CHIEF COMPLAINT: Chest pain.

PRESENT ILLNESS: 67yoM with hx of HCC s/p liver [**Month/Day/Year **] in [**2174**] now relisted,
s/p ichemic cholangiopathy with bilateral biliary stent
placements, and recent [**Hospital1 18**] admission for similiar symptoms,
re-presents today with persistent chest pain. During his prior
admission, dates ([**2178-8-23**]) through ([**2178-8-25**]), the patients chest
was worked up and was ruled out for MI, PE and Aortic Disection.
During the admission the patient had his left percutaneous
biliary catheter exchanged, treated for suspected cholangitis
with Cipro/Flagyl however his chest pain persisted. His Total
Bili, which was elevated to 7 from a baseline of 1.5 to 3,
improved following the drain exchange. An echo during the
admission saw a small pericardial effusion, which was not there
during a TTE in ([**5-24**]). The patient was given PO tylenol that
decreased the severity of the pain, however the pain was still
persistenting on his discharge.
.
Today the patient presents with continued chest pain. He
describes it as band like in nature across the front of his
chest with radiation across the top of the back and to his
proximal left arm. The pain is constant and severe, limiting him
from falling asleep. He states it is worse with movement and
upon deep inspiration. It is worse with leaning forward. No
alleviating symptoms. The patient was recently discontinued off
his Naloxone, which he was taking for persistent pruritis.
.
ROS is negative for fevers, chills, sweats, visual changes, loss
of consciousness. However the patient has reported two loose
dark brown-black stools per day. No BRBPR. One episode of
"spitting up", no coffee ground emesis. No weightloss. The
patient was admitted directly from his Gastroenterology
physicians clinic.

MEDICAL HISTORY: - Status post liver [**Month/Year (2) **] [**4-/2174**]
- Cirrohosis due to NASH
- History of HCC
- Diffuse biliary strictures due to ichemic cholangiopathy with
subsequent bilateral percutaneous biliary drains, with multiple
exchanges since placement
- Type 2 diabetes
- Hypertension
- Parathyroid adenoma status post parathyroidectomy [**8-/2175**]
- Chronic renal failure, baseline creatinine 1.3-1.4

MEDICATION ON ADMISSION: Rifampin 300 mg PO Q12H
Sertraline 100 mg PO QPM
Ezetimibe 10 mg PO QPM
Simvastatin 10 mg PO DAILY
Ferrous Gluconate 325 mg PO DAILY
Sulfameth/Trimethoprim SS 1 TAB PO DAILY Insulin SC
Tacrolimus 14 mg PO Q12H
Metoprolol Tartrate 50 mg PO TID
Terazosin 5 mg PO HS
Multivitamins 1 TAB PO DAILY
Triamterene-Hydrochlorothiazide 2 CAP PO DAILY
Mycophenolate Mofetil 1000 mg PO BID
Ursodiol 900 mg PO BID
Omeprazole 20 mg PO DAILY
Valsartan 320 mg PO DAILY
Potassium Chloride 20 mEq PO DAILY
Felodipine 10 mg SR PO DAILY

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 93.6 111/61 57 18 97%
Gen: Very mild distress, Middle-aged male, Generally Well
appearing
HEENT: PERRL, EOMI
Neck: Supple, No LAD
CV: S1S2, distant HS, No MRG
Resp: CTAB, ?reproduction of identical CP
Abd: Soft, NT, ND BS+. No biliary drainage
Ext: No C/C/E
Neuro: Motor Grossly intact in 4 extremities

FAMILY HISTORY: Father - [**Name (NI) **] CA
Mother- CVAs
Brother - DM, HTN
No family history for liver disease or colon CA.

SOCIAL HISTORY: Rare EtoH. Quit smoking [**2168**]. Retired. Previous director of
Health Services for Prison Service. Married with three children.
Acute pericarditis, unspecified,Acute kidney failure, unspecified,Obstruction of bile duct,Unspecified pleural effusion,Atrial flutter,Complications of transplanted liver,Cardiac tamponade,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of liver,Cirrhosis of liver without mention of alcohol,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
Acute pericarditis NOS,Acute kidney failure NOS,Obstruction of bile duct,Pleural effusion NOS,Atrial flutter,Compl liver transplant,Cardiac tamponade,Chronic kidney dis NOS,Hy kid NOS w cr kid I-IV,DMII wo cmp nt st uncntr,Hx of liver malignancy,Cirrhosis of liver NOS,Abn react-org transplant
Admission Date:  [**2178-8-31**]              Discharge Date:   [**2178-9-6**]

Date of Birth:  [**2111-7-10**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 943**]
Chief Complaint:
Chest pain.

