CHIEF COMPLAINT: choledocholithiasis

PRESENT ILLNESS: Ms. [**Known lastname 28893**] is a 53 year old woman with a past medical history
significant for schizophrenia, depression, fibromyalgia, chronic
fatigue syndrome, and a recent admission for gallstone
pancreatitis complicated by cholangitis.

MEDICAL HISTORY: Fibromyalgia
Chronic fatigue syndrome
Depression
Schizophrenia
Previous Admission: The patient was initially admitted to [**Hospital1 18**]
under from [**Date range (1) 90061**] with gallstone pancreatitis and cholangitis.
Her hospital course was complicated by hypotension and and
required admission to the SICU. At that time, she underwent ERCP
with sphincterotomy and a double pig-tail stent placement. She
was also treated with ciprofloxacin and Flagyl with improvement
in her LFTs, Tbili, and abdominal pain. Of note, her hospital
course was also complicated by hypoxemia with activity of
unclear etiology, but was discharged without supplemental oxygen
after a CTA ruled out PE.

MEDICATION ON ADMISSION: Lopid 600 mg po bid
Zantac 150 mg daily
Senna qhs
APAP
Clozaril 200 mg po qhs
Bisacodyl qhs
Ca-Vit D

ALLERGIES: Penicillins / Epinephrine / Ambien

PHYSICAL EXAM: Admission (ICU):
99.2 99/58 90 17 99% (on vent)
Gen:  NAD, intubated, sedated
HEENT: endotracheal tube in place, mmm
CV:  RRR, nl s1 and s2, no m/r/g
Pulm:  CTAB
Abd: obese, soft, nontender, nondistended, + bs
Ext:  no c/c/e

FAMILY HISTORY: Unknown

SOCIAL HISTORY: Social History: Lives alone, denies tobacco, EtOH, drugs
Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Cholangitis,Hemorrhage complicating a procedure,Myalgia and myositis, unspecified,Chronic fatigue syndrome,Edema of larynx,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified schizophrenia, unspecified,Other and unspecified hyperlipidemia
Gall&bil cal w/o ch w ob,Cholangitis,Hemorrhage complic proc,Myalgia and myositis NOS,Chronic fatigue syndrome,Edema of larynx,Abn react-procedure NEC,Schizophrenia NOS-unspec,Hyperlipidemia NEC/NOS
Admission Date:  [**2134-4-14**]              Discharge Date:   [**2134-4-20**]

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

Service: MEDICINE

Allergies:
Penicillins / Epinephrine / Ambien

Attending:[**First Name3 (LF) 832**]
Chief Complaint:
choledocholithiasis

Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and sphincteroplasty was performed. Not
all stones were removed and a 10FRx5cm double pigtail plastic
stent was placed.


History of Present Illness:
Ms. [**Known lastname 28893**] is a 53 year old woman with a past medical history
significant for schizophrenia, depression, fibromyalgia, chronic
fatigue syndrome, and a recent admission for gallstone
pancreatitis complicated by cholangitis.

She presented to [**Hospital1 18**] for an elective ERCP. She underwent a
complicated procedure with sphincteroplasty and extraction of
multiple stones. Complete bile duct clearance was not achieved
and she required a stent placement. Per the ERCP team, the
intubation was difficult and the back of the throat was noted to
be edematous and bleeding as the scope was passed many times to
complete this procedure. After the procedure, she had laryngeal
edema and oral bleeding. She remained intubated after the
procedure and was admitted to the ICU.

Past Medical History:
Fibromyalgia
Chronic fatigue syndrome
Depression
Schizophrenia
Previous Admission: The patient was initially admitted to [**Hospital1 18**]
under from [**Date range (1) 90061**] with gallstone pancreatitis and cholangitis.
Her hospital course was complicated by hypotension and and
required admission to the SICU. At that time, she underwent ERCP
with sphincterotomy and a double pig-tail stent placement. She
was also treated with ciprofloxacin and Flagyl with improvement
in her LFTs, Tbili, and abdominal pain. Of note, her hospital
course was also complicated by hypoxemia with activity of
unclear etiology, but was discharged without supplemental oxygen
after a CTA ruled out PE.

Past Surgical History: laparoscopic exploration


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


Family History:
Unknown

Physical Exam:
Admission (ICU):
99.2 99/58 90 17 99% (on vent)
Gen:  NAD, intubated, sedated
HEENT: endotracheal tube in place, mmm
CV:  RRR, nl s1 and s2, no m/r/g
Pulm:  CTAB
Abd: obese, soft, nontender, nondistended, + bs
Ext:  no c/c/e

Discharge Exam:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
No pain with eating a regular diet. Mild RUQ tenderness of
physical exam.

