CHIEF COMPLAINT: Cholelithiasis, duodenal perforation

PRESENT ILLNESS: 35F with a h/o active IV drug abuse who presented to an OSH ED
c/o jaundice and abdominal pain on [**2113-3-6**], found to have and
ultimately transferred to the [**Hospital1 18**] [**2113-3-10**] for ERCP.  Ms.
[**Last Name (un) 110632**] reports noticing RUQ pain intermittently for the
past three months, but it had not become bad enough for her to
seek medical attention.  When she also developed jaundice
associated
with generalized malaise and myalgias, she presented to the
[**Hospital3 **] ED, where she was found to have elevated LFTS (TB
9.6, DB 6.6, alb 3.6, AST 638, ALT 640, AP 615, and WBC 13.6),
and cholelithiasis without ductal dilation on ultrasound.
Hepatitis C titer was positive.  She was admitted for further
work-up.
When MRCP on [**1-/2030**] revealed cholelithiasis, possible
cholecystitis, and cystic duct stones without CBD or IHD
dilation, she was transferred to [**Hospital1 18**] on [**2113-3-10**] for ERCP.
ERCP revealed a laceration of the major papilla suggestive of
recent stone passage, and stones were noted in the lower CBD
with an impacted stone at the ampulla.  Sphincterotomy and stone
extraction were performed, but subsequent cholangiography
revealed constrast extravasation suggesting perforation.  Two
biliary stents and an NGT were placed, and arrangement for
direct admission to the West 2A Surgery service was made.

MEDICAL HISTORY: PMH:  Cholelithiasis, hepatitis C, IV drug abuse, anxiety,
depression, chronic low back pain, migraines

MEDICATION ON ADMISSION: Xanax 1''', Fioricet PRN, oxycodone 10 mg qid

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: On Admission:
Vitals:  98.9 79 127/55 22 99% RA
GEN: A&O, markedly jaundiced, uncomfortable
HEENT: + scleral icterus, mucus membranes dry, NGT in place,
very
poor dentition.
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: +diffuse TTP, no guard or rebound, soft, nondistended, no
palpable masses
SKIN: Marked jaundice, multiple tattoos
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: Mother and sister with symptomatic cholelithiasis requiring CCY.
 Father died in [**2107**] from MI, mother, alive, with alcoholic
cirrhoisis.

SOCIAL HISTORY: Unemployed and currently homeless, though she stays frequently
with her ex-husband.  Two children: ages 3 and 5.  +tobacco use,
1PPD currently.   Denies ETOH.  Using heroin, marijuana
regularly, most recently Saturday prior to her
admission to the OSH on Monday.
Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure with lesion of tubular necrosis,Other retroperitoneal abscess,Other candidiasis of other specified sites,Hydronephrosis,Other ureteric obstruction,Bacteremia,Opioid abuse, continuous,Unspecified viral hepatitis C without hepatic coma,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Other chronic pain,Lumbago,Lack of housing,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction,Other drugs and medicinal substances causing adverse effects in therapeutic use,Other non-narcotic analgesics causing adverse effects in therapeutic use
Accidental op laceration,Ac kidny fail, tubr necr,Retroperiton abscess NEC,Candidiasis site NEC,Hydronephrosis,Ureteric obstruction NEC,Bacteremia,Opioid abuse-continuous,Hpt C w/o hepat coma NOS,Other staphylococcus,Abn react-procedure NEC,Anxiety state NOS,Depressive disorder NEC,Chronic pain NEC,Lumbago,Lack of housing,Migrne unsp wo ntrc mgrn,Gall&bil cal w/o cho w/o,Adv eff medicinal NEC,Adv eff non-narc analgsc
Admission Date:  [**2113-3-10**]              Discharge Date:   [**2113-4-10**]

Date of Birth:  [**2077-9-28**]             Sex:   F

Service: SURGERY

Allergies:
Sulfa(Sulfonamide Antibiotics)

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Cholelithiasis, duodenal perforation

Major Surgical or Invasive Procedure:
[**2113-3-10**]: ERCP
.
[**2113-3-16**]: Successful CT-guided percutaneous drainage catheter
placement into the right perinephric space
.
[**2113-3-21**]:
1. Wide incision and drainage of retroperitoneal
abscess/infection/hematoma.
2. [**Location (un) **] patch of potential duodenal perforation region with
drainage.
3. Antecolic isoperistaltic side-to-side gastrojejunostomy.


