CHIEF COMPLAINT: Gallstone pancreatitis and cholangitis

PRESENT ILLNESS: The patient is a 54-years-old female with complicated
psychiatric history. She has been under the care of Dr. [**Last Name (STitle) **]
undergoing multiple ERCP and stent changes with a history of
gallstone pancreatitis and cholangitis initially last spring. At
that time, she had refused surgical intervention.  She did state
in [**2134-10-5**] that she would be interested in having her
cholecystectomy, and she was then transferred to our service and
prepared for surgery, but in the preoperative holding area again
changed her mind, and thus was ultimately discharged home as she
was no longer willing to undergo an ERCP either. In [**Month (only) 404**]
[**2134**], patient returned back to Dr. [**First Name (STitle) **] office to discuss
cholecystectomy again. All risks, benefits and possible outcomes
were discussed with the patient, and she was scheduled for
elective laparoscopic/open cholecystectomy on [**2135-1-11**].

MEDICAL HISTORY: Fibromyalgia
Chronic fatigue syndrome
Depression
Schizophrenia
Gallstone pancreatitis/cholangitis [**3-16**]
Cholelithiasis/choledocholithiasis
Possible sleep apnea

MEDICATION ON ADMISSION: Clozaril 200qHS, Cal/Vit D 500-400', Dulcolax 5 PO prn, Senokot
2'' prn, Tylenol 650'''' prn, Zantac 150'prn

ALLERGIES: Penicillins / Epinephrine / aspirin / Benadryl / grapes / red
peppers

PHYSICAL EXAM: On Discharge:
VS: 97.6, 87, 136/80, 12, 95% 3L NC
GEN: NAD, AAO x 3, somnolent
CV: RRR, no m/r/g
RESP: Diminished bilaterally on bases R > L
ABD: Obese. Right subcostal incision OTA with staples and c/d/i.
Right T-tube capped, insertion site with dry dressing and c/d/i.

FAMILY HISTORY: NO family history of gallstone disease

SOCIAL HISTORY: Social History: Lives alone, denies tobacco, EtOH, drugs
Acute pancreatitis,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Calculus of bile duct with acute cholecystitis, with obstruction,Cholangitis,Laparoscopic surgical procedure converted to open procedure,Other chronic nonalcoholic liver disease,Myalgia and myositis, unspecified,Unspecified schizophrenia, unspecified,Depressive disorder, not elsewhere classified,Chronic fatigue syndrome,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]
Acute pancreatitis,Ot pul insuf fol trm/srg,Choledochlith/ac gb-obst,Cholangitis,Lap surg convert to open,Chronic liver dis NEC,Myalgia and myositis NOS,Schizophrenia NOS-unspec,Depressive disorder NEC,Chronic fatigue syndrome,Elev transaminase/ldh
Admission Date:  [**2135-1-11**]              Discharge Date:   [**2135-1-20**]

Date of Birth:  [**2080-6-21**]             Sex:   F

Service: SURGERY

Allergies:
Penicillins / Epinephrine / aspirin / Benadryl / grapes / red
peppers

Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Gallstone pancreatitis and cholangitis

Major Surgical or Invasive Procedure:
[**2135-1-11**]:
1. Laparoscopic converted to open cholecystectomy with common
bile duct exploration.
2. Intraoperative cholangiogram and T-tube placement.
3. Liver biopsy.


History of Present Illness:
The patient is a 54-years-old female with complicated
psychiatric history. She has been under the care of Dr. [**Last Name (STitle) **]
undergoing multiple ERCP and stent changes with a history of
gallstone pancreatitis and cholangitis initially last spring. At
that time, she had refused surgical intervention.  She did state
in [**2134-10-5**] that she would be interested in having her
cholecystectomy, and she was then transferred to our service and
prepared for surgery, but in the preoperative holding area again
changed her mind, and thus was ultimately discharged home as she
was no longer willing to undergo an ERCP either. In [**Month (only) 404**]
[**2134**], patient returned back to Dr. [**First Name (STitle) **] office to discuss
cholecystectomy again. All risks, benefits and possible outcomes
were discussed with the patient, and she was scheduled for
elective laparoscopic/open cholecystectomy on [**2135-1-11**].


Past Medical History:
Fibromyalgia
Chronic fatigue syndrome
Depression
Schizophrenia
Gallstone pancreatitis/cholangitis [**3-16**]
Cholelithiasis/choledocholithiasis
Possible sleep apnea

Past Surgical History: laparoscopic exploration


Social History:
Social History: Lives alone, denies tobacco, EtOH, drugs


Family History:
NO family history of gallstone disease

Physical Exam:
On Discharge:
VS: 97.6, 87, 136/80, 12, 95% 3L NC
GEN: NAD, AAO x 3, somnolent
CV: RRR, no m/r/g
RESP: Diminished bilaterally on bases R > L
ABD: Obese. Right subcostal incision OTA with staples and c/d/i.
Right T-tube capped, insertion site with dry dressing and c/d/i.