Pertinent Results:
Admission Laboratory Studies:
[**2134-4-14**] 10:57PM   TYPE-ART PO2-86 PCO2-43 PH-7.37 TOTAL CO2-26
BASE XS-0
[**2134-4-14**] 10:57PM   LACTATE-3.5*
[**2134-4-14**] 02:30PM   UREA N-11 CREAT-0.7 SODIUM-143 POTASSIUM-4.3
CHLORIDE-102 TOTAL CO2-27 ANION GAP-18
[**2134-4-14**] 02:30PM   ALT(SGPT)-123* AST(SGOT)-89* ALK PHOS-217*
AMYLASE-30 TOT BILI-0.9 DIR BILI-0.4* INDIR BIL-0.5
[**2134-4-14**] 02:30PM   LIPASE-29
[**2134-4-14**] 02:30PM   ALBUMIN-4.5
[**2134-4-14**] 02:30PM   WBC-12.9* RBC-4.24 HGB-13.6 HCT-40.7 MCV-96
MCH-32.0 MCHC-33.3 RDW-15.8*
[**2134-4-14**] 02:30PM   NEUTS-74.0* LYMPHS-19.7 MONOS-3.5 EOS-2.5
BASOS-0.4
[**2134-4-14**] 02:30PM   PT-12.3 INR(PT)-1.0

Discharge Laboratory Studies:

ERCP [**2134-4-14**]:
Findings:
-Esophagus: Limited exam of the esophagus was normal
-Stomach: Limited exam of the stomach was normal
-Duodenum: Limited exam of the duodenum was normal
-Major Papilla: Normal major papilla with stent in-situ.Stent
removed with snare.Previous sphincterotomy noted.
-Cannulation:  Cannulation of the biliary duct was successful
and deep with a sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
-Biliary Tree: Many stones that were causing partial obstruction
were seen at the biliary tree.Sphincterotomy was extended with a
balloon sphincteroplasty using a 10 and 12mm balloon.Multiple
stones were removed with a balloon catheter.As duct clearance
could not be achieved with the balloon a basket was used to
retrive rest of the stones. The stones could not be completely
removed as the basket was impacted at the ampulla.Basket was
successfully removed with a rat-toothed forceps.Due to prolonged
procedure further attempts to clear duct were not made and a
10FRx5cm double pigtail plastic stent was inserted successfully.


Impression: Normal major papilla with stent in-situ.Stent
removed with snare.
-Previous sphincterotomy noted.
-Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
-Contrast medium was injected resulting in complete
opacification.
-Bile duct was dilated to 12 mm.
-Many stones that were causing partial obstruction were seen at
the biliary tree.
-Sphincterotomy was extended with a balloon sphincteroplasty
using a 10 and 12mm balloon.
-Multiple stones were removed with a balloon catheter.
-As duct clearance could not be achieved with the balloon a
basket was used to retrieve rest of the stones.
-The stones could not be completely removed as the basket was
impacted at the ampulla.
-Basket was successfully removed with a rat-toothed forceps.
-Due to prolonged procedure further attempts to clear duct were
not made and a 10FRx5cm double pigtail plastic stent was
inserted successfully.

CXR [**2134-4-14**]:
An endotracheal tube ends 4.7 cm above the carina. Lung volumes
are low.
Cardiac, mediastinal and hilar contours are unchanged. A dense
left basilar
opacity obscures the left hemidiaphragm, possibly aspiration,
pneumonia or
atelectasis. On the right, there is no pleural effusion and
there is no
pneumothorax. There is mild interval progression of pulmonary
vascular
congestion.


Brief Hospital Course:
Ms. [**Known lastname 28893**] is a 53 year old woman with a past medical history
significant for schizophrenia, depression, fibromyalgia, and a
recent admission for gallstone pancreatitis complicated by
cholangitis. She presented to [**Hospital1 18**] for an elective ERCP. This
was a complicated procedure due to high gallstone burden and
post-procedure laryngeal edema and bleeding. She remained
intubated after the procedure and was admitted to the ICU. Her
ICU course was uncomplicated and she was extubated on [**4-15**].

She was transferred out to the floor for further management
including observation, advancement of diet, and a 5-day course
of post-procedure ciprofloxacin as recommended by the ERCP team.

The general surgery team was consulted for evaluation for
cholecystectomy. This was offered to the patient but she
declined surgery. She will need a repeat ERCP in 2 months for
stent removal and further stone extraction considering not all
stones were able to be removed during procedure during this
admission.

