CHIEF COMPLAINT: Right Upper Quadrant Abdominal Pain

PRESENT ILLNESS: The patient is a 49 year old male with history of long standing
alcohol abuse with resultant alcoholic cirrhosis who presented
initially to [**Hospital3 4107**] on [**2183-12-15**] with symptoms of 2 days
of epigastric and right upper quadrant pain. The patient reports
his ain is sharp, stabbing, [**10-10**] at it's worst, and radiates to
his back. He reports associated symptoms of nausea and vomiting
of non-bloody, non-bilious fluid with associated chills. The
patient denies hematemsis, BRBPR, melena, chest pain. He does
report some shortness of breath which he attributes to
difficulty taking deep breaths because of his abdominal pain.
    At [**Hospital3 4107**] the patient had labs pertinent for Cr
1.4, Alb 3,9, Tb 4.1, Db 1.2, Alk Phos 102, ALT 68 and AST 77,
WBC 15.2 (2% Bands), HCt 44.2, and platelet 129. Per D/C
summary, the patient had an abdominal ultrasound which revealed
gallstones and CBD of 6mm, no ascites. A CT Abd/Pelvis was
subsequently performed which is reported to have revealed
cholelithiases with a 7mm stone in the distal CBD as well as
gallstones in the neck of the gallbladder (CT report not
accompanying). No intrahepatic lesions of dilated intrahepatic
ducts were noted. The liver was with irregular contour
suggestive of cirrhosis. Given report of stone present in the
CBD, the patient is now being transferred to [**Hospital1 18**] with plan for
ERCP.  In anticipation of the need for eventual cholecystectomy,
a surgical consult is requested by the hospitalist today.
   On arrival to the medical floor patient confirms history as
above. The patient reports he has history of relapsiing
alcoholism, however, he reports his alst drink was now 3 weeks
ago. He reports history of tremors and has undergone detox,
denies history of seizures or DTs. The patient reports ongoing
abdominal pain. On review of systems he reports some difficulty
taking deep breaths secondary to his abdominal pain, mild
sensation of associated air hunger. Remainder of ROS negative.

MEDICAL HISTORY: #. History of Alcohol abuse - history of tremors and blackouts.
Has been in detox
- no DTs, no seizures
#. Alcholic Cirrhosis
- denies history of variceal bleed although history of GI bleed
NOS previously
- denies history of ascites
- history of encephalopathy documented
#. Thrombocytopenia
#. History of GI Bleeding
#. Gastritis/Duodenitis
#. Cholelithiasis
#. Pancreatitis
#. Hypothyroidism

MEDICATION ON ADMISSION: Levothyroxine - dose unknown
Iron tab daily
Potassium Chloride daily
Prilosec 20mg daily

ALLERGIES: Shellfish Derived

PHYSICAL EXAM: Vitals on admission: 100.4, 112/80, 118, 16, 95% RA
General: Patient is a middle aged male, appears to be in pain,
no acute distress. Appropriate, oriented x 3. No asterixis
HEENT: NCAT, EOMI, sclera mildly icteric, conjunctiva WNL
OP: MMM, no lesions
Neck: Supple, no LAD, no JVD
Chest: Generally clear anterior. Small crackles at both bases,
poor air movement in general, + splinting. + spider angioma
Cor: Tachycardic, regular, no M/R/G
Abdomen: Mildly distended, hypoactive BS. Mod tenderness
throughout, severe tenderness in RUQ and epigastrium with
voluntary guarding, no rebound.
Rectal: empty rectal vault, guaiac negative fluid
Ext: No edema
Skin/Nails: + spider angioma
Neuro: Oriented x3, no asterixis, appropriate

