CHIEF COMPLAINT: cholecystitis

PRESENT ILLNESS: 74 y/o female with PMH significant for COPD, CAD, and
hypertension admitted to [**Hospital1 18**] on [**6-14**] to the surgery service
with two days of epigastric and right upper quadrant pain. She
had also been febrile to 101 and had one episode of nausea and
vomiting. Per notes, her abdominal exam was significant for
epitastric and right upper quadrant tenderness; positive
gaurding; and no rebound. Pt was guiac negative. CT showed a
distended gallbladder with wall thickening and a small amount of
pericholecystic fluid. Common duct was dilated up to 11 mm and
the pancreatinc duct was prominent at 5 mm. No free air or
fluid. Significant atherosclerotic disease with occlusion of the
[**Female First Name (un) 899**] and possible celiac and renal artery stenosis.

MEDICAL HISTORY: 1. [**Name (NI) 3672**] Pt has been intubated twice in the past. Her most
recent PFTs from [**2119-6-14**] whoed a FVC of 30% predicted, FEV1 of
24% predicted, and FEV1/FVC of 79% predicted. Her marked
obstructive ventilatory defect had worsened since PFTs from
[**2115**]. Also with a concurrent restrictive process given her
low-normal TLC.
2. Coronary artery disease- Pt is status post a cardiac
catheterization recently at the end of [**2117**] which showed a left
anterior descending artery 90% blockage which was stented and
her left circumflex artery underwent angioplasty with a balloon.
Stress in [**4-21**] showed a mild fixed septal defect. Recent echo
from [**2119-6-6**] whoed a normal RA and LA. LVEF with 55% with
normal regional LV systolic function. [**2-19**]+ AR. 1+ MR. [**First Name (Titles) 5544**] [**Last Name (Titles) **]R. Indeterminate PA systolic pressure.
3. Hypertension.
4. Hyperlipidemia.
5. Borderline pulmonary hypertension.
6. Irritable bowel syndrome.
7. S/P total abdominal hysterectomy in [**2079**].
8. S/P bilateral hernia repair in the remote past

MEDICATION ON ADMISSION: K-DUR 20 MEQ TBCR 1 tab po qd [**2119-6-12**]
 MORPHINE SULFATE CR 15 MG TB12 1 tab po q 12 h [**2119-6-1**]
 ADVAIR DISKUS 250-50 MCG/DOSE MISC 1 puff [**Hospital1 **] [**2119-6-1**]
 NOVOLIN N PENFILL 100 U/ML SUSP 16 units SC q am, 10 units SC
before supper [**2119-3-28**]
 ALBUTEROL AER 90MCG 2 puffs 4 times a day as needed [**2119-3-28**]
 ATROVENT 18 MCG/ACT AERS 2 puffs [**Hospital1 **] [**2118-11-24**]
 PREDNISONE 5 MG TABS 1 po q am [**2118-11-24**]
 FUROSEMIDE 40 MG TABS 1 po q am [**2118-11-15**]
 NITROGLYCERIN 0.4 MG SL TAB 1 SL prn CP, may repeat q 5min x 2
[**2118-5-12**]
 ASPIRIN TAB 325MG EC 1 po qd [**2118-4-21**]
 LIPITOR 40 MG TABS 1 po qd [**2118-2-24**]

ALLERGIES: Percocet

PHYSICAL EXAM: 97.9 103/57 114 23 100% BiPAP FiO2- .50 ePAP- 8 iPAP- 5
Gen- Lady resting in bed with BiPAP on. Appears uncomfortable.
Moaning. Asking to take mask off.
HEENT- NC AT. Anicteric sclera. BiPAP mask in place.
Cardiac- Very faint heart sounds which are difficult to hear
over pulmonary sounds. RRR.
Pulm- Coars breath sounds anteriorly and laterally with very
poor air movement.
Abdomen- Obese. Distended. Soft. NT. Percutaneous drainage tube
in place.
Extremities- No c/c/e.