Major Surgical or Invasive Procedure:
Pericardial drain placement [**2178-8-31**].

History of Present Illness:
67yoM with hx of HCC s/p liver [**Month/Day/Year **] in [**2174**] now relisted,
s/p ichemic cholangiopathy with bilateral biliary stent
placements, and recent [**Hospital1 18**] admission for similiar symptoms,
re-presents today with persistent chest pain. During his prior
admission, dates ([**2178-8-23**]) through ([**2178-8-25**]), the patients chest
was worked up and was ruled out for MI, PE and Aortic Disection.
During the admission the patient had his left percutaneous
biliary catheter exchanged, treated for suspected cholangitis
with Cipro/Flagyl however his chest pain persisted. His Total
Bili, which was elevated to 7 from a baseline of 1.5 to 3,
improved following the drain exchange. An echo during the
admission saw a small pericardial effusion, which was not there
during a TTE in ([**5-24**]). The patient was given PO tylenol that
decreased the severity of the pain, however the pain was still
persistenting on his discharge.
.
Today the patient presents with continued chest pain. He
describes it as band like in nature across the front of his
chest with radiation across the top of the back and to his
proximal left arm. The pain is constant and severe, limiting him
from falling asleep. He states it is worse with movement and
upon deep inspiration. It is worse with leaning forward. No
alleviating symptoms. The patient was recently discontinued off
his Naloxone, which he was taking for persistent pruritis.
.
ROS is negative for fevers, chills, sweats, visual changes, loss
of consciousness. However the patient has reported two loose
dark brown-black stools per day. No BRBPR. One episode of
"spitting up", no coffee ground emesis. No weightloss. The
patient was admitted directly from his Gastroenterology
physicians clinic.


Past Medical History:
- Status post liver [**Month/Year (2) **] [**4-/2174**]
- Cirrohosis due to NASH
- History of HCC
- Diffuse biliary strictures due to ichemic cholangiopathy with
subsequent bilateral percutaneous biliary drains, with multiple
exchanges since placement
- Type 2 diabetes
- Hypertension
- Parathyroid adenoma status post parathyroidectomy [**8-/2175**]
- Chronic renal failure, baseline creatinine 1.3-1.4


Social History:
Rare EtoH. Quit smoking [**2168**]. Retired. Previous director of
Health Services for Prison Service. Married with three children.


Family History:
Father - [**Name (NI) **] CA
Mother- CVAs
Brother - DM, HTN
No family history for liver disease or colon CA.


Physical Exam:
VS: 93.6 111/61 57 18 97%
Gen: Very mild distress, Middle-aged male, Generally Well
appearing
HEENT: PERRL, EOMI
Neck: Supple, No LAD
CV: S1S2, distant HS, No MRG
Resp: CTAB, ?reproduction of identical CP
Abd: Soft, NT, ND BS+. No biliary drainage
Ext: No C/C/E
Neuro: Motor Grossly intact in 4 extremities


