CHIEF COMPLAINT: abdominal pain, jaundice

PRESENT ILLNESS: HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: [**2142-2-19**]
ADMIT TIME: [**2129**]
.
59 yo F with pmhx significant for htn, GERD, RA and depression
presented to [**Hospital3 **] today with abdominal pain and
jaundice.
.
Patient reports three weeks of constant dull epigastric pain
that increases to [**8-20**] stabbing pain with po intake.  Also with
white loose stools, approx [**2-11**]/day.  Noted yellowing of eyes and
skin over the past week.  Endorses nausea without vomiting.  No
fever but occasional chills  + nightsweats x 1.5 weeks.  Poor
appetite.  Endorses 27 lbs weight loss over past three weeks.
.
Patient seen at [**Hospital3 **] ED and found to have total bili
of 12.5, direct bili 7.8, ast/alt 117/231 and alk phos 201.
Patient had a CT scan which showed a dilated CBD to 1.5 cm and
intrahepatic ducts with soft tissue in the distal common duct
consistent with distal stones, no pancreatic mass.  She was
transferred to [**Hospital1 18**] for ERCP.  No medications given.  Unable to
have MRCP due to interstim implanted one year ago for urinary
incontinence.
.
ED: 98.8  72P  18  130/76; RUQ ultrasound performed which showed
CBD 1.4 cm and 1.6-2cm hypoechecoic focus in the region of head,
without pancreatic ductal dilatation.  ERCP contact[**Name (NI) **] from [**Name (NI) **]
and will plan for ERCP in the am.  No medications given.
.
ROS: as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: HTN
RA
GERD
Depression
HSV on chronic suppression therapy
Urinary incontinence s/p insterstim [**2140-12-10**]
.
PSHx:
Appy
CCY 25 years ago for stones
Hysterectomy
Bilateral knee surgery

MEDICATION ON ADMISSION: Acyclovir 400mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Percocet 5/325 1 tab q6h prn
Fluoxetine 40mg daily
Trazodone 100mg qhs
Metoprolol xl 200mg daily
Lisinopril 40mg daily

ALLERGIES: Bactrim / Methotrexate / atorvastatin

PHYSICAL EXAM: VS:  97.4  152/72  60  18  96%RA
Appearance: alert, NAD, jaundiced appearing
Eyes: eomi, perrl, icteric sclera
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2  -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, + RUQ ttp, no distension, no rebound/guarding, neg
murphys, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]

FAMILY HISTORY: No known hx of pancreatic cancer or hepatobiliary malignancy.

SOCIAL HISTORY: Lives with dtr, son-in-law, [**Name (NI) 32774**] and [**Name2 (NI) 110060**] (5 days
old).  Works for a company that manages mailing for [**Company 110061**].  + tobacco with 2.5 ppd x 37 years, cut down to 5 per
day over past year.  No etoh or illicits.
Hemorrhage complicating a procedure,Calculus of bile duct without mention of cholecystitis, with obstruction,Blood in stool,Acute posthemorrhagic anemia,Other specified disorders of liver,Unspecified disease of pancreas,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Abnormal coagulation profile,Loss of weight,Unspecified essential hypertension,Reflux esophagitis,Rheumatoid arthritis,Depressive disorder, not elsewhere classified,Tobacco use disorder,Herpes simplex without mention of complication
Hemorrhage complic proc,Choledochlith NOS w obst,Blood in stool,Ac posthemorrhag anemia,Liver disorders NEC,Pancreatic disease NOS,Abn react-procedure NEC,Abnrml coagultion prfile,Abnormal loss of weight,Hypertension NOS,Reflux esophagitis,Rheumatoid arthritis,Depressive disorder NEC,Tobacco use disorder,Herpes simplex NOS
Admission Date:  [**2142-2-19**]              Discharge Date:   [**2142-2-21**]

Date of Birth:  [**2082-2-25**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim / Methotrexate / atorvastatin