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives in an [**Hospital3 **] facility. She is no longer able
to leave her home but does go down for meals. Widowed. Has six
children. Her HCP is her daughter [**Name (NI) **]. The pt is a retired
nurses aid. Pt smoked 1 pack per day for 60 years before quiting
1.5 years ago. No ETOH or drugs. + Pneumovax.
Calculus of gallbladder with acute cholecystitis, with obstruction,Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Unspecified pleural effusion,Diastolic heart failure, unspecified,Cellulitis and abscess of trunk,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Other chronic pulmonary heart diseases,Long-term (current) use of steroids,Obesity, unspecified,Disturbance of skin sensation,Unspecified essential hypertension
Cholelith/ac gb inf-obst,Acute & chronc resp fail,Obs chr bronc w(ac) exac,Pneumonia, organism NOS,Pleural effusion NOS,Diastolc hrt failure NOS,Cellulitis of trunk,DMII wo cmp nt st uncntr,Pain in limb,Chr pulmon heart dis NEC,Long-term use steroids,Obesity NOS,Skin sensation disturb,Hypertension NOS
Admission Date:  [**2119-6-14**]              Discharge Date:   [**2119-7-1**]

Date of Birth:  [**2045-3-23**]             Sex:   F

Service: MEDICINE

Allergies:
Percocet

Attending:[**First Name3 (LF) 562**]
Chief Complaint:
cholecystitis

Major Surgical or Invasive Procedure:
Intubation
Cholecystomy Tube placement
Thoracentesis


History of Present Illness:
74 y/o female with PMH significant for COPD, CAD, and
hypertension admitted to [**Hospital1 18**] on [**6-14**] to the surgery service
with two days of epigastric and right upper quadrant pain. She
had also been febrile to 101 and had one episode of nausea and
vomiting. Per notes, her abdominal exam was significant for
epitastric and right upper quadrant tenderness; positive
gaurding; and no rebound. Pt was guiac negative. CT showed a
distended gallbladder with wall thickening and a small amount of
pericholecystic fluid. Common duct was dilated up to 11 mm and
the pancreatinc duct was prominent at 5 mm. No free air or
fluid. Significant atherosclerotic disease with occlusion of the
[**Female First Name (un) 899**] and possible celiac and renal artery stenosis.

Past Medical History:
1. [**Name (NI) 3672**] Pt has been intubated twice in the past. Her most
recent PFTs from [**2119-6-14**] whoed a FVC of 30% predicted, FEV1 of
24% predicted, and FEV1/FVC of 79% predicted. Her marked
obstructive ventilatory defect had worsened since PFTs from
[**2115**]. Also with a concurrent restrictive process given her
low-normal TLC.
2. Coronary artery disease- Pt is status post a cardiac
catheterization recently at the end of [**2117**] which showed a left
anterior descending artery 90% blockage which was stented and
her left circumflex artery underwent angioplasty with a balloon.
Stress in [**4-21**] showed a mild fixed septal defect. Recent echo
from [**2119-6-6**] whoed a normal RA and LA. LVEF with 55% with
normal regional LV systolic function. [**2-19**]+ AR. 1+ MR. [**First Name (Titles) 5544**] [**Last Name (Titles) **]R. Indeterminate PA systolic pressure.
3. Hypertension.
4. Hyperlipidemia.
5. Borderline pulmonary hypertension.
6. Irritable bowel syndrome.
7. S/P total abdominal hysterectomy in [**2079**].
8. S/P bilateral hernia repair in the remote past


Social History:
Pt lives in an [**Hospital3 **] facility. She is no longer able
to leave her home but does go down for meals. Widowed. Has six
children. Her HCP is her daughter [**Name (NI) **]. The pt is a retired
nurses aid. Pt smoked 1 pack per day for 60 years before quiting
1.5 years ago. No ETOH or drugs. + Pneumovax.

Family History:
NC

Physical Exam:
97.9 103/57 114 23 100% BiPAP FiO2- .50 ePAP- 8 iPAP- 5
Gen- Lady resting in bed with BiPAP on. Appears uncomfortable.
Moaning. Asking to take mask off.
HEENT- NC AT. Anicteric sclera. BiPAP mask in place.
Cardiac- Very faint heart sounds which are difficult to hear
over pulmonary sounds. RRR.
Pulm- Coars breath sounds anteriorly and laterally with very
poor air movement.
Abdomen- Obese. Distended. Soft. NT. Percutaneous drainage tube
in place.
Extremities- No c/c/e.


