteoarthritis s/p R hip replacement
Recurrent UTIs
Anxiety
Fluid retention
Hyponatremia in the setting of HCTZ use


Social History:
Patient lives alone and is independent of all ADLs. She denies
any history of tobacco use.  She reports a history of social
alcohol use but denies any alcohol use in months.  She denies
use of illicit drugs and herbal medications.


Family History:
Unable to obtain as patient confused.


Physical Exam:
Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 99.4 BP: 119/65 HR: 140 RR: 21 O2sat 95% RA
GEN: pleasant, jaundiced, drowsy comfortable, NAD
HEENT: PERRL, disconjugate gaze, icteric, very dry MM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
JVD difficult to assess
RESP: poor inspiratory effort, good air movement throughout
CV: distant heart sounds, tachycardic, irregular, no m/r/g
ABD: obese, no ascites, nd, +b/s, soft, nt
EXT: no c/c/e , 2+ distal pulses
SKIN: diffusely juandiced, no rashes
NEURO: awake but drowsy, oriented to person x 2. Cn II-XII
intact. Strength difficult to assess given inattentiveness, and
drowsiness.  Moving all four extremities, + tremor with exertion
vs asterixis, No sensory deficits to light touch appreciated.


Pertinent Results:
[**2185-11-8**] 12:19PM BLOOD WBC-14.7* RBC-4.18* Hgb-13.0 Hct-36.3
MCV-87 MCH-31.0 MCHC-35.8* RDW-14.0 Plt Ct-177
[**2185-11-8**] 12:19PM BLOOD Neuts-84* Bands-0 Lymphs-11* Monos-4
Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0
[**2185-11-8**] 12:19PM BLOOD PT-13.2 PTT-19.5* INR(PT)-1.1
[**2185-11-8**] 12:19PM BLOOD Glucose-137* UreaN-24* Creat-0.8 Na-151*
K-3.7 Cl-118* HCO3-24 AnGap-13
[**2185-11-8**] 12:19PM BLOOD ALT-137* AST-105* AlkPhos-233*
TotBili-17.4* DirBili-15.0* IndBili-2.4
[**2185-11-8**] 12:19PM BLOOD Lipase-40
[**2185-11-8**] 12:19PM BLOOD Calcium-9.2 Phos-1.5* Mg-2.3
[**2185-11-8**] 12:19PM BLOOD TSH-2.3
[**2185-11-8**] 09:36PM URINE Color-Brown Appear-Clear Sp [**Last Name (un) **]-1.019
[**2185-11-8**] 09:36PM URINE Blood-SM  Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-SM
[**2185-11-8**] 09:36PM URINE RBC-2 WBC-11* Bacteri-FEW Yeast-NONE
Epi-<1
[**2185-11-8**] 09:36PM URINE Mucous-RARE

=================
MICROBIOLOGY
=================
[**2185-11-8**]
- MRSA screen:------
- Urine cx: negative

=================
IMAGING
=================
[**2185-11-8**]
- CXR: A single semi-upright portable view of the chest was
obtained. Low lung volumes result in bronchovascular crowding.
No focal consolidation, effusion, or pneumothorax is seen. Right
hilar prominence is noted without other findings of overt edema,
which may represent vascular crowding versus central vascular
congestion. No osseous abnormality is identified.
.

ERCP
IMPRESSION: Right hilar prominence may represent crowding versus
central
vascular congestion. If clinically feasible, consider PA and
lateral views for more sensitive evaluation.
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
moderate sedation. The patient was placed in the prone position
and an endoscope was introduced through the mouth and advanced
under direct visualization until the third part of the duodenum
was reached. Careful visualization was performed. The procedure
was not difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: There was pus discharge at the major papilla.
Cannulation:  Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in partial opacification.
Biliary Tree: On partial opacification of the CBD, several
stones were seen in the distal CBD with associated biliary
dilation. Full contrast opacification was not undertaken because
of evidence of cholangitis.
Procedures: A 8cm by 10FR biliary stent was placed successfully
in the CBD.
Impression: Pus was seen at the major papilla.
Successful biliary cannulation was achieved with a
sphincterotome
On partial opacification of the CBD, several stones were seen in
the distal CBD with associated biliary dilation. Full
cholangiogram was not undertaken because of the evidence of
cholangitis
A 8cm x 10Fr biliary stent was placed successfully for
decompression
Otherwise normal ERCP to 3rd portion of duodenum
Recommendations: Juices when awake and alert, then advance diet
astolerated
Continue IV antibiotics during hospitalization, then PO
antibiotics (augmentin, or cipro/flagyl) for total 14 day
course.
Repeat ERCP in [**1-19**] weeks for stent removal and
sphincterotomy/sphincteroplasty with stone extraction.