Attending:[**Doctor First Name 2080**]
Chief Complaint:
abdominal pain, jaundice

Major Surgical or Invasive Procedure:
ERCP with sphincterotomy


History of Present Illness:
HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: [**2142-2-19**]
ADMIT TIME: [**2129**]
.
59 yo F with pmhx significant for htn, GERD, RA and depression
presented to [**Hospital3 **] today with abdominal pain and
jaundice.
.
Patient reports three weeks of constant dull epigastric pain
that increases to [**8-20**] stabbing pain with po intake.  Also with
white loose stools, approx [**2-11**]/day.  Noted yellowing of eyes and
skin over the past week.  Endorses nausea without vomiting.  No
fever but occasional chills  + nightsweats x 1.5 weeks.  Poor
appetite.  Endorses 27 lbs weight loss over past three weeks.
.
Patient seen at [**Hospital3 **] ED and found to have total bili
of 12.5, direct bili 7.8, ast/alt 117/231 and alk phos 201.
Patient had a CT scan which showed a dilated CBD to 1.5 cm and
intrahepatic ducts with soft tissue in the distal common duct
consistent with distal stones, no pancreatic mass.  She was
transferred to [**Hospital1 18**] for ERCP.  No medications given.  Unable to
have MRCP due to interstim implanted one year ago for urinary
incontinence.
.
ED: 98.8  72P  18  130/76; RUQ ultrasound performed which showed
CBD 1.4 cm and 1.6-2cm hypoechecoic focus in the region of head,
without pancreatic ductal dilatation.  ERCP contact[**Name (NI) **] from [**Name (NI) **]
and will plan for ERCP in the am.  No medications given.
.
ROS: as per HPI, 10 pt ROS otherwise negative


Past Medical History:
HTN
RA
GERD
Depression
HSV on chronic suppression therapy
Urinary incontinence s/p insterstim [**2140-12-10**]
.
PSHx:
Appy
CCY 25 years ago for stones
Hysterectomy
Bilateral knee surgery

Social History:
Lives with dtr, son-in-law, [**Name (NI) 32774**] and [**Name2 (NI) 110060**] (5 days
old).  Works for a company that manages mailing for [**Company 110061**].  + tobacco with 2.5 ppd x 37 years, cut down to 5 per
day over past year.  No etoh or illicits.

Family History:
No known hx of pancreatic cancer or hepatobiliary malignancy.

Physical Exam:
VS:  97.4  152/72  60  18  96%RA
Appearance: alert, NAD, jaundiced appearing
Eyes: eomi, perrl, icteric sclera
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2  -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, + RUQ ttp, no distension, no rebound/guarding, neg
murphys, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]


Pertinent Results:
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Labs [**2142-2-19**]:
.
139  103  10
-----------< 110
4.3  28  0.5
.
ast/alt 117/231
alk phos 201
lipase 70
tbil 12.5
dbil 7.8
.
8> 13/37 <253
.
[**2142-2-19**] CT a/p with IV contrast (no oral) at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]:
Dilated CBD and intrahepatic duct with soft tissue in the distal
CBD consistent with distal stones, no pancreatic mass.
Incidental sigmoid diverticula.

ERCP:
Impression: Normal appearance of major papilla
Limited pancreatogram was obtained and the PD appeared
unremarkable in the head and body of the pancreas.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
A filling defect was noted at the lower CBD consistent with a 1
cm stone. There was post obstructive dilation of the CBD with
the CBD measuring 15 mm. Rest of the biliary tree appeared
unremarkable. Evidence of previous CCY was noted.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Attempts were made to extract the stone initially with a balloon
extractor and then with a basket. However repeated attempts at
stone extraction were unsuccessful.
A 5cm by 10FR double pig tail biliary stent was placed
successfully. Good bile flow was noted through the stent.
Otherwise normal ercp to second part of the duodenum