History of Present Illness:
35F with a h/o active IV drug abuse who presented to an OSH ED
c/o jaundice and abdominal pain on [**2113-3-6**], found to have and
ultimately transferred to the [**Hospital1 18**] [**2113-3-10**] for ERCP.  Ms.
[**Last Name (un) 110632**] reports noticing RUQ pain intermittently for the
past three months, but it had not become bad enough for her to
seek medical attention.  When she also developed jaundice
associated
with generalized malaise and myalgias, she presented to the
[**Hospital3 **] ED, where she was found to have elevated LFTS (TB
9.6, DB 6.6, alb 3.6, AST 638, ALT 640, AP 615, and WBC 13.6),
and cholelithiasis without ductal dilation on ultrasound.
Hepatitis C titer was positive.  She was admitted for further
work-up.
When MRCP on [**1-/2030**] revealed cholelithiasis, possible
cholecystitis, and cystic duct stones without CBD or IHD
dilation, she was transferred to [**Hospital1 18**] on [**2113-3-10**] for ERCP.
ERCP revealed a laceration of the major papilla suggestive of
recent stone passage, and stones were noted in the lower CBD
with an impacted stone at the ampulla.  Sphincterotomy and stone
extraction were performed, but subsequent cholangiography
revealed constrast extravasation suggesting perforation.  Two
biliary stents and an NGT were placed, and arrangement for
direct admission to the West 2A Surgery service was made.


Past Medical History:
PMH:  Cholelithiasis, hepatitis C, IV drug abuse, anxiety,
depression, chronic low back pain, migraines

PSH:  Tubal ligation


Social History:
Unemployed and currently homeless, though she stays frequently
with her ex-husband.  Two children: ages 3 and 5.  +tobacco use,
1PPD currently.   Denies ETOH.  Using heroin, marijuana
regularly, most recently Saturday prior to her
admission to the OSH on Monday.


Family History:
Mother and sister with symptomatic cholelithiasis requiring CCY.
 Father died in [**2107**] from MI, mother, alive, with alcoholic
cirrhoisis.


Physical Exam:
On Admission:
Vitals:  98.9 79 127/55 22 99% RA
GEN: A&O, markedly jaundiced, uncomfortable
HEENT: + scleral icterus, mucus membranes dry, NGT in place,
very
poor dentition.
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: +diffuse TTP, no guard or rebound, soft, nondistended, no
palpable masses
SKIN: Marked jaundice, multiple tattoos
Ext: No LE edema, LE warm and well perfused

On Discharge:
VS; 98.6, 92, 126/76, 14, 98% RA
GEN: NAD, AAO x 3
CV: RRR
RESP: Diminished breath sounds on right base, left cta
ABD: Midline abdominal incision open to air with steri strips
and c/d/i. RLQ JP drain to bulb suction with stopcock for
flushing/aspirating.
EXTR: Warm, no c/c/e


Pertinent Results:
[**2113-4-10**] 06:35AM BLOOD WBC-12.3* RBC-4.10* Hgb-11.6* Hct-38.3
MCV-93 MCH-28.2 MCHC-30.2* RDW-13.6 Plt Ct-433
[**2113-4-8**] 08:10AM BLOOD Neuts-78.7* Lymphs-14.7* Monos-3.9
Eos-2.1 Baso-0.6
[**2113-4-10**] 06:35AM BLOOD Glucose-90 UreaN-10 Creat-1.5* Na-137
K-4.0 Cl-94* HCO3-28 AnGap-19
[**2113-4-7**] 06:10AM BLOOD Calcium-8.2* Phos-4.4 Mg-1.8