Pertinent Results:
Labwork on admission:
[**2178-8-31**] 09:00AM   WBC-12.4*# RBC-3.29* HGB-10.8* HCT-31.0*
MCV-94 MCH-32.8* MCHC-34.8 RDW-13.3
[**2178-8-31**] 09:00AM   PLT COUNT-196
[**2178-8-31**] 09:00AM   UREA N-50* CREAT-2.1* SODIUM-118*
POTASSIUM-4.8 CHLORIDE-91* TOTAL CO2-16* ANION GAP-16
[**2178-8-31**] 09:00AM   GLUCOSE-120*
[**2178-8-31**] 09:00AM   PT-14.8* INR(PT)-1.3*
[**2178-8-31**] 09:00AM   CALCIUM-8.8 PHOSPHATE-4.9*# MAGNESIUM-2.3
[**2178-8-31**] 09:00AM   ALT(SGPT)-67* AST(SGOT)-66* ALK PHOS-497* TOT
BILI-4.0*
[**2178-8-31**] 09:00AM   tacroFK-6.2
[**2178-8-31**] 10:55AM   CK-MB-NotDone cTropnT-<0.01
.
ECG Study Date of [**2178-8-31**]
Sinus rhythm. Prolonged A-V conduction. Ventricular ectopy.
Borderline
low voltage in the limb leads. Slightly prolonged Q-T interval.
Compared to the previous tracing of [**2178-8-25**] diffuse ST segment
elevations have improved. Ventricular ectopy is not as frequent.
Voltage in the limb leads, and to some degree the precordial
leads, has decreased.
.
TTE (Complete) Done [**2178-8-31**]
The left atrium is mildly dilated. The right atrial pressure is
indeterminate. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is borderline pulmonary artery
systolic hypertension. There is a moderate sized circumferential
pericardial effusion with sustained right atrial collapse,
consistent with low filling pressures or early tamponade.
Compared with the prior study (images reviewed) of [**2178-8-25**], the
pericardial effusion is larger and increased pericardial
pressure is now suggested. Serial evaluation and clinical
correlation is suggested.
.
DUPLEX DOPP ABD/PEL Study Date of [**2178-8-31**]
IMPRESSION:
1. Large regional/geographic hypoechoic area involving the
central portion of the liver, not in a vascular distribution.
Findings are nonspecific, however, concerning for possible
ischemia or cholangitis. Further evaluation with
contrast-enhanced CT or MR is recommended. This was discussed
with Dr. [**First Name8 (NamePattern2) 1169**] [**Last Name (NamePattern1) **] on [**2178-8-31**].
2. Bilateral pleural effusions and small pericardial effusion.
.
CHEST (PA & LAT) Study Date of [**2178-8-31**]
IMPRESSION: Worsening left lower lobe atelectasis. No acute
cardiopulmonary process or displaced rib fractures.
.
C.CATH Study Date of [**2178-9-1**]
FINAL DIAGNOSIS:
1. Pericardial tamponade with improvement in hemodynamics after
removal
of 610 cc of bloody fluid.
2. Moderate systemic arterial hypertension, post
pericardiocentesis.
.
Portable TTE (Focused views) Done [**2178-9-2**]
The left atrium is moderately dilated. There is mild symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. The aortic root is mildly dilated at
the sinus level. The ascending aorta is mildly dilated. The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion. There are no
echocardiographic signs of tamponade.
.
CT ABD W&W/O C Study Date of [**2178-9-4**]
IMPRESSION:
1. Small-to-moderate pericardial effusion. Bilateral large
pleural effusions with bibasilar atelectasis.
2. Non-obstructive left renal calculus.
3. Focal hyperemia in the left hepatic lobe as described above;
this could
represent early inflammatory hyperemia or focal pericholangitis
or reactive changes secondary to trauma from recent percutaneous
catheter exchange. No microabscesses, focal hepatic lesions, or
masses were identified. There is mild intrahepatic biliary
ductal dilation, unchanged.
.
CHEST (PA & LAT) Study Date of [**2178-9-4**]
IMPRESSION:
1) Slight decrease in pericardial effusion.
2) Slight increase in right pleural effusion but unchanged small
left pleural effusion.
.
Labwork on discharge:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2178-9-6**] 05:00AM    6.1 2.64* 8.6* 25.2* 95 32.5* 34.0 13.7
204
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
[**2178-9-6**] 05:00AM    127* 29* 1.5* 131* 3.9 96 24 15
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
[**2178-9-6**] 05:00AM    68* 60*     673*   3.1*