Brief Hospital Course:
59 yo F with pmhx significant for htn, GERD and depression
admitted with epigastric pain, jaundice and weight loss and
found to have dilated CBD on imaging and possible distal
obstructing stones.
.
#Obstructive jaundice: tbili 12.5, dbili 7.8, CBD 1.5 cm on OSH
CT with soft tissue in distal CBD thought to be consistent with
stones, no pancreatic mass however RUQ ultrasound showed 1.6-2
cm hypoechecoic focus in region of head of pancreas.  Concerning
for malignancy given weight loss.  Patient is s/p CCY 25 years
ago for stones.  Patient underwent uncomplicated ERCP with
sphincterotomy and extraction of a stone.  She tolerated the
procedure well without complications.  She was transitioned to
orals and was discharged to complete a 7 day course of Cipro.
- She will need a repeat ERCP in 1 month for further stone
extraction/lithotripsy.  To be arranged by ERCP
.
#HTN: benign
--continued metoprolol xl
--resumed all meds on discharge
.
#GERD:
--continued omeprazole
.
#Depression:
--continued fluoxetine and trazodone
.
#HSV ppx: suppression therapy per pt
--continued acyclovir
.
#RA:
--percocet on hold while receiving IV pain meds
.
DNR/DNI per discussion with patient
Dtr: [**Known firstname **] [**Last Name (NamePattern1) 110062**] [**Telephone/Fax (1) 110063**]


Medications on Admission:
Acyclovir 400mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Percocet 5/325 1 tab q6h prn
Fluoxetine 40mg daily
Trazodone 100mg qhs
Metoprolol xl 200mg daily
Lisinopril 40mg daily


Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
5. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily).
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 5
days.
Disp:*10 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Bile obstruction
Choledocholithiasis
Jaundice
Hypertension
Depression


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


Discharge Instructions:
You were admitted with abdominal pain and jaundice.  You had an
ERCP with removal of a gallstone.  Your jaundice is improving.
You will need to return in 1 month for another procedure, to be
arranged by Dr. [**Last Name (STitle) **] (see below).  You will also need to
complete a course of Ciprofloxacin.

Please avoid NSAIDS/aspirin for the next 7 days.  Please resume
your medications otherwise.

Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3708**]
When: Tuesday [**2142-3-6**] at 3:20 PM
Location: [**Location (un) 2274**]-[**Hospital1 **]
Address: [**Location (un) 17467**], [**Hospital1 **],[**Numeric Identifier 10727**]
Phone: [**Telephone/Fax (1) 68410**]

Department: ENDO SUITES
When: FRIDAY [**2142-3-23**] at 11:30 AM

Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2142-3-23**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST     Best Parking: Main Garage





Admission Date:  [**2142-2-22**]              Discharge Date:   [**2142-2-25**]

Date of Birth:  [**2082-2-25**]             Sex:   F

Service: MEDICINE

Allergies:
Bactrim / Methotrexate / atorvastatin / Sulfa(Sulfonamide
Antibiotics)

Attending:[**First Name3 (LF) 1253**]
Chief Complaint:
bright red blood per rectum


Major Surgical or Invasive Procedure:
[**2142-11-24**] - ERCP with epinepherine injection and electrocautery
of bleeding vessel, and biliary stent replacement