Pertinent Results:
[**2119-6-14**] 03:40PM   ALT(SGPT)-17 AST(SGOT)-18 ALK PHOS-111
AMYLASE-64 TOT BILI-0.6
[**2119-6-14**] 03:40PM   LIPASE-16
[**2119-6-14**] 03:40PM   ALBUMIN-3.6
[**2119-6-14**] 12:35AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010
[**2119-6-14**] 12:35AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2119-6-13**] 10:20PM   GLUCOSE-95 UREA N-16 CREAT-0.8 SODIUM-139
POTASSIUM-3.4 CHLORIDE-95* TOTAL CO2-28 ANION GAP-19
[**2119-6-13**] 10:20PM   ALT(SGPT)-21 AST(SGOT)-22 ALK PHOS-131*
AMYLASE-63 TOT BILI-0.9
[**2119-6-13**] 10:20PM   LIPASE-16
[**2119-6-13**] 10:20PM   WBC-9.2 RBC-4.83 HGB-13.6 HCT-40.2 MCV-83
MCH-28.2 MCHC-33.9 RDW-15.1
[**2119-6-13**] 10:20PM   PLT COUNT-330
[**2119-6-13**] 10:12PM   LACTATE-2.1*
.
[**6-14**] CT
1) Distended gallbladder with wall edema and possible
pericholecystic fluid. Intra and extrahepatic ductal dilatation
is noted as well as prominence of the pancreatic duct. Further
evaluation with ERCP or MRCP is recommended.
2) Significant atherosclerotic disease with occlusion of the [**Female First Name (un) 899**]
and possible celiac and renal artery stenosis. The patient's
abdominal pain could be related to intestinal angina. Further
evaluation can be obtained with mesenteric CTA.
3) No evidence of diverticulitis.
4) Stable left pleural effusion.
5) Stable right renal cyst.
6) Stable small low attenuation focus in the spleen, which is
too small to be characterized.
.
[**6-20**] CT
1. Cholecystostomy tube in good position with no evidence of
fluid collection around it.
2. Ostial calcifications with narrowing of the mesenteric
vessels with no evidence of bowel wall thickening, edema, or
fluid.
.
[**6-26**] CTA
1) No evidence of pulmonary embolus.
2) Marked interval increase in left-sided pleural effusion and
left lower lobe atelectasis. No evidence of central obstructing
lesion.
3) Unchanged appearance of pulmonary nodules; in the absence of
a known primary malignancy, one-year follow-up is recommended to
ensure stability.
4) Mild upper lobe emphysematous changes.

Brief Hospital Course:
Although it was felt that the pt had cholycytstitis, it was felt
that she was an extremely high risk surgical candidate given her
significant pulmonary and cardiac disease. Therefore, a
percutaneous cholecyst tube was placed on [**6-15**] instead of doing
a cholecystectomy. Following this, the pt had a good decreased
in her pain and her fevers decreased into the 99 range. Doing an
ERCP was considered but as the pt had normal LFTs and bili this
was deferred as there was a concern that it would require
intubation. On [**6-19**], the pt spiked to 101.2 and redeveloped
right upper quadrant tenderness. On [**6-20**], she developed an
acutely more distended abdomen associated with nausea. At that
time, she began to desatruate to 70% with associated tachypnea,
accesory muscle use, and tachycardia into the 130s. An ABG at
that time was 7.44/39/52. CXR showed minimal worsening of a left
lower lobe consolidation with prominent bilateral vascular
markings. At that time, the pt was transferred to the SICU for
closer monitoring.
.
In the SICU, her oxygen saturation initially increased to 90% on
4L NC. Following transfer, she spiked to 103.6 and was started
on vancomycin and zosyn for a left lower lobe PNA. She was also
started on steroids for her COPD component. LFTs remained within
normal limits and there continued to be good drainage from her
choly tube. Pt defervesced over the nex few days and her
oxygenation stablalized on 4 L NC with a sat in the high 90s and
RR in the high teens. Then, on the evening of [**6-25**], the pt
received 1 mg ativan and 4 mg morphine for anxiety then desatted
to 100% on a NRB. In addition, pt had a low blood sugar of 65
which was treated with 1/2 amp D50. ABG obtained at that time
showed 7.38/56/66. Pt also received an extra 40 mg of IV lasix.
This morning, after receiving her morning nebs, the pt reported
that she could not breath and her oxygen sat began to drop
quickly going from 95 to 65%. Pt was given another treatment and
her BiPAP settings were increased with an improvement in her
sat. However, she became more tachypnic, tachycardic, and was
using her accessory muscles to breath. Pulmonary saw the pt and
was concerned that this acute respiratory failure coud be
secondary to bronchospasm. The pt had been off of high dose
steroids for 24 hours. However, PE was the primary concern to
rule out given her acute hypoxia, tachycardia, and relative
hypotension. A CTA was negative for PE however demonstrated a
large pleural effusion.  At this time the patient's respiratory
status was quite tenuous requiring mask ventillation.
.
The effusion was tapped producing 1 L of transudative fluid
which was culture negative.  The patient's respiratory status
markedly improved and her oxygen requirements decreased to 4L
NC.  She was transferred to the floor where she felt much
better.  The patient had one desatturation to 89% on 3L on [**6-29**]
which quickly resolved with nebs.  Otherwise the patient has
been at her baselie which is unfortunately poor.  At home she is
on [**3-23**] L NC and  requires freq nebs.  She will complete a 14 day
course of vanc/zosyn for her pneumonia.
.
The patient's liver funcitions decreased after tube placement
and stayed down.  She will complete a 14 day course of
vanc/zosyn for her cholecystitis.  The patient will have the
tube in place for 4-6 weeks total and follow up with IR as an
outpatient.
.
Of note the patient noticed numbness in her R hand where her a
line was placed.  The are was largely ecchymotic.  However this
improved once the line was taken out and returned to her
baseline neuropathy which is equal bilaterally.
.
Furthemore the patient had pain in her feet.  She was noted to
have pitting edema to her mid calf.  She was diuresed with
lasix.  the patient was also noted to have an ecchymosis on the
dorsum of her foot, [**3-22**] a phone falling.  XRays were negative.

