CHIEF COMPLAINT: transfer for ? portal-biliary fistula, obstructive jaundice,
pancreatitis w/ likely Klatskin tumor

PRESENT ILLNESS: The patient is a 48 year old Laotian man with a history of
chronic alcohol abuse who is transferred to [**Hospital1 18**] with a
possible
portal-biliary fistula, obstructive jaundice, and pancreatitis
s/p ERCP with stent [**2152-3-31**] to evaluate likely Klatskin tumor.

MEDICAL HISTORY: PMH: ETOH abuse
PSH: None

MEDICATION ON ADMISSION: Pepcid PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: - Temp 99.1  HR 76  BP 153/89  98% RA
- NAD, non-toxic appearing Laotian man
- + scleral icterus
- RRR, no murmurs
- lungs clear to auscultation
- Abdomen soft, tender to palpation in epigastrium and RUQ with
mild voluntary guarding; there is no rebound tenderness and no
peritoneal signs
- Rectal exam: good tone; + dark melanotic stool; strongly
guaiac
positive

FAMILY HISTORY: N/C

SOCIAL HISTORY: Soc Hx: married, not currently working, denies illicit drug use;
+ heavy EtOH use (stopped drinking approximately 4 weeks ago)
Hemorrhage complicating a procedure,Acute pancreatitis,Malignant neoplasm of intrahepatic bile ducts,Obstruction of bile duct,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anxiety state, unspecified
Hemorrhage complic proc,Acute pancreatitis,Mal neo intrahepat ducts,Obstruction of bile duct,Abn react-surg proc NEC,Anxiety state NOS
Name:  [**Known lastname 13232**],[**Known firstname 13233**]             Unit No:   [**Numeric Identifier 13234**]

Admission Date:  [**2152-4-3**]              Discharge Date:   [**2152-4-6**]

Date of Birth:  [**2103-9-5**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 48**]
Addendum:
Left PTC (percutaneous transhepatic cholangiography tube) MUST
stay in place to prevent jaundice.

Discharge Disposition:
Extended Care

Facility:
[**Hospital6 13235**] - [**Hospital1 1612**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 51**] MD, [**MD Number(3) 52**]

Completed by:[**2152-4-6**]

Admission Date:  [**2152-4-3**]              Discharge Date:   [**2152-4-6**]

Date of Birth:  [**2103-9-5**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 695**]
Chief Complaint:
transfer for ? portal-biliary fistula, obstructive jaundice,
pancreatitis w/ likely Klatskin tumor



Major Surgical or Invasive Procedure:
[**2152-4-3**]: PTC placement
[**2152-4-3**]: Hepatic angiogram

History of Present Illness:
The patient is a 48 year old Laotian man with a history of
chronic alcohol abuse who is transferred to [**Hospital1 18**] with a
possible
portal-biliary fistula, obstructive jaundice, and pancreatitis
s/p ERCP with stent [**2152-3-31**] to evaluate likely Klatskin tumor.

The patient presented to [**Hospital6 204**] on [**2152-3-28**] with
a 1 month history of epigastric pain and a 2 week history of
jaundice.  He has a history of heavy alcohol use, but had
stopped
drinking over the previous 4 weeks because of associated
epigastric pain.  He was admitted for further workup and a MRCP
was obtained, demonstrating intra-hepatic ductal dilatation with
a filling defect at the biliary confluence.  This was concerning
for a Klatskin tumor and, given the patient's obstructive
biliary
picture, he was taken for ERCP on [**2152-3-31**].  At this time his R
and
L ducts were dilated, a sphincterotomy was performed, and a 15cm
10Fr stent was placed in the R ductal system (the L was unable
to
be stented due to tight stricture).

Post-procedurally, the patient developed abdominal pain and RUQ
tenderness.  He was noted to have melanotic stools, and serial
laboratory studies demonstrated a drop in his hematocrit of ~10
points (from 40 to 29).  Additionally, he was found to have
increasing serum bilirubin levels; at the time of transfer his
total bilirubin level was 9.2 (increased from 6 at the time of
admission to [**Hospital3 **]).  His lipase was also significantly
elevated at 1100, and his amylase was 200.  A CT scan performed
emergently on [**4-2**], demonstrated a possible fistula between the
stent and a portal venous vessel, and he was therefore
transferred to [**Hospital1 18**] for further care.

At the time of transfer, his INR was 1.5, his platelet count was
251, and his hematocrit was 29.6.  He received 2U FFP and 1U
PRBC
prior to transfer, and he has been hemodynamically stable
without
tachycardia or hypotension.



Past Medical History:
PMH: ETOH abuse
PSH: None

Social History:
Soc Hx: married, not currently working, denies illicit drug use;
+ heavy EtOH use (stopped drinking approximately 4 weeks ago)



Family History:
N/C

Physical Exam:
- Temp 99.1  HR 76  BP 153/89  98% RA
- NAD, non-toxic appearing Laotian man
- + scleral icterus
- RRR, no murmurs
- lungs clear to auscultation
- Abdomen soft, tender to palpation in epigastrium and RUQ with
mild voluntary guarding; there is no rebound tenderness and no
peritoneal signs
- Rectal exam: good tone; + dark melanotic stool; strongly
guaiac
positive