History of Present Illness:
This is a 59 year-old Female with a PMH significant for
hypertension, rheumatoid arthritis, reflux esophagitis,
depression, sigmoid diverticula, prior cholecystectomy (25 years
prior) who was recently admitted to [**Hospital1 18**] on [**2142-2-19**] after
presenting with abdominal pain and obstructive jaundice who
underwent sphincterotomy and biliary stent placement and was
discharged on [**2142-2-21**] and now presents with bright red blood per
rectum with clot burden and passing of a biliary stent.
.
The patient was hospitalized at [**Hospital1 18**] from [**2142-2-19**] to [**2142-2-21**]
after presented with epigastric abdominal pain, jaundice and
weight loss. She was found to have an bilirubinemia of 12.5,
mild transaminitis and abdominal imaging showing 1.6-cm
dilatation of her common bile duct with RUQ showing intrahepatic
or extrahepatic biliary ductal dilatation with a hypoechoic
focus at the level of pancreatic head. Subsequent ERCP ([**2142-2-20**])
was performed showing 1-cm gallstone at the lower CBD. Repeated
attempts at extraction were unsuccessful, and sphincterotomy
with placement of a 5-cm by 10-Fr double pigtail biliary stent
occurred. There was no pancreatic mass and the pancreatic duct
appeared normal. She resumed her diet and was discharged on
[**2142-2-21**] with 7-days of Ciprofloxacin prophylaxis.
.
The patient notes she was feeling well and went to sleep without
issue the day prior to admission. She awoke and had a single,
large frankly bloody bowel movement with clot burden and passing
of the biliary stent (that filled the bowel). She drank some tea
and then subsequently felt lightheaded and dizzy and syncoped
without LOC or head injury and recalls the events surrounding
her fall. The patient presented to [**Hospital6 33**] with
these complaints. Her hemoglobin was reportedly 7.2 g/dL at the
OSH and she was given 2L NS prior to transfer (her hemoglobin
and hematocrit on discharged from [**Hospital1 18**] was 10.6 g/dL and
34.5%).
.
Of note, she has had a 27-lb weight loss over several months
with worsening fatigue and associated decreased PO intake and
nightsweats with chills. She denies fevers.
.
On arrival to [**Hospital1 18**], initial VS 98.9 96 101/51 18 98%RA. Exam
revealed one more episode of frank hematochezia with clot that
filled the bedpan in the ED. She appeared hemodynamically
stable. Laboratory data revealed WBC 10.0, hemoglobin 6.2%, HCT
18.3%, platelets 219. Creatinine 0.6. INR 2.0 (from 1.2 on
[**2-19**]). She was given an additional 1L NS x 1 and she was
transfused 1 unit of packed red cells. The patient was evaluated
by ERCP and there was plan for repeat ERCP the date of
admission. Prior to transfer, VS 102 123/63 99% 2L NC.
.
On arrival to the [**Hospital Unit Name 153**], she appears stable and denies abdominal
pain, nausea or emesis. She has had no further bleeding since
her episode in the ED. She denies chest pain or trouble
breathing. She denies lightheadedness or dizziness.
.
ROS: Denies headaches or vision changes. No cough or upper
respiratory symptoms. Denies chest pain, dizziness or
lightheadedness; no palpitations. Denies shortness of breath. No
nausea or vomiting, denies abdominal pain. No dysuria or
hematuria. Denies myalgias or neurologic complaints.


Past Medical History:
PAST MEDICAL & SURGICAL HISTORY:
1. Hypertension
2. Rheumatoid arthritis
3. Reflux esophagitis, GERD
4. Depression
5. Recurrent herpes simplex virus (on chronic suppressive
therapy)
6. Urinary incontinence (Interstim therapy in [**12/2140**])
7. s/p appendectomy
8. s/p cholecystectomy (25 years prior)
9. s/p hysterectomy
10. s/p bilateral knee surgery
[**40**]. s/p left wrist fusion surgery

Social History:
Patient lives at home with daughter, son-in-law and
grandchildren. Works for a company that manages mailing for [**Company 110064**]. Current smoker (2.5 PPD for 37-years, cutdown to 5
cigarettes per day over 1 year). Denies alcohol use; no
recreational substance use.

Family History:
No known history of pancreatic cancer or hepatobiliary
malignancy. No history of bleeding diasthesis.

Physical Exam:
ADMISSION PHYSICAL EXAM:
.
VITALS: 100-103  100-120/51-60  16-18    98-99%RA
GENERAL: Appears in no acute distress. Alert and interactive.
Jaundiced with scleral icterus.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD not elevated.
CVS: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft without scars, non-tender, non-distended, with
normoactive bowel sounds. No palpable masses or peritoneal
signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength 5/5 bilaterally, sensation grossly intact. Gait
deferred.
RECTAL: external peri-anal region with some skin tags, without
fissures. Digital exam reveals normal tone. No masses or
internal hemorrhoids. Active bleeding noted. No stool in the
rectal vault.
.
DISCHARGE EXAM:
.
VS: Afebrile  133/65  p72  R18  97RA
GEN: Jaundiced, but otherwise well appearing. NAD. Comfortable.
RESP:  CTA B. No WRR.
CV: RRR. No MRG.
Abd: +BS. Soft, NT/ND.


Pertinent Results:
[**2142-2-22**] ERCP
Procedures: Three epinephrine injections 2 cc each was applied
for hemostasis successfully at the sphincterotomy
[**Hospital1 **]-CAP electrocautery was applied for hemostasis successfully at
the sphincterotomy. Complete hemostasis was achieved
A 5cm by 10mm double pig tail biliary stent was placed
successfully.