Brief Hospital Course:
67 year-old man with history of hepatocellular carcinoma status
post liver [**Year (4 digits) **] in [**2174**] now relisted presenting with chest
pain and found to have tamponade/pericarditis.
.
1. Tamponade/pericarditis: The patient presented with tamponade
physiology and was sent to the cardiac cath laboratory [**2178-9-1**]
for drain placement, with 700 cc serosanguinous drainage.  The
patient was initially monitored in the CCU.  The drain was
removed [**2178-9-2**] and repeat TTE showed only a trivial effusion.
The etiology of the effusion remains unclear. Differential
diagnosis includes cirrhosis, infection, malignant.  Bacterial
cultures are negative at the time of discharge.  Viral cultures
and serologies for EBV, CMV, VZV, adenovirus, and [**Location (un) **]
virus are pending at the time of discharge and should be
followed-up as an outpatient.  This was unlikely to represent TB
with [**Doctor First Name **] minimally elevated and PPD negative.  Cytology was
negative for malignant cells.  An autoimmune etiology is
unlikely given his degree of immunosuppression.  The patient was
initially treated with NSAIDs, which were discontinued due to
chronic renal failure, and he was subsequently treated with a
prednisone burst with good effect.  He was treated with
prednisone 20 mg daily x 2 days and 10 mg x 2 days during
admission, and discharged with 10 mg x 4 days until further
evaluation by Dr. [**Last Name (STitle) 497**] at his follow-up appointment.  He was
scheduled for follow-up with Dr. [**Last Name (STitle) 171**] in cardiology.
.
2. Hyperechoic liver lesion: There was a hyperechoic liver
lesion noted on ultrasound as above.  CT abdomen was performed
for further evaluation, and the lesion was most likely an area
of hyperemia or inflammation, and was not thought to represent a
recurrence of hepatoma.
.
3. Atrial flutter/fibrillation: The patient had atrial flutter
with variable block during the time of transfer to the CCU with
tamponade.  He reverted back to sinus rhythm, but then returned
to atrial flutter during admission.  He was rate-controlled with
metoprolol.  It is unlikely that this represented cardiac
ischemia and cardiac enzymes were negative at the time, however,
he has numerous risk factors and should be considered for
outpatient cardiac stress test for further evaluation.  His
CHADS2 score is 2, and he should be considered for
anticoagulation as an outpatient.  Anticoagulation was not
addressed during admission due to pericarditis and risk of
hemorrhagic effusion.  He was scheduled for follow-up with Dr.
[**Last Name (STitle) 171**] in cardiology.
.
4. Acute on chronic renal failure: Baseline creatinine 1.6, with
creatinine 2.1 on admission.  Hydrochlorothiazide and valsartan
were held.  The patient's creatinine improved with gentle
fluids.
.
5. Bilateral pleural effusions: He was noted to have small
bilateral pleural effusions on chest x-ray.  The patient denied
shortness of breath or other symptoms.  The effusions may be
related to liver disease.  Further evaluation and management was
deferred to the outpatient setting.
.
6. Hyponatremia: Improved on discharge.  The patient is
hypervolemic and his hyponatremia is likely from cirrhosis.
Diuretic use was likely contributing, and his
hydrochlorothiazide was held during admission.  He was placed on
free water restriction of 1.2 liters per day.
.
7. Status post liver [**Last Name (STitle) **]: He is now relisted due to
donor-graft-associated cholangiography.  The patient was
continued on tacrolimus and mycophenolate, with adjustment of
the tacrolimus level during admission.  He was continued on
rifampin and bactrim prophylaxis.  He was continued on ursodiol
for cholangiopathy.
.
8. Hypertension: The patient was normotensive during admission.
His valsartan and triamterene-hydrochlorothiazide were held for
acute renal failure as above.  His valsartan was restarted on
discharge, but triamterene-hydrochlorothiazide was not.  He was
continued on felodipine and metoprolol.
.
9. Type 2 diabetes: No active issues. The patient was continued
on with lantus with sliding scale insulin.
.
10. Hyperlipidemia: No active issues.  The patient was continued
on statin, zetia.

Medications on Admission:
Rifampin 300 mg PO Q12H
Sertraline 100 mg PO QPM
Ezetimibe 10 mg PO QPM
Simvastatin 10 mg PO DAILY
Ferrous Gluconate 325 mg PO DAILY
Sulfameth/Trimethoprim SS 1 TAB PO DAILY Insulin SC
Tacrolimus 14 mg PO Q12H
Metoprolol Tartrate 50 mg PO TID
Terazosin 5 mg PO HS
Multivitamins 1 TAB PO DAILY
Triamterene-Hydrochlorothiazide 2 CAP PO DAILY
Mycophenolate Mofetil 1000 mg PO BID
Ursodiol 900 mg PO BID
Omeprazole 20 mg PO DAILY
Valsartan 320 mg PO DAILY
Potassium Chloride 20 mEq PO DAILY
Felodipine 10 mg SR PO DAILY