Medications on Admission:
K-DUR 20 MEQ TBCR 1 tab po qd [**2119-6-12**]
 MORPHINE SULFATE CR 15 MG TB12 1 tab po q 12 h [**2119-6-1**]
 ADVAIR DISKUS 250-50 MCG/DOSE MISC 1 puff [**Hospital1 **] [**2119-6-1**]
 NOVOLIN N PENFILL 100 U/ML SUSP 16 units SC q am, 10 units SC
before supper [**2119-3-28**]
 ALBUTEROL AER 90MCG 2 puffs 4 times a day as needed [**2119-3-28**]
 ATROVENT 18 MCG/ACT AERS 2 puffs [**Hospital1 **] [**2118-11-24**]
 PREDNISONE 5 MG TABS 1 po q am [**2118-11-24**]
 FUROSEMIDE 40 MG TABS 1 po q am [**2118-11-15**]
 NITROGLYCERIN 0.4 MG SL TAB 1 SL prn CP, may repeat q 5min x 2
[**2118-5-12**]
 ASPIRIN TAB 325MG EC 1 po qd [**2118-4-21**]
 LIPITOR 40 MG TABS 1 po qd [**2118-2-24**]


Discharge Medications:
1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Insulin Regular Human 100 unit/mL Solution Sig: see attached
sheet units Injection ASDIR (AS DIRECTED).
3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  TID
(3 times a day) as needed.
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q2H (every 2 hours) as needed for shortness of breath
or wheezing.
5. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation every six (6) hours.
6. Prednisone 20 mg Tablet Sig: As Dir Tablet PO DAILY (Daily):
Give 60 mg for 3 days, then decrease by 10 every 3 days.
7. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q3H (every 3 hours).
8. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) puff Inhalation [**Hospital1 **] (2 times a day).
10. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day.
11. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous  Q6H (every 6 hours) for 2 days.
12. Vancomycin HCl in Dextrose 1 g/200 mL Piggyback Sig: One (1)
g Intravenous  Q24H (every 24 hours) for 2 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Cholecystis
COPD Exacebation
Pneumonia
Respiratory Failure
Diabetes


Discharge Condition:
Stable

Discharge Instructions:
Please take all medications and make all appointments as listed
in the discharge paper work.

Followup Instructions:
Patient will need to have biliary tube removed by interventional
radiology in early [**Month (only) 596**] ([**7-19**]).  Please call Dr.
[**Last Name (STitle) 5545**].  [**Telephone/Fax (1) 5546**].  2 day prior to this appointment the
tube should be clamped.
.
Please follow up with Dr. [**Last Name (STitle) **] in [**2-19**] weeks. [**Telephone/Fax (1) 2393**].
.
Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Where: [**Hospital6 29**]
PULMONARY FUNCTION LAB Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2119-7-6**]
4:15
.
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Where: [**Hospital6 29**] MEDICAL
SPECIALTIES Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2119-7-6**] 4:30
{'Calculus of gallbladder with acute cholecystitis, with obstruction,Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Unspecified pleural effusion,Diastolic heart failure, unspecified,Cellulitis and abscess of trunk,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Other chronic pulmonary heart diseases,Long-term (current) use of steroids,Obesity, unspecified,Disturbance of skin sensation,Unspecified essential hypertension'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: cholecystitis

PRESENT ILLNESS: 74 y/o female with PMH significant for COPD, CAD, and
hypertension admitted to [**Hospital1 18**] on [**6-14**] to the surgery service
with two days of epigastric and right upper quadrant pain. She
had also been febrile to 101 and had one episode of nausea and
vomiting. Per notes, her abdominal exam was significant for
epitastric and right upper quadrant tenderness; positive
gaurding; and no rebound. Pt was guiac negative. CT showed a
distended gallbladder with wall thickening and a small amount of
pericholecystic fluid. Common duct was dilated up to 11 mm and
the pancreatinc duct was prominent at 5 mm. No free air or
fluid. Significant atherosclerotic disease with occlusion of the
[**Female First Name (un) 899**] and possible celiac and renal artery stenosis.