Impression: A sphincterotomy was noted.  The previously placed
stent was absent.
A pulsatile, actively bleeding blood vessel was noted at the
sphincterotomy.  Moderate amount of blood was noted in the
second part of duodenum
Three epinephrine injections 1 cc each was applied for
hemostasis successfully at the sphincterotomy
[**Hospital1 **]-CAP electrocautery was applied for hemostasis successfully at
the sphincterotomy
Complete hemostasis was achieved
A filling defect was noted at the lower CBD consistent with the
previously noted stone. There was post obstructive dilation of
the CBD with the CBD measuring 15 mm. Rest of the biliary tree
appeared unremarkable.
A 5cm by 10mm double pig tail biliary stent was placed
successfully
 (hemostasis, hemostasis, stent placement)
Otherwise normal ercp to third part of the duodenum
Recommendations: Transfuse pRBC and FFP as needed
Q8hr hct checks
NPO overnight until hct stabilizes and no evidence of active
bleeding is noted.
Please page ERCP fellow with questions.
Repeat ERCP in Dr. [**Last Name (STitle) **] in 1 month
_____________________________________________

CTA ABD W&W/O C & RECONS Study Date of [**2142-2-23**]
FINDINGS: The lung bases are clear. No pleural or pericardial
effusion is
seen. Pneumobilia is likely post-procedural. A biliary stent
courses along
the expected route into the duodenum; there has been interval
improvement in biliary ductal dilation. No focal liver lesions
are detected. The patient is status post cholecystectomy and
surgical clips are seen in the gallbladder fossa. The spleen,
adrenal glands, kidneys, visualized portions of the ureters,
stomach, and small bowel are within normal limits. Colonic
diverticula do not demonstrate evidence for inflammation. No
free intraperitoneal air or ascites is detected.

In the superior portion of the head of the pancreas, there is a
hypodense
lesion which measures roughly 14 x 12 mm in the axial plane.
There is no
pancreatic duct dilation. A few small retroperitoneal lymph
nodes are noted; the largest measures 9 mm in short axis
dimension. There is a 1-cm portocaval node. The GDA node
measures 7-mm in short axis.

This mass mildly indents the inferior aspect of the proximal
main portal vein less than 1 cm from the confluence and it
appears that the low density abnormality involves the portal
vein wall for roughly 90 degress along its inferior aspect for
less than 1 cm in length. Visualized vasculature is otherwise
uninvolved and within normal limits including the splenic vein,
superior mesenteric vein, celiac trunk and branches, superior
mesenteric artery, and visualized portion of the inferior
mesenteric artery. Note is made of an accessory right renal
artery. Extensive arterial atherosclerotic calcification is
noted. The origins of the renal arteries appear patent.

No concerning lytic or sclerotic osseous lesions are detected.
Hardware is
partially imaged in the right gluteal subcutaneous fat.

IMPRESSION:
Roughly 14 mm hypodense lesion in the superior head of the
pancreas with
concern for involvement of a short portion of the inferior wall
of the main portal vein. No definite adenopathy or metastasis.
__________________________________________________________