[**2113-4-6**] 8:31 am PERITONEAL FLUID

   GRAM STAIN (Final [**2113-4-6**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   FLUID CULTURE (Preliminary):
      Reported to and read back by DR. [**Last Name (STitle) **] [**Name (STitle) **] #[**Numeric Identifier 11536**]
[**2113-4-7**] 10:46AM.
      YEAST.    SPARSE GROWTH.
         Fluconazole Susceptibility testing requested by DR.
[**Last Name (STitle) **] [**Name (STitle) **]
         #[**Numeric Identifier 11536**] [**2113-4-7**].  SENSITIVE TO Fluconazole.
         sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].
         This test has not been FDA approved but has been
verified
         following Clinical and Laboratory Standards Institute
guidelines
         by [**Hospital1 69**] Clinical
Microbiology
         Laboratory..

   ANAEROBIC CULTURE (Preliminary):    NO ANAEROBES ISOLATED.

   FUNGAL CULTURE (Preliminary):
      [**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION.
         ID PERFORMED ON CORRESPONDING ROUTINE CULTURE.

[**2113-3-15**] 8:19 am BLOOD CULTURE      Source: Line-left picc 1 OF
2.

                            **FINAL REPORT [**2113-3-21**]**

   Blood Culture, Routine (Final [**2113-3-21**]):
      STAPHYLOCOCCUS EPIDERMIDIS.    FINAL SENSITIVITIES.
         This isolate is presumed to be resistant to clindamycin
based on
         the detection of inducible resistance .

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPHYLOCOCCUS EPIDERMIDIS
                             |
CLINDAMYCIN-----------       R
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------     4 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE----------     2 S
VANCOMYCIN------------     2 S

   Anaerobic Bottle Gram Stain (Final [**2113-3-16**]):
      GRAM POSITIVE COCCI IN CLUSTERS.
      Reported to and read back by DR [**First Name (STitle) **] [**Doctor Last Name **] 2PM [**2113-3-16**].

[**2113-3-12**] CT ABD:
IMPRESSION:
1. Large amount of intraperitoneal and retroperitoneal free air.
A large
amount of fluid in the right anterior and posterior pararenal
spaces tracking down to the lower quadrant of the abdomen. No
obvious leak of contrast to identify the site of perforation. If
needed a delayed non-contrast CT abdomen can be obtained to
assess for a delayed leak.
2. Small amount of pneumomediastinum.
3. A small simple right pleural effusion with right basilar
atelectasis.

[**2113-3-16**] CT ABD:
IMPRESSION:
1. Decreased but persistent large intraperitoneal and
retroperitoneal free
air. A large amount of fluid in the right retroperitoneum is
seen with
anterior displacement of the right kidney. No rim-enhancing
fluid collection is seen.
2. Decreased pneumomediastinum.
3. Bilateral pleural effusions with adjacent atelectasis as
described above.

[**2113-3-20**] CT ABD:
IMPRESSION:
1. Improvement in right lower lobe consolidation and decrease in
right
pleural effusion.
2. Slight decrease in fluid component of right perinephric
collection at site of Drain. Extensive multiloculated
phlegmonous change with no significant large fluid component to
target for drainage.
3. No new collections are identified.
4. Persistent extensive free intra-abdominal air with multiple
pockets of air surrounding the second part of duodenum, likely
at site of duodenal
perforation.

[**2113-3-29**] CT ABD:
IMPRESSION:
1. Decrease in size of loculated gas-fluid collections with four
drains in
place. There are small pockets of loculated collections that may
not be
adequately drained. Significant resolution of intra-abdominal
free air.
2. Right hydronephrosis likely from obstruction of ureter due to
surrounding inflammation.
3. Slight improvement in right lower lobe consolidation;
however, slight
increase in right pleural effusion.