Discharge Medications:
1. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
3. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours).
4. Sertraline 100 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
5. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
8. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
9. Ursodiol 300 mg Capsule Sig: Three (3) Capsule PO BID (2
times a day).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
11. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
12. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units
Subcutaneous at bedtime.
14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain for 5 days.
Disp:*30 Tablet(s)* Refills:*0*
15. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily)
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
16. Tacrolimus 1 mg Capsule Sig: Ten (10) Capsule PO 6am and
6pm: Adjust as indicated.
17. Valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily): 320mg dose.  (Diovan).
18. Felodipine 10 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
19. Humalog 100 unit/mL Cartridge Sig: per sliding scale
Subcutaneous [**First Name8 (NamePattern2) **] [**Last Name (un) **] Recs.
20. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal
Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO once a day.


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
- Tamponade
- Pericarditis
- Hypoechoic liver lesion
- Atrial flutter
- Acute on chronic renal failure
.
Secondary:
- Status post liver [**Last Name (un) **] [**4-/2174**]
- Cirrohosis due to NASH
- History of HCC
- Diffuse biliary strictures due to ichemic cholangiopathy with
subsequent bilateral percutaneous biliary drains, with multiple
exchanges since placement
- Type 2 diabetes
- Hypertension
- Parathyroid adenoma status post parathyroidectomy [**8-/2175**]
- Chronic renal failure, baseline creatinine 1.3-1.4


Discharge Condition:
Afebrile, vital signs stable.  Chest-pain free.


Discharge Instructions:
You were admitted to the hospital with fluid and inflammation in
the sac surrounding your heart, called tamponade and
pericarditis.  Your pain improved after drainage of the fluid
and treatment with steroids and oxycodone.  We remain unsure as
to the cause of your symptoms, but it likely represented an
infection, with some studies pending.
.
You had an area of concern noted on liver ultrasound.  You had
an abdominal CT that showed this area was unlikely to be a
cancer and was more likely an area of inflammation.
.
While in the hospital, you developed an irregular heart rhythm
called atrial flutter or fibrillation.  You should discuss
future use of coumadin, a blood thinner, and your personal risk
of stroke with your primary care physician and cardiologist.
.
You had a bump in your kidney tests on admission.  This improved
with discontinuation of Triamterene-Hydrochlorothiazide.  These
medications have been on hold.  You should discuss with Dr.
[**Last Name (STitle) 497**] resuming this medication.
.
Please contact a physician or report to an emergency department
if you experience fevers, chills, chest pain, shortness of
breath, abdominal pain, nausea, vomiting, diarrhea, or any other
concerning symptoms.
.
Please take your medications as prescribed.
- You should continue Prednisone 10 mg daily for 4 more
days--until your appointment as with Dr. [**Last Name (STitle) 497**].
- You can take Oxycodone every four hours as needed for pain;
this medication is sedating and you should use caution when
driving or operating heavy machinery.
- Your Tacrolimus dose was adjusted to 10 mg daily.  Dr. [**Last Name (STitle) 497**]
will contact you regarding dosage adjustment.
- Your Triamterene-Hydrochlorothiazide was discontinued.
- No other changes were made to your medications.
.
Please keep your follow-up appointments as below.

Followup Instructions:
Previously scheduled appointments:
Follow-up with your primary care doctor: Provider: [**Name10 (NameIs) **] [**Name Initial (NameIs) **]
[**Name12 (NameIs) **], M.D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-9-18**] 10:00
Provider: [**Name10 (NameIs) 1037**] [**Name8 (MD) 5647**], MD Phone:[**Telephone/Fax (1) 1971**]
Date/Time:[**2178-11-5**] 3:15
Provider: [**Name10 (NameIs) 454**],ONE [**Name10 (NameIs) 454**] Date/Time:[**2178-11-18**] 7:00
.
Please see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] as scheduled this week, call his
office at ([**Telephone/Fax (1) 1582**] with questions about the time.
.
Please call Dr.[**Name (NI) 5103**] office to schedule an appointment for
follow-up within the next 10days.
{'Acute pericarditis, unspecified,Acute kidney failure, unspecified,Obstruction of bile duct,Unspecified pleural effusion,Atrial flutter,Complications of transplanted liver,Cardiac tamponade,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of liver,Cirrhosis of liver without mention of alcohol,Surgical operation with transplant of whole organ 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: Chest pain.