[**2142-2-21**] 06:30AM BLOOD WBC-6.6 RBC-3.60* Hgb-10.6* Hct-34.5*
MCV-96 MCH-29.5 MCHC-30.7* RDW-16.4* Plt Ct-198
[**2142-2-22**] 11:00AM BLOOD WBC-10.0# RBC-1.98*# Hgb-6.2*# Hct-18.3*#
MCV-92 MCH-31.1 MCHC-33.7 RDW-16.6* Plt Ct-219
[**2142-2-23**] 05:09AM BLOOD WBC-10.1 RBC-3.06* Hgb-9.3* Hct-26.8*
MCV-88 MCH-30.5 MCHC-34.8 RDW-17.0* Plt Ct-162
[**2142-2-24**] 06:25AM BLOOD WBC-8.3 RBC-3.26* Hgb-9.7* Hct-29.4*
MCV-90 MCH-29.7 MCHC-33.0 RDW-17.0* Plt Ct-173
[**2142-2-25**] 06:40AM BLOOD WBC-6.0 RBC-3.28* Hgb-10.0* Hct-30.0*
MCV-92 MCH-30.4 MCHC-33.2 RDW-17.1* Plt Ct-206
[**2142-2-22**] 11:00AM BLOOD PT-21.1* PTT-30.3 INR(PT)-2.0*
[**2142-2-24**] 06:25AM BLOOD PT-11.7 PTT-27.2 INR(PT)-1.1
[**2142-2-25**] 06:40AM BLOOD Glucose-140* UreaN-12 Creat-0.7 Na-142
K-3.5 Cl-106 HCO3-23 AnGap-17
[**2142-2-21**] 06:30AM BLOOD ALT-140* AST-51* AlkPhos-172*
TotBili-5.9*
[**2142-2-22**] 11:00AM BLOOD ALT-133* AST-93* AlkPhos-137*
TotBili-7.2*
[**2142-2-23**] 05:09AM BLOOD ALT-96* AST-55* AlkPhos-111* TotBili-5.8*
[**2142-2-24**] 06:25AM BLOOD ALT-128* AST-84* AlkPhos-119*
TotBili-3.9*
[**2142-2-25**] 06:40AM BLOOD Calcium-9.1 Phos-4.0# Mg-1.9

MRSA screen: negative

Brief Hospital Course:
59F with a PMH significant for hypertension, rheumatoid
arthritis, reflux esophagitis, depression, sigmoid diverticula,
prior cholecystectomy (25 years prior) who was recently admitted
to [**Hospital1 18**] on [**2142-2-19**] after presenting with abdominal pain and
obstructive jaundice who underwent sphincterotomy and biliary
stent placement and was discharged on [**2142-2-21**] and presented on
[**2-22**] with bright red blood per rectum with clot burden and
passing of a biliary stent, inappropriately elevated INR, and
2-cm pancreatic head mass who required multiple blood products,
found to have actively bleeding sphincterotomy site on repeat
ERCP with identified source, intervention and hemostasis with
stable post-transfusion hematocrit and preserved hemodynamic
stability.
.
# BRIGHT RED BLOOD PER RECTUM, FALLING HEMATOCRIT - Patient
presented with rectal bleeding with hematochezia in the setting
of recent ERCP that involved biliary stenting and
sphincterotomy. Also presented with INR of 2.0 without
anticoagulation, antiplatelet or strong NSAID history.
Hemoglobin 6.2 g/dL, hematocrit 18.3% (recent values 10.6 g/dL,
34.5%). She received IVF and 4 units of packed red cells and 2
units of FFP, and 4 mg of PO vitamin K. She was urgently taken
to ERCP ([**2-22**]) and pt was noted to have an acute arterial bleed
at the recent sphincterotomy site. The 1-cm retained distal CBD
stone was also noted. The bleeeding was stopped during ERCP with
epinepherine injection and electrocautery.  The previously
dislodged biliary stent was replaced.
.
# RETAINED BILIARY DUCT STONE/BILE DUCT OBSTRUCTION
# HYPERBILIRUBINEMIA/JAUNDICE/CHOLESTATIC HEPATITIS
Patient presented on [**2142-2-19**] with obstructive jaundice, weight
loss and abdominal pain complaints. ERCP demonstrated 1-cm
distal CBD stone which was unsuccessfully extracted and
sphincterotomy with biliary stenting was performed on [**2143-2-20**].
Given failed stone removal, patient was encouraged to follow-up
for extraction vs. lithotripsy. Now presenting with improving
transaminitis, alkaline phosphatase, total bilirubinemia. She
had no abdominal pain complaints; no fevers to suggest
cholangitis. Status-post cholecystectomy. Repeat ERCP visualized
her retained stone and will need to be repeated in 1-month for
further intervention. She received post-procedural Cirpofloxacin
500 mg PO BID for 5-days from [**2-22**] (second ERCP) given her
recent instrumentation.
.
# PANCREATIC HEAD MASS, WEIGHT LOSS - Despite her recent biliary
stone obstruction with ERCP procedure, the patient also has also
endorsed 27-lb weight loss over 3-weeks (on admission 69.3 kg).
No report of nightsweats, fevers or chills. Has had no increased
fatigue. Denied fatty or voluminous stool output. Recent RUQ U/S
on [**2142-2-19**] demonstrated a 1.6-2 cm hypoechecoic focus in the
region of the pancreatic head, without pancreatic ductal
dilatation (which was confirmed on ERCP). Given Interstim
placement for urinary issues, MRCP should be avoided. She
underwent CTA Pancreas, which showed 14 mm hypodense lesion in
the superior head of the pancreas with concern for involvement
of a short portion of the inferior wall of the main
portal vein.  See results for full report.  These results were
discussed with ERCP team, and patient will return in
approximately 1 week for EUS with FNA biopsy of the mass for
further evaluation.
.
# INAPPROPRIATELY ELEVATED INR - Pt was noted to have INR 2 at
time of admission, likely due to decreased PO intake with recent
weight loss. Has also been on Ciprofloxacin for recent biliary
instrumentation. INR normalized after 2 units of FFP and vitamin
K 4 mg PO.
.
# HYPERTENSION - Presented with diagnosis of hypertension and
home regimen of beta-blocker and ACEI. In the setting of GI
bleeding concerns, her beta-blocker and ACEi were initially
held. Repeat EKGs stable. Her blood pressure medications were
resumed once her hematocrit stabilized.
.
# RHEUMATOID ARTHRITIS - Patient reportedly has stable disease
and has been on Percocet 5/325 mg PO 1-2 tabs PO Q4-6H PRN pain.
.
# REFLUX ESOPHAGITIS, GERD - Remote history without active
symptoms. Limited evaluation of the esophagus and stomach on
ERCP ([**2142-2-21**]) was normal. Home dose of PPI of Omeprazole 20 mg
EC PO BID, was continued.
.
# DEPRESSION - Mood appears stable. We continued home dosing of
Fluoxetine 40 mg PO daily and Trazodone 100 mg PO QHS.
.
# Hx RECURRENT HSV INFECTION - No current evidence of active
infection. Continued home Acyclovir 400 mg PO Q12 hours.
.
TRANSITION OF CARE ISSUES:
[ ] outpatient EUS/FNA of pancreatic mass; in approx 1 week
[ ] Repeat ERCP in 1 month for biliary stent removal
[ ] Follow up LFT's and Coags at outpatient follow up, to ensure
stability
[ ] Follow up nutritional status and monitor for further weight
loss