Discharge labs:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2185-11-10**] 03:01    9.7 3.37* 10.1* 30.5* 90 29.9 33.1 15.0 149*

RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2185-11-10**] 03:01    [**Telephone/Fax (2) 87671**]* 3.4 116* 25 9
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili IndBili
[**2185-11-10**] 03:01    85* 56*     199*   9.2*


Brief Hospital Course:
A/P:  73 year old woman with h/o HTN presents to OSH with AMS
and jaundice found to have choledocholithiasis and UTI.
.
#  Obstructive jaundice:  RUQ Ultrasound and CT confirm
choledocholithiasis. Pain was well controlled, and patient was
afebrile throughout her hospital stay, and she was
hemodynamically stable.  She underwent ERCP in which a stent was
placed but no sphincterotomy was preformed.  She was kept on IV
Zosyn with a plan to convert to PO augmentin as an outpatient
with empiric coverage for her UTI.  She will need a repeat ERCP
for sphincterotomy and stent removal
- Please continue IV Zosyn
- Please convert oral regiment to Augmentin or
Cipro/Metronidazole (depending on UTI)
.
# Atrial fibrillation: Patient presented in new Afib with RVR.
Heart rate initially poorly controlled by diltiazem. No
documented episodes of hypotension with elevated heart rates.
Patient converted to sinus rhythm shortly after arrival to the
ICU.  Her diltiazem was weaned, and she had two transient brief
episodes of SVT.  She was not empirically started on any
additional rate control.  She had conversion within 24 hours and
no anti-coagulation was started.
.
# UTI: Patient with history of recurrent UTIs.  UA from OSH with
elevated WBC count.
A urine culture was taken which shows no growth.
- Continue Zosyn empirically
- Check sensitivities since patient has history of multiple
UTI's
.
# Hypernatremia: Initial hypernatremia was thought to be
secondary to hypovolemia.  She was given 1/2 NS, and later D5W.
After her procedure she was given free water and a diet.
- Check serum Na this evening (prior to discharge 147 down from
152).
.
# Confusion: Patient's mental status is consistent delirium
experienced during prior UTIs and current choledocholithiasis.
Her delirium improved with continued antibiotics and hydration.
Post procedure she was alert and oriented x 3 with occasional
inapprioriate statements.
.
# HTN: Upon arrival her hypertensive medications were held.


Medications on Admission:
(per OSH records):
Lasix 20 mg daily
Prempro 0.45/1.5 one tablet daily
Potassium 10 meq [**Hospital1 **]
Trazodone 12.5 mg qhs
Atorvastatin 20 mg daily
Ibuprofen 600 mg tid
Polyethylene glycol 17 g daily
Docusate 100 mg po bid
Cozaar 100 mg daily
Nexium 40 mg daily
Zyrtec 10 mg daily
Omega 3 1200 mg [**Hospital1 **]
Vitamin E 400 IU daily
Calcium carbonate 600 Vitamin D one daily
MV daily
Cymbalta 60 mg daily


Discharge Medications:
1. Piperacillin-Tazobactam 4.5 g IV Q8H
2. Morphine Sulfate 2 mg IV Q6H:PRN pain or SOB
Please hold if sedated or RR < 14
3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary Diagnosis: Choledocholithiasis

Secondary Diagnosis:
UTI


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Ms. [**Known lastname 30380**]-

Thank you for receiving your care at [**Hospital1 18**].  You were admitted
for an ERCP for a gallstone.  You also had a urinary tract
infection in addition to an abnormal heart rhythm (AFIB) that
subsequently resolved.  You were discharged to another hospital
for continued care.  You will need IV antibiotics while in the
hospital, and PO antibiotics after you are discharged for an
additional 2 weeks.  You were discharged from [**Hospital3 **]
Hospital with a stable heart rhythm.  You will be accepted by
Dr. [**Last Name (STitle) 87672**]: [**Apartment Address(1) 87673**], [**Telephone/Fax (1) 87674**].