PRESENT ILLNESS: 67yoM with hx of HCC s/p liver [**Month/Day/Year **] in [**2174**] now relisted,
s/p ichemic cholangiopathy with bilateral biliary stent
placements, and recent [**Hospital1 18**] admission for similiar symptoms,
re-presents today with persistent chest pain. During his prior
admission, dates ([**2178-8-23**]) through ([**2178-8-25**]), the patients chest
was worked up and was ruled out for MI, PE and Aortic Disection.
During the admission the patient had his left percutaneous
biliary catheter exchanged, treated for suspected cholangitis
with Cipro/Flagyl however his chest pain persisted. His Total
Bili, which was elevated to 7 from a baseline of 1.5 to 3,
improved following the drain exchange. An echo during the
admission saw a small pericardial effusion, which was not there
during a TTE in ([**5-24**]). The patient was given PO tylenol that
decreased the severity of the pain, however the pain was still
persistenting on his discharge.
.
Today the patient presents with continued chest pain. He
describes it as band like in nature across the front of his
chest with radiation across the top of the back and to his
proximal left arm. The pain is constant and severe, limiting him
from falling asleep. He states it is worse with movement and
upon deep inspiration. It is worse with leaning forward. No
alleviating symptoms. The patient was recently discontinued off
his Naloxone, which he was taking for persistent pruritis.
.
ROS is negative for fevers, chills, sweats, visual changes, loss
of consciousness. However the patient has reported two loose
dark brown-black stools per day. No BRBPR. One episode of
"spitting up", no coffee ground emesis. No weightloss. The
patient was admitted directly from his Gastroenterology
physicians clinic.

MEDICAL HISTORY: - Status post liver [**Month/Year (2) **] [**4-/2174**]
- Cirrohosis due to NASH
- History of HCC
- Diffuse biliary strictures due to ichemic cholangiopathy with
subsequent bilateral percutaneous biliary drains, with multiple
exchanges since placement
- Type 2 diabetes
- Hypertension
- Parathyroid adenoma status post parathyroidectomy [**8-/2175**]
- Chronic renal failure, baseline creatinine 1.3-1.4

MEDICATION ON ADMISSION: Rifampin 300 mg PO Q12H
Sertraline 100 mg PO QPM
Ezetimibe 10 mg PO QPM
Simvastatin 10 mg PO DAILY
Ferrous Gluconate 325 mg PO DAILY
Sulfameth/Trimethoprim SS 1 TAB PO DAILY Insulin SC
Tacrolimus 14 mg PO Q12H
Metoprolol Tartrate 50 mg PO TID
Terazosin 5 mg PO HS
Multivitamins 1 TAB PO DAILY
Triamterene-Hydrochlorothiazide 2 CAP PO DAILY
Mycophenolate Mofetil 1000 mg PO BID
Ursodiol 900 mg PO BID
Omeprazole 20 mg PO DAILY
Valsartan 320 mg PO DAILY
Potassium Chloride 20 mEq PO DAILY
Felodipine 10 mg SR PO DAILY

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: 93.6 111/61 57 18 97%
Gen: Very mild distress, Middle-aged male, Generally Well
appearing
HEENT: PERRL, EOMI
Neck: Supple, No LAD
CV: S1S2, distant HS, No MRG
Resp: CTAB, ?reproduction of identical CP
Abd: Soft, NT, ND BS+. No biliary drainage
Ext: No C/C/E
Neuro: Motor Grossly intact in 4 extremities

FAMILY HISTORY: Father - [**Name (NI) **] CA
Mother- CVAs
Brother - DM, HTN
No family history for liver disease or colon CA.

SOCIAL HISTORY: Rare EtoH. Quit smoking [**2168**]. Retired. Previous director of
Health Services for Prison Service. Married with three children. 

### Response:
{'Acute pericarditis, unspecified,Acute kidney failure, unspecified,Obstruction of bile duct,Unspecified pleural effusion,Atrial flutter,Complications of transplanted liver,Cardiac tamponade,Chronic kidney disease, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of malignant neoplasm of liver,Cirrhosis of liver without mention of alcohol,Surgical operation with transplant of whole organ causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