[**2113-3-31**] RENAL US:
FINDINGS:
1. There is stable mild hydronephrosis in the right kidney.
Adjacent to the lower pole, is a partially imaged complex fluid
collection containing a drain. The right kidney measures
approximately 14 cm.
2. The left kidney measures approximately 14.2 cm. There is no
hydronephrosis, renal lesion or nephrolithiasis.
3. The bladder is minimally distended limiting evaluation and
grossly
unremarkable.

[**2113-4-6**] CT ABD:
IMPRESSION:
1. Limited study due to lack of intravenous and oral contrast
demonstrates an interval decrease in the phlegmonous collection
in the right perinephric space now measuring 8.0 x 3.0 cm with a
drain in place. Multiple adjacent collections with air and fluid
are again noted and appear relatively stable to minimally
decreased in size. Three of the previously visualized drains
have since been removed.
2. Continued mild right hydronephrosis.
3. Resolution of right pleural effusion. Right lower lobe
opactiy has
decreased in size.
4. Two common bile duct stents are in place with pneumobilia.
5. 2-mm non-obstructive left renal stone.


Brief Hospital Course:
The patient was admitted to the General Surgical Service with
duodenal perforation status post ERCP. The patient was made NPO
with NGT, started on IV fluids and IV Zosyn, and Dilaudid PCA
for pain control. CT scan on HD # 2 demonstrated large amount of
fluid in the right anterior and posterior pararenal spaces
tracking down to the lower quadrant of the abdomen and large
amount of free air. Nutritional consult was called for TPN
recommendations and PICC line was placed. The patient continued
to spike low grade fever and her blood cultures were positive
for STAPHYLOCOCCUS EPIDERMIDIS, Vancomycin Iv was added on HD #
6. Repeat abdominal CT demonstrated  decreased but persistent
large intraperitoneal and retroperitoneal free  air with a large
amount of fluid in the right retroperitoneum is seen with
anterior displacement of the right kidney. The patient continued
to spike fever and IR drainage of the right retroperitoneal
fluid collection was ordered. The patient underwent CT-guided
percutaneous drainage catheter placement into the right
perinephric space on HD # 6 and fluid was sent for cultures. The
patient's diet was advanced as tolerated on POD # 8, and was
well tolerated. The cultures were positive for [**Female First Name (un) 564**] Albicans
and IV Fluconazole was added. Despite antibiotics treatment
patient continued to spike fever and her abdominal pain was
continued to be significantly high requiring large amount of IV
Dilaudid, Ativan and Ketorolac to manage it, patient's WBC also
continued to increased (16->38).Repeat abdominal CT scan on HD #
10 revealed slight decrease in fluid component of right
perinephric collection, extensive multi loculated phlegmonous
change with no significant large fluid component to target for
drainage and persistent extensive free intra-abdominal air with
multiple pockets of air  surrounding the second part of
duodenum. The decision was made to take the patient in OR for
washout.
On [**2112-3-20**], the patient underwent wide incision and drainage of
retroperitoneal
abscess/infection/hematoma, [**Location (un) **] patch of potential duodenal
perforation region
with drainage and antecolic isoperistaltic side-to-side
gastrojejunostomy and JP drains placement x 4, which went well
without complication (reader referred to the Operative Note for
details). Intraoperatively patient received 2 units of pRBC, she
was extubated post op and was transferred in ICU for
observation. On POD # 2, patient received 2 units of pRBC for
HCT 23.4, her post transfusion Hct was 28.3. The patient was
transferred to the floor on POD # 3, NPO on TPN and IV fluids,
and Dilaudid PCA for pain control. The patient was continued to
have low grade fever and she was continued on IV Vancomycin,
Zosyn and Fluconazole. The patient was hydrodynamically stable.