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient lives in [**Hospital1 **] with his sister. [**Name (NI) **] was previously
employed insecurity at a hotel, now going to start new job as
security in a hotel.
ETOH: No use x 3 weeks, previous 18 beers daily or 2 pints of
vodka daily
Tobacco: None
Illicits: None
Calculus of bile duct with acute cholecystitis, with obstruction,Acute kidney failure, unspecified,Cholangitis,Hemorrhage complicating a procedure,Hyposmolality and/or hyponatremia,Portal hypertension,Acute posthemorrhagic anemia,Alcoholic cirrhosis of liver,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Other and unspecified alcohol dependence, episodic,Laparoscopic surgical procedure converted to open procedure,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
Choledochlith/ac gb-obst,Acute kidney failure NOS,Cholangitis,Hemorrhage complic proc,Hyposmolality,Portal hypertension,Ac posthemorrhag anemia,Alcohol cirrhosis liver,Abn reac-organ rem NEC,Thrombocytopenia NOS,Hypothyroidism NOS,Alcoh dep NEC/NOS-episod,Lap surg convert to open,Enterococcus group d,Gstr/ddnts NOS w/o hmrhg
Admission Date:  [**2183-12-16**]              Discharge Date:   [**2183-12-24**]

Date of Birth:  [**2133-12-19**]             Sex:   M

Service: SURGERY

Allergies:
Shellfish Derived

Attending:[**First Name3 (LF) 6346**]
Chief Complaint:
Right Upper Quadrant Abdominal Pain


Major Surgical or Invasive Procedure:
ERCP with sphincterotomy [**2183-12-16**]
Laparoscopic converted to open cholecystectomy [**2183-12-18**]

History of Present Illness:
The patient is a 49 year old male with history of long standing
alcohol abuse with resultant alcoholic cirrhosis who presented
initially to [**Hospital3 4107**] on [**2183-12-15**] with symptoms of 2 days
of epigastric and right upper quadrant pain. The patient reports
his ain is sharp, stabbing, [**10-10**] at it's worst, and radiates to
his back. He reports associated symptoms of nausea and vomiting
of non-bloody, non-bilious fluid with associated chills. The
patient denies hematemsis, BRBPR, melena, chest pain. He does
report some shortness of breath which he attributes to
difficulty taking deep breaths because of his abdominal pain.
    At [**Hospital3 4107**] the patient had labs pertinent for Cr
1.4, Alb 3,9, Tb 4.1, Db 1.2, Alk Phos 102, ALT 68 and AST 77,
WBC 15.2 (2% Bands), HCt 44.2, and platelet 129. Per D/C
summary, the patient had an abdominal ultrasound which revealed
gallstones and CBD of 6mm, no ascites. A CT Abd/Pelvis was
subsequently performed which is reported to have revealed
cholelithiases with a 7mm stone in the distal CBD as well as
gallstones in the neck of the gallbladder (CT report not
accompanying). No intrahepatic lesions of dilated intrahepatic
ducts were noted. The liver was with irregular contour
suggestive of cirrhosis. Given report of stone present in the
CBD, the patient is now being transferred to [**Hospital1 18**] with plan for
ERCP.  In anticipation of the need for eventual cholecystectomy,
a surgical consult is requested by the hospitalist today.
   On arrival to the medical floor patient confirms history as
above. The patient reports he has history of relapsiing
alcoholism, however, he reports his alst drink was now 3 weeks
ago. He reports history of tremors and has undergone detox,
denies history of seizures or DTs. The patient reports ongoing
abdominal pain. On review of systems he reports some difficulty
taking deep breaths secondary to his abdominal pain, mild
sensation of associated air hunger. Remainder of ROS negative.


Past Medical History:
#. History of Alcohol abuse - history of tremors and blackouts.
Has been in detox
- no DTs, no seizures
#. Alcholic Cirrhosis
- denies history of variceal bleed although history of GI bleed
NOS previously
- denies history of ascites
- history of encephalopathy documented
#. Thrombocytopenia
#. History of GI Bleeding
#. Gastritis/Duodenitis
#. Cholelithiasis
#. Pancreatitis
#. Hypothyroidism


Social History:
The patient lives in [**Hospital1 **] with his sister. [**Name (NI) **] was previously
employed insecurity at a hotel, now going to start new job as
security in a hotel.
ETOH: No use x 3 weeks, previous 18 beers daily or 2 pints of
vodka daily
Tobacco: None
Illicits: None