The patient was evaluated by our social work and psychiatry
consult service. She is felt to have the capacity currently to
decline surgery. She has good home services (a psych team that
makes home visits multiple times per week) and scheduled
follow-up with her primary care doctor and it is hoped that she
will become amenable to cholecystectomy. If not, the issue of
capacity to decline should be re-addressed as her long term risk
of life threatening complication is extremely high.

Home Clozaril was continued for schizophrenia.

Medications on Admission:
Lopid 600 mg po bid
Zantac 150 mg daily
Senna qhs
APAP
Clozaril 200 mg po qhs
Bisacodyl qhs
Ca-Vit D

Discharge Medications:
1. clozapine 100 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
2. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day as
needed for heartburn.
4. senna 8.6 mg Tablet Sig: 1-2 Tablets PO once a day as needed
for constipation.
5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for pain.
6. bisacodyl 10 mg Suppository Sig: One (1) tablet Rectal once a
day as needed for constipation.
7. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1)
Tablet PO once a day.
8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 3 days.
Disp:*6 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Doctor First Name **] services - VNA

Discharge Diagnosis:
Choledocholithiasis with obstruction
Schizophrenia
Fibromyalgia


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
No pain with eating a regular diet.


Discharge Instructions:
Dear Ms. [**Known lastname 28893**],

You were admitted for an ERCP. During this procedure, you were
noted to have multiple gallstones. They were not able to remove
all of these stones and a plastic stent was placed. You will
need to return in 2 months to have this stent removed and to
have the rest of the stones removed.

We also recommend that you have your gall bladder removed to
prevent this from happening again. You are declining this at
this time. If you change your mind and would like to schedule a
surgery please call Dr.[**Name (NI) 5067**] office at [**Telephone/Fax (1) 2998**]. In the
meantime, please discuss this further with your primary care
doctor

We treated you with antibiotics and your last dose was on [**4-19**].
We made no other changes to your medications.

Followup Instructions:
Please return in 2 months to have your stent removed and
additional gallstones removed. Your primary care doctor can help
you schedule this procedure.

If you decide to have your gall bladder removed please call Dr. [**Name (NI) 76749**] office at [**Telephone/Fax (1) 2998**]. In the meantime, please discuss
this further with your primary care doctor.

Name: [**Name6 (MD) **] [**Last Name (NamePattern4) 90062**],MD
Specialty: Internal Medicine
When: Friday [**4-30**] at 11:30am
Address: [**Street Address(2) 78853**], [**Location (un) **],[**Numeric Identifier 78233**]
Phone: [**Telephone/Fax (1) 51033**]
{'Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Cholangitis,Hemorrhage complicating a procedure,Myalgia and myositis, unspecified,Chronic fatigue syndrome,Edema of larynx,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified schizophrenia, unspecified,Other and unspecified hyperlipidemia'}


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: choledocholithiasis

PRESENT ILLNESS: Ms. [**Known lastname 28893**] is a 53 year old woman with a past medical history
significant for schizophrenia, depression, fibromyalgia, chronic
fatigue syndrome, and a recent admission for gallstone
pancreatitis complicated by cholangitis.

MEDICAL HISTORY: Fibromyalgia
Chronic fatigue syndrome
Depression
Schizophrenia
Previous Admission: The patient was initially admitted to [**Hospital1 18**]
under from [**Date range (1) 90061**] with gallstone pancreatitis and cholangitis.
Her hospital course was complicated by hypotension and and
required admission to the SICU. At that time, she underwent ERCP
with sphincterotomy and a double pig-tail stent placement. She
was also treated with ciprofloxacin and Flagyl with improvement
in her LFTs, Tbili, and abdominal pain. Of note, her hospital
course was also complicated by hypoxemia with activity of
unclear etiology, but was discharged without supplemental oxygen
after a CTA ruled out PE.

MEDICATION ON ADMISSION: Lopid 600 mg po bid
Zantac 150 mg daily
Senna qhs
APAP
Clozaril 200 mg po qhs
Bisacodyl qhs
Ca-Vit D

ALLERGIES: Penicillins / Epinephrine / Ambien

PHYSICAL EXAM: Admission (ICU):
99.2 99/58 90 17 99% (on vent)
Gen:  NAD, intubated, sedated
HEENT: endotracheal tube in place, mmm
CV:  RRR, nl s1 and s2, no m/r/g
Pulm:  CTAB
Abd: obese, soft, nontender, nondistended, + bs
Ext:  no c/c/e

FAMILY HISTORY: Unknown

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

### Response:
{'Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Cholangitis,Hemorrhage complicating a procedure,Myalgia and myositis, unspecified,Chronic fatigue syndrome,Edema of larynx,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified schizophrenia, unspecified,Other and unspecified hyperlipidemia'}