EXTR: Warm, no c/c/e

Pertinent Results:
[**2135-1-13**] 06:40AM BLOOD WBC-16.4* RBC-3.96* Hgb-12.0 Hct-36.4
MCV-92 MCH-30.2 MCHC-32.9 RDW-13.9 Plt Ct-163
[**2135-1-17**] 03:40PM BLOOD ALT-100* AST-42* AlkPhos-164* TotBili-0.4
[**2135-1-13**] 06:40AM BLOOD Calcium-8.0* Phos-2.0*# Mg-2.6


                      Pathology Examination
Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 90063**],[**Known firstname 1521**]       [**2080-6-21**]    54 Female      [**Numeric Identifier 90064**]
[**Numeric Identifier 90065**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
[**Last Name (NamePattern1) 2093**] Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 90066**]/mtd

SPECIMEN SUBMITTED: Gallbladder, Bile duct stent, Common Duct
Stones, Liver biopsy.
Procedure date     Tissue received     Report Date    Diagnosed
by
[**2135-1-11**] [**2135-1-11**] [**2135-1-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/mrr??????
************This report contains an addendum***********

DIAGNOSIS:
I. Gallbladder (A): Acute and chronic cholecystitis.
II. Bile duct stent: Gross examination performed.
III. Common duct stones: Gross examination performed on mixed
type calculi.
IV. Liver, needle core biopsy (B):
A. Severe mixed macro- and microvesicular steatosis with foci
suspicious for ballooning degeneration.
B. Single focus of portal non-necrotizing granulomatous
inflammation; see note.
C. Mild portal and lobular mixed inflammation including
lymphocytes, eosinophils, and neutrophils.
D. Trichrome stain demonstrates increased sinusoidal and portal
fibrosis (Stage 2 fibrosis).
E. Iron stain shows minimal stainable iron focally in foci of
granulomatous inflammation.

Note: Overall, the above histologic features in the liver
support a chronic, active injury of a toxic/metabolic (fatty
liver disease/steatohepatitis) etiology. The additional finding
of a well-formed portal non-necrotizing granuloma raises the
possibility of a  a foreign body reaction (such as to
intrahepatic calculi), a granulomatous drug reaction, or if
clinically relevant, a systemic granulomatous disease such as
sarcoidosis. Special stains to rule out infections with acid
fast bacilli and fungal organisms, although uncommon in
well-formed, non-necrotizing granulomas, are in progress and
will be reported in an addendum.

ADDENDUM:
Special stains for fungal organisms (GMS) and acid fast bacilli
(AFB) are negative with adequate controls.
Addendum added by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/rna
Date: [**2135-1-15**]

Clinical: Cholelithiasis.


Brief Hospital Course:
The patient was admitted to the General Surgical Service for
elective cholecystectomy. On [**2135-1-11**], the patient underwent
laparoscopic converted to open cholecystectomy with common bile
duct exploration, intraoperative cholangiogram and T-tube
placement and liver biopsy, which went well without complication
(reader referred to the Operative Note for details). After
extubation in the PACU, patient was required 6L of supplemental
O2 via face mask. She was monitored overnight in the PACU and
was transferred on the floor in satisfactory condition. On the
floor patient was NPO, on IV fluids, with a foley catheter, and
IV Dilaudid for pain control.  The patient was hemodynamically
stable.
Neuro: The patient has past PMH significant for schizophrenia
and depression, her home medications were restarted on POD # 2.
The patient more somnolent and less responsive in AMs, but
returns to baseline AAO x 3 without difficulties. The patient
received IV Dilaudid with good effect and adequate pain control.
 When tolerating oral intake, the patient was transitioned to
oral pain medications. Prior discharge, oral pain medication was
discontinued.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient has a history of questionable sleep
apnea. After she was extubated in the PACU, she was required
supplemental O2 via face mask. On The floor, patient was
continue to receive O2 via nasal cannula. Patient's blood gases
revealed chronic hypercarbia, she refused to have CPAP overnight
and was recommended to see her PCP to discuss possible OSA after
discharge as outpatient. Prior discharge, patient's O2
requirements were weaned off during day time, she still requires
3 L NC overnight.
GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Diet was advanced when appropriate, which was well
tolerated.  Patient's intake and output were closely monitored,
and IV fluid was adjusted when necessary.  Electrolytes were
routinely followed, and repleted when necessary.
Patient had increased LFTs post operatively secondary to liver
biopsy. LFTs were monitored post op and LFTs started to downward
on POD # 2, T-tube was capped on POD # 5.
The foley catheter was discontinued at midnight of POD# 1. The
patient subsequently voided without problem.
ID: Wound was evaluated daily and no signs and symptoms of
infections were noticed prior discharge. Staples will be removed
during her follow up appointment with Dr. [**First Name (STitle) **].
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay. Physical and
Occupational Therapy evaluated the patient and recommended to
discharge her in Rehab.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a regular
diet, ambulating with assist, voiding without assistance, and
pain was well controlled.  The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.