Family History:
Noncontributory

Physical Exam:
Vitals on admission: 100.4, 112/80, 118, 16, 95% RA
General: Patient is a middle aged male, appears to be in pain,
no acute distress. Appropriate, oriented x 3. No asterixis
HEENT: NCAT, EOMI, sclera mildly icteric, conjunctiva WNL
OP: MMM, no lesions
Neck: Supple, no LAD, no JVD
Chest: Generally clear anterior. Small crackles at both bases,
poor air movement in general, + splinting. + spider angioma
Cor: Tachycardic, regular, no M/R/G
Abdomen: Mildly distended, hypoactive BS. Mod tenderness
throughout, severe tenderness in RUQ and epigastrium with
voluntary guarding, no rebound.
Rectal: empty rectal vault, guaiac negative fluid
Ext: No edema
Skin/Nails: + spider angioma
Neuro: Oriented x3, no asterixis, appropriate

Vitals on discharge: 100.2, 99.8, 98, 110/80, 20, 96RA
Gen: NADS, AAO x 3
Lungs: CTA
Cardio: Tachy, normal sinus rhythm
Abd: soft, distended, non-tender, act bowel sounds
Wound: staples to subcostal area, mildly erythematous. Areas
packed with wtd to midline and right lateral edge. No purulent
drainage
Ext: No C,C,E


Pertinent Results:
.
CXR [**2183-12-16**]: Bibasilar atelectasis, small R pleural effusion,
low lung volumes
.
ERCP [**2183-12-17**]:
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: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome. Contrast medium was injected
resulting in complete opacification. A 0.035in in diameter and
260cm in length straight tip glidewire was placed. The existing
guidewire was replaced with a jagwire.
.
Biliary Tree: A mild diffuse dilation was seen at the main duct
with the CBD measuring 9mm. There were filling defects that
appeared like sludge in the lower third of the common bile duct.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire. Post
sphincterotomy, pus could be seen coming out from the major
papilla. Some sludge was extracted successfully using a 8 mm
balloon.
Impression: A mild diffuse dilation was seen at the main duct
with the CBD measuring 9mm.
There were filling defects that appeared like sludge in the
lower third of the common bile duct.
Successful sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Post sphincterotomy, pus could be seen coming out from the major
papilla.
Successful extraction of  sludge using a 8 mm balloon.

[**2183-12-22**] Cholangiogram: No evidence of biliary leak.

[**2183-12-18**] 05:30PM BLOOD WBC-8.1 RBC-2.85* Hgb-9.6* Hct-27.5*
MCV-97 MCH-33.9* MCHC-35.0 RDW-14.6 Plt Ct-118*
[**2183-12-18**] 07:21PM BLOOD WBC-8.4 RBC-2.93* Hgb-9.9* Hct-28.5*
MCV-97 MCH-33.8* MCHC-34.8 RDW-14.8 Plt Ct-99*
[**2183-12-19**] 02:48AM BLOOD WBC-6.4 RBC-2.90* Hgb-9.8* Hct-27.4*
MCV-95 MCH-34.0* MCHC-35.9* RDW-15.8* Plt Ct-97*
[**2183-12-20**] 06:35AM BLOOD WBC-8.9 RBC-3.13* Hgb-10.3* Hct-29.8*
MCV-95 MCH-33.0* MCHC-34.6 RDW-15.2 Plt Ct-126*
[**2183-12-21**] 03:15AM BLOOD WBC-8.3 RBC-2.91* Hgb-9.7* Hct-27.9*
MCV-96 MCH-33.2* MCHC-34.7 RDW-15.1 Plt Ct-139*
[**2183-12-22**] 06:00AM BLOOD WBC-6.7 RBC-2.69* Hgb-8.9* Hct-24.9*
MCV-93 MCH-32.9* MCHC-35.5* RDW-14.8 Plt Ct-124*
[**2183-12-16**] 01:30AM BLOOD Glucose-107* UreaN-22* Creat-1.6* Na-128*
K-4.5 Cl-93* HCO3-25 AnGap-15
[**2183-12-16**] 07:05AM BLOOD Glucose-97 UreaN-21* Creat-1.5* Na-131*
K-3.3 Cl-96 HCO3-27 AnGap-11
[**2183-12-17**] 07:10AM BLOOD Glucose-88 UreaN-14 Creat-1.2 Na-135
K-3.5 Cl-100 HCO3-25 AnGap-14
[**2183-12-19**] 02:48AM BLOOD Glucose-119* UreaN-11 Creat-0.9 Na-140
K-4.1 Cl-109* HCO3-24 AnGap-11
[**2183-12-16**] 01:30AM BLOOD ALT-55* AST-74* LD(LDH)-480* AlkPhos-74
Amylase-34 TotBili-4.7* DirBili-1.8* IndBili-2.9
[**2183-12-17**] 07:10AM BLOOD ALT-38 AST-35 AlkPhos-121* TotBili-5.0*
[**2183-12-18**] 07:30AM BLOOD ALT-27 AST-25 AlkPhos-106 TotBili-3.2*
[**2183-12-21**] 03:15AM BLOOD ALT-22 AST-44* AlkPhos-78 TotBili-2.3*
DirBili-1.3* IndBili-1.0
[**2183-12-22**] 06:00AM BLOOD ALT-16 AST-34 AlkPhos-69 TotBili-1.5
DirBili-0.9* IndBili-0.6