Medications on Admission:
1. Acyclovir 400 mg PO Q12 hours
2. Omeprazole 20 mg EC PO BID
3. Fluoxetine 40 mg PO daily
4. Trazodone 100 mg PO QHS
5. Metoprolol succinate XL 200 mg PO daily
6. Lisinopril 40 mg PO daily
7. Ciprofloxacin 500 mg PO BID (5-days, [**2142-2-21**] to [**2142-2-25**])


Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
3. fluoxetine 40 mg Capsule Sig: One (1) Capsule PO once a day.

4. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
6. lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 2 days.
Disp:*4 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
# Acute Gastrointestinal Bleed s/p ERCP, at sphincterotomy site
# Bile duct obstruction due to biliary stone
# Cholestatic hepatitis
# Pancreatic mass, unclear etiology


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


Discharge Instructions:
You were hospitalized with an acute bleed from your ERCP
procedure.  You received blood transfusions, and you had a
repeat ERCP procedure to stop the bleeding and replace the stent
in your bile duct.  The bleeding stopped, and your blood levels
have stabilized.  During this hospitalization, imaging showed a
mass in your pancreas.  While it remains unclear what this mass
is, it is extremely important that this is further evaluated.
You will be contact[**Name (NI) **] by the Gastroenterology Department to
schedule an appointment in approximately 1 week for an
endoscopic ultrasound and biopsy of this area.  If you have not
heard from them within the next several days, please call their
office to schedule an appointment at:
Dr. [**Last Name (STitle) **]
Department of Gastroenterology
Office Phone: ([**Telephone/Fax (1) 2306**]

Followup Instructions:
See above.