Medications on Admission:
Clozaril 200qHS, Cal/Vit D 500-400', Dulcolax 5 PO prn, Senokot
2'' prn, Tylenol 650'''' prn, Zantac 150'prn

Discharge Medications:
1. clozapine 200 mg Tablet Sig: One (1) Tablet PO at bedtime.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight
(8) hours as needed for fever or pain.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Calcium 500 With D 500 mg(1,250mg) -400 unit Tablet Sig: One
(1) Tablet PO once a day.
7. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
One (1) puff Inhalation every six (6) hours.
8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] LivingCenter - [**Location (un) 14663**]

Discharge Diagnosis:
1. Choledocholithiasis
2. Fatty liver disease
3. Acute and chronic cholecystitis


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**4-14**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.
.
T-drain care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain.  Call
the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently.  Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water or 1/2 strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.


Followup Instructions:
Department: SURGICAL SPECIALTIES
When: WEDNESDAY [**2135-1-26**] at 2:15 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD [**Telephone/Fax (1) 2998**]
Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Parking on Site
.
Please follow up with Dr.  [**Last Name (STitle) 51969**] (PCP) in [**1-7**] weeks after
discharge



Completed by:[**2135-1-20**]
{'Acute pancreatitis,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Calculus of bile duct with acute cholecystitis, with obstruction,Cholangitis,Laparoscopic surgical procedure converted to open procedure,Other chronic nonalcoholic liver disease,Myalgia and myositis, unspecified,Unspecified schizophrenia, unspecified,Depressive disorder, not elsewhere classified,Chronic fatigue syndrome,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]'}


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: Gallstone pancreatitis and cholangitis

PRESENT ILLNESS: The patient is a 54-years-old female with complicated
psychiatric history. She has been under the care of Dr. [**Last Name (STitle) **]
undergoing multiple ERCP and stent changes with a history of
gallstone pancreatitis and cholangitis initially last spring. At
that time, she had refused surgical intervention.  She did state
in [**2134-10-5**] that she would be interested in having her
cholecystectomy, and she was then transferred to our service and
prepared for surgery, but in the preoperative holding area again
changed her mind, and thus was ultimately discharged home as she
was no longer willing to undergo an ERCP either. In [**Month (only) 404**]
[**2134**], patient returned back to Dr. [**First Name (STitle) **] office to discuss
cholecystectomy again. All risks, benefits and possible outcomes
were discussed with the patient, and she was scheduled for
elective laparoscopic/open cholecystectomy on [**2135-1-11**].

MEDICAL HISTORY: Fibromyalgia
Chronic fatigue syndrome
Depression
Schizophrenia
Gallstone pancreatitis/cholangitis [**3-16**]
Cholelithiasis/choledocholithiasis
Possible sleep apnea

MEDICATION ON ADMISSION: Clozaril 200qHS, Cal/Vit D 500-400', Dulcolax 5 PO prn, Senokot
2'' prn, Tylenol 650'''' prn, Zantac 150'prn

ALLERGIES: Penicillins / Epinephrine / aspirin / Benadryl / grapes / red
peppers

PHYSICAL EXAM: On Discharge:
VS: 97.6, 87, 136/80, 12, 95% 3L NC
GEN: NAD, AAO x 3, somnolent
CV: RRR, no m/r/g
RESP: Diminished bilaterally on bases R > L
ABD: Obese. Right subcostal incision OTA with staples and c/d/i.
Right T-tube capped, insertion site with dry dressing and c/d/i.

FAMILY HISTORY: NO family history of gallstone disease

SOCIAL HISTORY: Social History: Lives alone, denies tobacco, EtOH, drugs 

### Response:
{'Acute pancreatitis,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Calculus of bile duct with acute cholecystitis, with obstruction,Cholangitis,Laparoscopic surgical procedure converted to open procedure,Other chronic nonalcoholic liver disease,Myalgia and myositis, unspecified,Unspecified schizophrenia, unspecified,Depressive disorder, not elsewhere classified,Chronic fatigue syndrome,Nonspecific elevation of levels of transaminase or lactic acid dehydrogenase [LDH]'}