Brief Hospital Course:
The patient is a 49 year old male with medical history of
alcoholic cirrhosis who presented with epigastric and RUQ pain
with concern for impacted stone on CT seen at OSH. He was
transferred from [**Hospital3 **]. He was found to have
cholangitis.

#. Biliary Obstruction/Cholangitis/Fever/Cholecystitis:  At
[**Hospital3 4107**] the patient had labs pertinent for Cr 1.4,  Tb
4.1, Db 1.2, Alk Phos 102, ALT 68 and AST 77, WBC 15.2 (2%
Bands).  At the outside hospital, the patient had an abdominal
ultrasound which revealed gallstones and CBD of 6mm, no ascites.
A CT Abd/Pelvis was subsequently performed which is reported to
have revealed cholelithiases with a 7mm stone in the distal CBD
as well as gallstones in the neck of the gallbladder (CT report
not accompanying). No intrahepatic lesions of dilated
intrahepatic ducts were noted. The liver was with irregular
contour suggestive of cirrhosis. Given report of stone present
in the CBD, the patient was transferred to [**Hospital1 18**] with plan for
ERCP. The patient here was treated with IVF, dilaudid for pain,
and IV Levo/flagyl given his bandemia at the OSH. He was febrile
here to 102 prior to his ERCP. He underwent ERCP on [**12-17**] which
showed a mild diffuse dilation at the main duct with the CBD
measuring 9mm. There were filling defects that appeared like
sludge in the lower third of the common bile duct. Successful
sphincterotomy was performed. Post sphincterotomy, pus could be
seen coming out from the major papilla. Successful extraction of
 sludge using a 8 mm balloon. He was treated with IV Levo/flagyl
for 2 additional days.Surgery was consulted for consideration of
cholecystectomy.

Patient was then admitted to general surgical service and was
taken to the operating room on [**2183-12-18**] for a laparoscopic
cholecystectomy. With low platelets of 71,000, platelets were
placed on call to the operating room. During procedure, there
was extensive bleeding and because of the difficult dissection,
surgery converted to open cholecystectomy. Overall fluid
balances were - received 3400ml crystalloid, 3 units pRBC, 2
units FFP, 1 six-pack platelets for EBL 1600cc, UOP 250cc.
Patient was kept intubated and transferred to SICU for O/N
observation. He maintained hemodynamically stable and
postoperative Hct of 28.5.
On POD1-2, patient was weaned from ventilation and extubated. He
was kept on IV levaquin and flagyl. His NGT, arterial line and
foley were removed. Patient was transferred to the general
surgical floor for further post-operative recovery. He remained
tachycardic but completely asymptomatic. Patient's diet was
advanced from sips to clears.
On POD3-4, patient developed a fever of 102.3. He was
pan-cultured. Bile cultures returned to have sparse
enterococcus. He was started on augmentin in which he will be
kept on for 2 weeks. Medial aspect of his abdominal staple
incision was opened and swabbed. Gram stain result showed gram
positive coccus and sensitivities are still pending on day of
discharge. Incisional areas were packed wet to dry and will be
changed twice a day. There appeared to be a darker colored
output from the JP drain from a serosanguinous color.
On POD5, HIDA scan was ordered to assess for any intra-biliary
leaks. Results from imaging showed patent ducts with no
extravasation of material. He was discharged home on POD6 with a
two week course of augmentin and VNA to teach patient to pack
wound with wet to dry dressings twice a day. He is tolerating a
regular diet, ambulating and voiding without difficulty. He is
to call Dr. [**First Name (STitle) 2819**] to schedule an appointment for follow up clinic
visit.