Pertinent Results:
On Admission: [**2152-4-3**]
WBC-13.3* RBC-3.91* Hgb-11.4* Hct-32.9* MCV-84 MCH-29.2
MCHC-34.7 RDW-15.3 Plt Ct-273
PT-17.7* PTT-31.0 INR(PT)-1.6*
Glucose-105 UreaN-9 Creat-0.8 Na-137 K-3.9 Cl-101 HCO3-25
AnGap-15
ALT-53* AST-31 LD(LDH)-183 CK(CPK)-56 AlkPhos-144* Amylase-131*
TotBili-11.3* DirBili-7.7* IndBili-3.6
Albumin-3.8 Calcium-8.9 Phos-3.5 Mg-2.1 Iron-93
calTIBC-241* Ferritn-723* TRF-185*
HBsAg-NEGATIVE HBsAb-NEGATIVE IgM HAV-NEGATIVE HCV Ab-NEGATIVE
HCG-<5, CEA-1.5, AFP-16.8* CA [**61**]-9 -Test  8
At Discharge: [**2152-4-6**]
WBC-11.5* RBC-3.65* Hgb-10.5* Hct-30.9* MCV-85 MCH-28.7
MCHC-33.9 RDW-15.8* Plt Ct-367
PT-13.4 PTT-28.5 INR(PT)-1.2*
Glucose-150* UreaN-11 Creat-0.8 Na-136 K-3.7 Cl-103 HCO3-25
AnGap-12
ALT-51* AST-33 AlkPhos-132* TotBili-9.4* Albumin-3.6
Calcium-8.6 Phos-2.9 Mg-2.2

Brief Hospital Course:
48 y/o male transferred to [**Hospital1 18**] from [**Hospital6 204**].
At the outpatient hospital he had undergone ERCP and post
procedurally he developed a post ERCP pancreatitis as well as a
10 point Hct drop with grossly melanotic stool with concern for
arterio-biliary fistula. He was noted to have active bleeding
into the biliary tree upon arrival at [**Hospital1 18**]. A stent had been
placed in the right biliary system but the left system remained
obstructed at the time of transfer.
On [**4-3**] he underwent a hepatic angiogram which showed no evidence
of arterial biliary fistula, but there is a small area of
contrast pooling seen on portal venogram in segment VII adjacent
to endoscopically placed biliary drain done the same day. He
also had successful embolization of segment VII  portal vein
with Gelfoam and successful placement of external left biliary
drain.
His hematocrit then remained stable through the hospitalization.
He was treated with one day of Unasyn and Flagyl and was then
switched to PO Cipro for prophylaxis.
The PTC drain was opened to bag drainage and draining 100-200 cc
daily.
Interventional radiology was to attempt a second PTC drain on
[**4-5**] through the left side following stent removal by ERCP. The
patient, through the interpretive services and discussion with
his family and the hepatobiliary team has decided to forego
these procedures at this time.
He was noted to be hypertensive to the 160's systolic on the
morning of [**4-6**] and he was given one dose of IV lopressor and
then started on PO beta blockade.
Patient has requested transfer back to [**Hospital6 204**].


Medications on Admission:
Pepcid PRN

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H
(every 24 hours).
3. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
6. Hydromorphone (PF) 1 mg/mL Syringe Sig: 0.5-1 mg Injection
Q3H (every 3 hours) as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 204**] - [**Hospital1 189**]

Discharge Diagnosis:
probable Klatskins tumor


Discharge Condition:
Fair


Discharge Instructions:
Transfer to [**Hospital6 204**] (originating hospital for
transfer)
Drain and record PTC output. Teach patient drain care. Capping
drain at this time will likely produce fever and possible
infection, please leave open to bag draiange
Advance diet as tolerated
Continue PO Cipro

Followup Instructions:
If patient changes his mind about pursuing second PTC placement
and surgery, patient can contact Dr [**Name (NI) 4727**] office at
[**Telephone/Fax (1) 673**]


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**]

Completed by:[**2152-4-6**]
{'Hemorrhage complicating a procedure,Acute pancreatitis,Malignant neoplasm of intrahepatic bile ducts,Obstruction of bile duct,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anxiety state, 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: transfer for ? portal-biliary fistula, obstructive jaundice,
pancreatitis w/ likely Klatskin tumor

PRESENT ILLNESS: The patient is a 48 year old Laotian man with a history of
chronic alcohol abuse who is transferred to [**Hospital1 18**] with a
possible
portal-biliary fistula, obstructive jaundice, and pancreatitis
s/p ERCP with stent [**2152-3-31**] to evaluate likely Klatskin tumor.

MEDICAL HISTORY: PMH: ETOH abuse
PSH: None

MEDICATION ON ADMISSION: Pepcid PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: - Temp 99.1  HR 76  BP 153/89  98% RA
- NAD, non-toxic appearing Laotian man
- + scleral icterus
- RRR, no murmurs
- lungs clear to auscultation
- Abdomen soft, tender to palpation in epigastrium and RUQ with
mild voluntary guarding; there is no rebound tenderness and no
peritoneal signs
- Rectal exam: good tone; + dark melanotic stool; strongly
guaiac
positive

FAMILY HISTORY: N/C

SOCIAL HISTORY: Soc Hx: married, not currently working, denies illicit drug use;
+ heavy EtOH use (stopped drinking approximately 4 weeks ago) 

### Response:
{'Hemorrhage complicating a procedure,Acute pancreatitis,Malignant neoplasm of intrahepatic bile ducts,Obstruction of bile duct,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anxiety state, unspecified'}