The following medications were added to your regiment:
Zosyn

The following medicaitons were stopped (during your hospital
stay):
Lasix 20 mg daily
Prempro 0.45/1.5 one tablet daily
Potassium 10 meq [**Hospital1 **]
Trazodone 12.5 mg qhs
Atorvastatin 20 mg daily
Ibuprofen 600 mg tid
Polyethylene glycol 17 g daily
Docusate 100 mg po bid
Cozaar 100 mg daily
Nexium 40 mg daily
Zyrtec 10 mg daily
Omega 3 1200 mg [**Hospital1 **]
Vitamin E 400 IU daily
Calcium carbonate 600 Vitamin D one daily
MV daily
Cymbalta 60 mg daily

The following medications were changed:
None


Followup Instructions:
Please follow up with your PCP as recommended by your new team.


You will need to call the [**Hospital **] clinic at [**Hospital3 **] Hospital to
schedule another ERCP to remove the stent in your bile duct and
have a sphincterotomy.



Completed by:[**2185-12-25**]
{'Calculus of bile duct without mention of cholecystitis, with obstruction,Hyperosmolality and/or hypernatremia,Cholangitis,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension'}


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: Obstructive jaundice
Reason for MICU transfer: AF with RVR

PRESENT ILLNESS: Ms. [**Known lastname 30380**] is a 73 year old woman with history of HTN and
recurrent UTIs was brought in to OSH ED by EMS with confusion
and jaundice.  At the OSH she was found to have a UA suggestive
of UTI with WBC "too numerous to count".  RUQ US and CT were
performed showing bile duct dilation to over 2 cm with the
presence of stones, sludge and debris. Labs were significant for
WBC 17, T bili 16.7, Alk phos 234, ast/alt 112/150, cr 0.7. She
was given Zosyn 4.5 g IV empirically for her UTI and concern for
biliary infection.  She remained afebrile and hemodynamically
stable throughout. She was then transferred to [**Hospital1 18**] for
definitive treatment with ERCP.  En route to [**Hospital1 18**] patient
developed an irregular tachycardia with rates to 150s.  She was
asymptomatic and denied chest pain or shortness of breath.
73-year-old female who was being transferred from outside
hospital here for ERCP, en route developed tachycardia to 170s,
by EMS found to be in atrial fibrillation. She states she was at
another hospital yesterday the 2 abdominal pain and jaundice,
was supposed to have ERCP done today. Currently she says she
feels chills, no pain.

MEDICAL HISTORY: HTN
Spinal stenosis
Osteoarthritis s/p R hip replacement
Recurrent UTIs
Anxiety
Fluid retention
Hyponatremia in the setting of HCTZ use

MEDICATION ON ADMISSION: (per OSH records):
Lasix 20 mg daily
Prempro 0.45/1.5 one tablet daily
Potassium 10 meq [**Hospital1 **]
Trazodone 12.5 mg qhs
Atorvastatin 20 mg daily
Ibuprofen 600 mg tid
Polyethylene glycol 17 g daily
Docusate 100 mg po bid
Cozaar 100 mg daily
Nexium 40 mg daily
Zyrtec 10 mg daily
Omega 3 1200 mg [**Hospital1 **]
Vitamin E 400 IU daily
Calcium carbonate 600 Vitamin D one daily
MV daily
Cymbalta 60 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Physical Exam on Arrival to [**Hospital Unit Name 2112**]: Temp: 99.4 BP: 119/65 HR: 140 RR: 21 O2sat 95% RA
GEN: pleasant, jaundiced, drowsy comfortable, NAD
HEENT: PERRL, disconjugate gaze, icteric, very dry MM, op
without lesions, no supraclavicular or cervical lymphadenopathy,
JVD difficult to assess
RESP: poor inspiratory effort, good air movement throughout
CV: distant heart sounds, tachycardic, irregular, no m/r/g
ABD: obese, no ascites, nd, +b/s, soft, nt
EXT: no c/c/e , 2+ distal pulses
SKIN: diffusely juandiced, no rashes
NEURO: awake but drowsy, oriented to person x 2. Cn II-XII
intact. Strength difficult to assess given inattentiveness, and
drowsiness.  Moving all four extremities, + tremor with exertion
vs asterixis, No sensory deficits to light touch appreciated.

FAMILY HISTORY: Unable to obtain as patient confused.

SOCIAL HISTORY: Patient lives alone and is independent of all ADLs. She denies
any history of tobacco use.  She reports a history of social
alcohol use but denies any alcohol use in months.  She denies
use of illicit drugs and herbal medications. 

### Response:
{'Calculus of bile duct without mention of cholecystitis, with obstruction,Hyperosmolality and/or hypernatremia,Cholangitis,Urinary tract infection, site not specified,Atrial fibrillation,Unspecified essential hypertension'}