#. Acute Renal Failure: Patient's baseline unknown (1.2 in
[**2181**]), Cr was 1.4 at outside hospital the day prior to
admission, and was 1.6 on admission here. Differential was
pre-renal vs. contrast-nephropathy from his CT scan.  FeNa was
0.2%, and creatinine trended down with IVF, consistent with
pre-renal/dehydration. After IVF, his Creatinine was back down
to 1.2.
.
#. Anemia: Hct at OSH 44, repeat on arrival here 35.0 Patient
guaiac negative on exam, prior baseline in [**2181**] appears to be
near 36. Elevated Hct at OSH likely reflective of
hemoconcentration
-trend
.
#. Hyponatremia: Sodium was 128 on admission, and patient
appeared hypovolemic with urine chemistries consistent with
prerenal etiology of ARF. He was hydrated with IVF with
resolution of his hyponatremia.
.
#. Dyspnea: Symptoms seemed related to splinting and
hypoventilation from pain. CXR showed bibasilar atelectasis and
small r pleural effusion. BNP only 400s.  He was treated with
pain control and incentive spirometry.
.
#. Coagulopathy: Likely related to underlying cirrhosis, no
active evidence of bleeding. Vit K 10mg once on admission as
well as 2 units of FFP prior to ERCP.
.
#. Alcoholic Cirrhosis: Currently without bleeding, appears to
be without encephalopathy. Abdominal exam limited by pain, no
obvious ascites (none on US at OSH per report)
-eval for varices on ERCP; would likely benefit from nadolol
given varices seen on CT at OSH
-would obviously benefit from long term alcohol abstinence
-outpatient management for ongoing cirrhosis management: HCC
screening, variceal bleed ppx, etc


Medications on Admission:
Levothyroxine - dose unknown
Iron tab daily
Potassium Chloride daily
Prilosec 20mg daily


Discharge Medications:
1. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q8H (every 8 hours) for 12 days.
Disp:*36 Tablet(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain: do not operate heavy machinery or
consume alcohol. [**Month (only) 116**] cause drowsiness.
Disp:*40 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice
a day: take while using narcotics for pain control to help
prevent constipation.
Disp:*60 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

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

Discharge Diagnosis:
Cholelithiasis and choledocholithiasis
Gangrenous Cholecystitis
Alcoholic Cirrhosis
Acute Blood Loss Anemia
Wound Infection
Gastritis
Hypothyroidism
Thrombocytopenia

Discharge Condition:
Tolerating regular diet
Ambulating and voiding without difficulty
Incisional area with staples, 2 areas packed with gauze
Normal bowel movements


Discharge Instructions:
General:
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 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.

*Avoid lifting objects > 5lbs until your follow-up appointment
with the surgeon.

*Avoid driving or operating heavy machinery while taking pain
medications.
* 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.
* Continue to ambulate several times per day.
Please pack wound with wet to dry dressings twice a day.


Followup Instructions:
Follow up with Dr. [**First Name (STitle) 2819**] in [**1-1**] weeks; please call ([**Telephone/Fax (1) 8105**]
to schedule an appointment
Follow up with PCP [**Last Name (NamePattern4) **] 1 week
{'Calculus of bile duct with acute cholecystitis, with obstruction,Acute kidney failure, unspecified,Cholangitis,Hemorrhage complicating a procedure,Hyposmolality and/or hyponatremia,Portal hypertension,Acute posthemorrhagic anemia,Alcoholic cirrhosis of liver,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Other and unspecified alcohol dependence, episodic,Laparoscopic surgical procedure converted to open procedure,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}