MEDICAL HISTORY: 1. [**Name (NI) 3672**] Pt has been intubated twice in the past. Her most
recent PFTs from [**2119-6-14**] whoed a FVC of 30% predicted, FEV1 of
24% predicted, and FEV1/FVC of 79% predicted. Her marked
obstructive ventilatory defect had worsened since PFTs from
[**2115**]. Also with a concurrent restrictive process given her
low-normal TLC.
2. Coronary artery disease- Pt is status post a cardiac
catheterization recently at the end of [**2117**] which showed a left
anterior descending artery 90% blockage which was stented and
her left circumflex artery underwent angioplasty with a balloon.
Stress in [**4-21**] showed a mild fixed septal defect. Recent echo
from [**2119-6-6**] whoed a normal RA and LA. LVEF with 55% with
normal regional LV systolic function. [**2-19**]+ AR. 1+ MR. [**First Name (Titles) 5544**] [**Last Name (Titles) **]R. Indeterminate PA systolic pressure.
3. Hypertension.
4. Hyperlipidemia.
5. Borderline pulmonary hypertension.
6. Irritable bowel syndrome.
7. S/P total abdominal hysterectomy in [**2079**].
8. S/P bilateral hernia repair in the remote past

MEDICATION ON ADMISSION: K-DUR 20 MEQ TBCR 1 tab po qd [**2119-6-12**]
 MORPHINE SULFATE CR 15 MG TB12 1 tab po q 12 h [**2119-6-1**]
 ADVAIR DISKUS 250-50 MCG/DOSE MISC 1 puff [**Hospital1 **] [**2119-6-1**]
 NOVOLIN N PENFILL 100 U/ML SUSP 16 units SC q am, 10 units SC
before supper [**2119-3-28**]
 ALBUTEROL AER 90MCG 2 puffs 4 times a day as needed [**2119-3-28**]
 ATROVENT 18 MCG/ACT AERS 2 puffs [**Hospital1 **] [**2118-11-24**]
 PREDNISONE 5 MG TABS 1 po q am [**2118-11-24**]
 FUROSEMIDE 40 MG TABS 1 po q am [**2118-11-15**]
 NITROGLYCERIN 0.4 MG SL TAB 1 SL prn CP, may repeat q 5min x 2
[**2118-5-12**]
 ASPIRIN TAB 325MG EC 1 po qd [**2118-4-21**]
 LIPITOR 40 MG TABS 1 po qd [**2118-2-24**]

ALLERGIES: Percocet

PHYSICAL EXAM: 97.9 103/57 114 23 100% BiPAP FiO2- .50 ePAP- 8 iPAP- 5
Gen- Lady resting in bed with BiPAP on. Appears uncomfortable.
Moaning. Asking to take mask off.
HEENT- NC AT. Anicteric sclera. BiPAP mask in place.
Cardiac- Very faint heart sounds which are difficult to hear
over pulmonary sounds. RRR.
Pulm- Coars breath sounds anteriorly and laterally with very
poor air movement.
Abdomen- Obese. Distended. Soft. NT. Percutaneous drainage tube
in place.
Extremities- No c/c/e.

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives in an [**Hospital3 **] facility. She is no longer able
to leave her home but does go down for meals. Widowed. Has six
children. Her HCP is her daughter [**Name (NI) **]. The pt is a retired
nurses aid. Pt smoked 1 pack per day for 60 years before quiting
1.5 years ago. No ETOH or drugs. + Pneumovax. 

### Response:
{'Calculus of gallbladder with acute cholecystitis, with obstruction,Acute and chronic respiratory failure,Obstructive chronic bronchitis with (acute) exacerbation,Pneumonia, organism unspecified,Unspecified pleural effusion,Diastolic heart failure, unspecified,Cellulitis and abscess of trunk,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Pain in limb,Other chronic pulmonary heart diseases,Long-term (current) use of steroids,Obesity, unspecified,Disturbance of skin sensation,Unspecified essential hypertension'}