Department: DIGESTIVE DISEASE CENTER
When: FRIDAY [**2142-3-23**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2839**], MD [**Telephone/Fax (1) 463**]
Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**]
Campus: EAST     Best Parking: Main Garage
{'Hemorrhage complicating a procedure,Calculus of bile duct without mention of cholecystitis, with obstruction,Blood in stool,Acute posthemorrhagic anemia,Other specified disorders of liver,Unspecified disease of pancreas,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Abnormal coagulation profile,Loss of weight,Unspecified essential hypertension,Reflux esophagitis,Rheumatoid arthritis,Depressive disorder, not elsewhere classified,Tobacco use disorder,Herpes simplex without mention of complication'}


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: abdominal pain, jaundice

PRESENT ILLNESS: HMED ATTENDING ADMISSION NOTE
.
ADMIT DATE: [**2142-2-19**]
ADMIT TIME: [**2129**]
.
59 yo F with pmhx significant for htn, GERD, RA and depression
presented to [**Hospital3 **] today with abdominal pain and
jaundice.
.
Patient reports three weeks of constant dull epigastric pain
that increases to [**8-20**] stabbing pain with po intake.  Also with
white loose stools, approx [**2-11**]/day.  Noted yellowing of eyes and
skin over the past week.  Endorses nausea without vomiting.  No
fever but occasional chills  + nightsweats x 1.5 weeks.  Poor
appetite.  Endorses 27 lbs weight loss over past three weeks.
.
Patient seen at [**Hospital3 **] ED and found to have total bili
of 12.5, direct bili 7.8, ast/alt 117/231 and alk phos 201.
Patient had a CT scan which showed a dilated CBD to 1.5 cm and
intrahepatic ducts with soft tissue in the distal common duct
consistent with distal stones, no pancreatic mass.  She was
transferred to [**Hospital1 18**] for ERCP.  No medications given.  Unable to
have MRCP due to interstim implanted one year ago for urinary
incontinence.
.
ED: 98.8  72P  18  130/76; RUQ ultrasound performed which showed
CBD 1.4 cm and 1.6-2cm hypoechecoic focus in the region of head,
without pancreatic ductal dilatation.  ERCP contact[**Name (NI) **] from [**Name (NI) **]
and will plan for ERCP in the am.  No medications given.
.
ROS: as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: HTN
RA
GERD
Depression
HSV on chronic suppression therapy
Urinary incontinence s/p insterstim [**2140-12-10**]
.
PSHx:
Appy
CCY 25 years ago for stones
Hysterectomy
Bilateral knee surgery

MEDICATION ON ADMISSION: Acyclovir 400mg [**Hospital1 **]
Omeprazole 20mg [**Hospital1 **]
Percocet 5/325 1 tab q6h prn
Fluoxetine 40mg daily
Trazodone 100mg qhs
Metoprolol xl 200mg daily
Lisinopril 40mg daily

ALLERGIES: Bactrim / Methotrexate / atorvastatin

PHYSICAL EXAM: VS:  97.4  152/72  60  18  96%RA
Appearance: alert, NAD, jaundiced appearing
Eyes: eomi, perrl, icteric sclera
ENT: OP clear s lesions, mmd, no JVD, neck supple
Cv: +s1, s2  -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: clear bilaterally
Abd: soft, + RUQ ttp, no distension, no rebound/guarding, neg
murphys, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, no focal deficits
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]

FAMILY HISTORY: No known hx of pancreatic cancer or hepatobiliary malignancy.

SOCIAL HISTORY: Lives with dtr, son-in-law, [**Name (NI) 32774**] and [**Name2 (NI) 110060**] (5 days
old).  Works for a company that manages mailing for [**Company 110061**].  + tobacco with 2.5 ppd x 37 years, cut down to 5 per
day over past year.  No etoh or illicits. 

### Response:
{'Hemorrhage complicating a procedure,Calculus of bile duct without mention of cholecystitis, with obstruction,Blood in stool,Acute posthemorrhagic anemia,Other specified disorders of liver,Unspecified disease of pancreas,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Abnormal coagulation profile,Loss of weight,Unspecified essential hypertension,Reflux esophagitis,Rheumatoid arthritis,Depressive disorder, not elsewhere classified,Tobacco use disorder,Herpes simplex without mention of complication'}