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 a 49 year old male with history of long standing
alcohol abuse with resultant alcoholic cirrhosis who presented
initially to [**Hospital3 4107**] on [**2183-12-15**] with symptoms of 2 days
of epigastric and right upper quadrant pain. The patient reports
his ain is sharp, stabbing, [**10-10**] at it's worst, and radiates to
his back. He reports associated symptoms of nausea and vomiting
of non-bloody, non-bilious fluid with associated chills. The
patient denies hematemsis, BRBPR, melena, chest pain. He does
report some shortness of breath which he attributes to
difficulty taking deep breaths because of his abdominal pain.
    At [**Hospital3 4107**] the patient had labs pertinent for Cr
1.4, Alb 3,9, Tb 4.1, Db 1.2, Alk Phos 102, ALT 68 and AST 77,
WBC 15.2 (2% Bands), HCt 44.2, and platelet 129. Per D/C
summary, the patient had an abdominal ultrasound which revealed
gallstones and CBD of 6mm, no ascites. A CT Abd/Pelvis was
subsequently performed which is reported to have revealed
cholelithiases with a 7mm stone in the distal CBD as well as
gallstones in the neck of the gallbladder (CT report not
accompanying). No intrahepatic lesions of dilated intrahepatic
ducts were noted. The liver was with irregular contour
suggestive of cirrhosis. Given report of stone present in the
CBD, the patient is now being transferred to [**Hospital1 18**] with plan for
ERCP.  In anticipation of the need for eventual cholecystectomy,
a surgical consult is requested by the hospitalist today.
   On arrival to the medical floor patient confirms history as
above. The patient reports he has history of relapsiing
alcoholism, however, he reports his alst drink was now 3 weeks
ago. He reports history of tremors and has undergone detox,
denies history of seizures or DTs. The patient reports ongoing
abdominal pain. On review of systems he reports some difficulty
taking deep breaths secondary to his abdominal pain, mild
sensation of associated air hunger. Remainder of ROS negative.

MEDICAL HISTORY: #. History of Alcohol abuse - history of tremors and blackouts.
Has been in detox
- no DTs, no seizures
#. Alcholic Cirrhosis
- denies history of variceal bleed although history of GI bleed
NOS previously
- denies history of ascites
- history of encephalopathy documented
#. Thrombocytopenia
#. History of GI Bleeding
#. Gastritis/Duodenitis
#. Cholelithiasis
#. Pancreatitis
#. Hypothyroidism

MEDICATION ON ADMISSION: Levothyroxine - dose unknown
Iron tab daily
Potassium Chloride daily
Prilosec 20mg daily

ALLERGIES: Shellfish Derived

PHYSICAL EXAM: Vitals on admission: 100.4, 112/80, 118, 16, 95% RA
General: Patient is a middle aged male, appears to be in pain,
no acute distress. Appropriate, oriented x 3. No asterixis
HEENT: NCAT, EOMI, sclera mildly icteric, conjunctiva WNL
OP: MMM, no lesions
Neck: Supple, no LAD, no JVD
Chest: Generally clear anterior. Small crackles at both bases,
poor air movement in general, + splinting. + spider angioma
Cor: Tachycardic, regular, no M/R/G
Abdomen: Mildly distended, hypoactive BS. Mod tenderness
throughout, severe tenderness in RUQ and epigastrium with
voluntary guarding, no rebound.
Rectal: empty rectal vault, guaiac negative fluid
Ext: No edema
Skin/Nails: + spider angioma
Neuro: Oriented x3, no asterixis, appropriate

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: The patient lives in [**Hospital1 **] with his sister. [**Name (NI) **] was previously
employed insecurity at a hotel, now going to start new job as
security in a hotel.
ETOH: No use x 3 weeks, previous 18 beers daily or 2 pints of
vodka daily
Tobacco: None
Illicits: None 

### Response:
{'Calculus of bile duct with acute cholecystitis, with obstruction,Acute kidney failure, unspecified,Cholangitis,Hemorrhage complicating a procedure,Hyposmolality and/or hyponatremia,Portal hypertension,Acute posthemorrhagic anemia,Alcoholic cirrhosis of liver,Removal of other organ (partial) (total) causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Thrombocytopenia, unspecified,Unspecified acquired hypothyroidism,Other and unspecified alcohol dependence, episodic,Laparoscopic surgical procedure converted to open procedure,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}