Neuro: The patient is an active Heroin user. Her pain was
controlled with Dilaudid PCA and she had high requirements for
pain medication. When tolerating oral intake, the patient was
transitioned to oral Dilaudid and Chronic Pain Service was
consulted. The patient's pain medications was weaned to [**1-14**] gm
of Dilaudid PO Q4H and patient instructed to continue wean off
her pain medications in home.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI: The patient was started on TPN on admission. Her diet was
advanced to clears on HD # 6 and to regular on HD # 8. The
patient was made NPO prior surgery and TPN was continued. Diet
was advanced to clears on POD # 5 and to regular on POD # 9, TPN
was weaned off and d/c/d on POD # 8. The patient was able to
tolerate regular diet prior discharge. Electrolytes were
routinely followed, and repleted when necessary.
Renal/GU: The patient's Cre/BUN were monitored routinely, on HD
# 21 (POD # 10) her Cre increased to 1.9. During hospitalization
patient underwent several abdominal CT scans with contrast, she
received IV Vancomycin x 14 days, and she received IV Toradol
for pain control. The combination of these factors and
inflammatory respond from fluid collection, which lead to mild
right kidney hydronephrosis contributed to patient's acute renal
injury. Urology and Renal were called for consult and their
recommendations were followed. The kidney function started to
improve on POD # 16, and returned to 1.5 prior discharge. The
patient continued to urinate without any difficulties and her
electrolyte balance was generally within normal limits. The
patient will required to have a follow up Renal US to
re-evaluate her hydronephrosis in 6 months as outpatient.
ID: The patient had a positive blood cultures on admission with
STAPHYLOCOCCUS EPIDERMIDIS, she was treated with IV Vancomycin
for 14 days. Surveillance blood cultures were negative. Intra
abdominal fluid was positive for [**Female First Name (un) 564**] and patient was started
on IV Fluconazole for 14 days also. After discontinue of IV
antibiotics, the patient continued to spike low grade fever and
her increased on POD # 15. Blood and urine cultures were
negative, intra abdominal cultures were positive with [**Female First Name (un) 564**].
The patient was restarted on PO Fluconazole and Augmentin. WBC
and fevers subsided after abx was started. She will continue on
PO Abx for 10 days after discharge. She was discharged with one
JP left within biggest fluid collection, she will follow up with
Dr. [**Last Name (STitle) 468**] in 2 weeks with Ct scan to evaluate her fluid
collection and possible d/c JP drain.
Hematology: The patient's complete blood count was examined
routinely; she received total 6 units of pRBC during
hospitalization. Her Hct was stable prior discharge and no
further transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs.  The patient was tolerating a regular
diet, ambulating, 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:
Xanax 1''', Fioricet PRN, oxycodone 10 mg qid


Discharge Medications:
1. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 2
weeks.
Disp:*14 Adhesive Patch, Medicated(s)* Refills:*0*
2. acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS
DIRECTED).
Disp:*1 tube* Refills:*0*
3. alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day) as needed for anxiety.
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*0*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
7. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
8. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 10 days.
Disp:*20 Tablet(s)* Refills:*0*
9. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
Disp:*20 Tablet, Rapid Dissolve(s)* Refills:*0*
10. Xanax 1 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for anxiety.
Disp:*10 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
1. Choledocholithiasis
2. Doudenal perforation s/p ERCP
3. Infected right perinephric fluid collection
4. Right hydronephrosis
5. Acute kidney injury
6. Chronic pain


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


Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for treatment
of duodenal perforation s/p ERCP. Your condition continuing to
improve and are now safe to return home to complete your
recovery with the following instructions:

*You will need to repeat Renal Ultrasound six months after
discharge. Please follow up with Dr. [**Last Name (STitle) **] (PCP) to schedule this
test.

*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 [**4-20**] 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 steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.

JP Drain Care:
*Flush and aspirate drain with 10 cc of NS daily.
*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).
*Maintain suction of the bulb.
*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.
*You may shower; wash the area gently with warm, soapy water.
*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:
Please follow up with Dr. [**Last Name (STitle) **] in 1 week after discharge to
check you kidney function test.
Follow up with Dr. [**Last Name (STitle) **] (PCP) in 6 month with Renal Ultrasound
to follow up on your right kidney hydronephrosis and left kidney
2-mm non-obstructive left renal stone.
.
Department: RADIOLOGY
When: MONDAY [**2113-4-24**] at 9:15 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: Gz [**Hospital Ward Name 2104**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**]
Campus: EAST     Best Parking: Main Garage
.
Department: SURGICAL SPECIALTIES
When: MONDAY [**2113-4-24**] at 10:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage



Completed by:[**2113-4-10**]
{'Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure with lesion of tubular necrosis,Other retroperitoneal abscess,Other candidiasis of other specified sites,Hydronephrosis,Other ureteric obstruction,Bacteremia,Opioid abuse, continuous,Unspecified viral hepatitis C without hepatic coma,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Other chronic pain,Lumbago,Lack of housing,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction,Other drugs and medicinal substances causing adverse effects in therapeutic use,Other non-narcotic analgesics causing adverse effects in therapeutic use'}


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: Cholelithiasis, duodenal perforation

PRESENT ILLNESS: 35F with a h/o active IV drug abuse who presented to an OSH ED
c/o jaundice and abdominal pain on [**2113-3-6**], found to have and
ultimately transferred to the [**Hospital1 18**] [**2113-3-10**] for ERCP.  Ms.
[**Last Name (un) 110632**] reports noticing RUQ pain intermittently for the
past three months, but it had not become bad enough for her to
seek medical attention.  When she also developed jaundice
associated
with generalized malaise and myalgias, she presented to the
[**Hospital3 **] ED, where she was found to have elevated LFTS (TB
9.6, DB 6.6, alb 3.6, AST 638, ALT 640, AP 615, and WBC 13.6),
and cholelithiasis without ductal dilation on ultrasound.
Hepatitis C titer was positive.  She was admitted for further
work-up.
When MRCP on [**1-/2030**] revealed cholelithiasis, possible
cholecystitis, and cystic duct stones without CBD or IHD
dilation, she was transferred to [**Hospital1 18**] on [**2113-3-10**] for ERCP.
ERCP revealed a laceration of the major papilla suggestive of
recent stone passage, and stones were noted in the lower CBD
with an impacted stone at the ampulla.  Sphincterotomy and stone
extraction were performed, but subsequent cholangiography
revealed constrast extravasation suggesting perforation.  Two
biliary stents and an NGT were placed, and arrangement for
direct admission to the West 2A Surgery service was made.

MEDICAL HISTORY: PMH:  Cholelithiasis, hepatitis C, IV drug abuse, anxiety,
depression, chronic low back pain, migraines

MEDICATION ON ADMISSION: Xanax 1''', Fioricet PRN, oxycodone 10 mg qid

ALLERGIES: Sulfa(Sulfonamide Antibiotics)

PHYSICAL EXAM: On Admission:
Vitals:  98.9 79 127/55 22 99% RA
GEN: A&O, markedly jaundiced, uncomfortable
HEENT: + scleral icterus, mucus membranes dry, NGT in place,
very
poor dentition.
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: +diffuse TTP, no guard or rebound, soft, nondistended, no
palpable masses
SKIN: Marked jaundice, multiple tattoos
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: Mother and sister with symptomatic cholelithiasis requiring CCY.
 Father died in [**2107**] from MI, mother, alive, with alcoholic
cirrhoisis.

SOCIAL HISTORY: Unemployed and currently homeless, though she stays frequently
with her ex-husband.  Two children: ages 3 and 5.  +tobacco use,
1PPD currently.   Denies ETOH.  Using heroin, marijuana
regularly, most recently Saturday prior to her
admission to the OSH on Monday. 

### Response:
{'Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure with lesion of tubular necrosis,Other retroperitoneal abscess,Other candidiasis of other specified sites,Hydronephrosis,Other ureteric obstruction,Bacteremia,Opioid abuse, continuous,Unspecified viral hepatitis C without hepatic coma,Staphylococcus infection in conditions classified elsewhere and of unspecified site, other staphylococcus,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Other chronic pain,Lumbago,Lack of housing,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Calculus of gallbladder and bile duct without cholecystitis, without mention of obstruction,Other drugs and medicinal substances causing adverse effects in therapeutic use,Other non-narcotic analgesics causing adverse effects in therapeutic use'}
