CHIEF COMPLAINT: ascending cholangitis

PRESENT ILLNESS: 80 M with h/o gallstone pancreatitis, CAD s/p stent, Alzheimer's
dementia, presenting with somnolence and AMS.  Most of his
history is relayed per his wife as the patient is intermittently
attentive and hard of hearing.  As per wife, patient has been
less active than usual for about the past week.  He has also had
decreased PO intake for about 1-2 days.  Last night, she noticed
him to be having some difficulty breathing while lying on the
couch.  He also had one loose BM in her presence.  He became
increasing somnlent and unresponse and she took him to the ED.

MEDICAL HISTORY: Dementia
hearing loss
CAD s/p stenting in [**2180-12-13**] (1 vessel disease)
prostatic cancer s/p radiation therapy [**2180**]
acute cholecystitis/pancreatitis in [**2180-11-13**] (rx. with abx)
MDS

MEDICATION ON ADMISSION: - Aspirin 81 mg qd
- Lisinopril 20 mg qd
- Simvastatin 20 mg qd
- Omeprazole 40 mg qd
- Celexa 10 mg qd
- Flomax 0.4 mg qd
- Ferrous Sulfate 65 mg [**Hospital1 **]
- Razadyne 8 mg [**Hospital1 **]
- Vitamin D 1000 u qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
General: Appears jaundiced, in NAD, alert and oriented to person
and place but not date ([**2172**])
HEENT: positive sclera icterus, otherwise MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, +S1/S2, +systolic murmur heard best
left sternal border, otherwise no rubs, gallops
Lungs: + crackles in LLB posteriology, no rales/rhonchi/wheezing

FAMILY HISTORY: Brother had MI in his 70s.  Sister has [**Name (NI) 11964**].
Sister: gastric cancer.

SOCIAL HISTORY: Former smoker, quit 35 years ago. Has 1-2 drinks EtOH/day.
Lives with wife.  Is retired research physicist.  Used to be in
the NAVY.
Unspecified septicemia,Acute pancreatitis,Cholangitis,Acute kidney failure, unspecified,Acidosis,Calculus of bile duct without mention of cholecystitis, with obstruction,Sepsis,Unspecified hearing loss,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Personal history of malignant neoplasm of prostate,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Thrombocytopenia, unspecified,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Septicemia NOS,Acute pancreatitis,Cholangitis,Acute kidney failure NOS,Acidosis,Choledochlith NOS w obst,Sepsis,Hearing loss NOS,Crnry athrscl natve vssl,Status-post ptca,Hx-prostatic malignancy,Alzheimer's disease,Dementia w/o behav dist,Thrombocytopenia NOS,Chr kidney dis stage III,Hy kid NOS w cr kid I-IV
Admission Date:  [**2182-9-7**]              Discharge Date:   [**2182-9-10**]

Date of Birth:  [**2102-8-13**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 15397**]
Chief Complaint:
ascending cholangitis


Major Surgical or Invasive Procedure:
ERCP


History of Present Illness:
80 M with h/o gallstone pancreatitis, CAD s/p stent, Alzheimer's
dementia, presenting with somnolence and AMS.  Most of his
history is relayed per his wife as the patient is intermittently
attentive and hard of hearing.  As per wife, patient has been
less active than usual for about the past week.  He has also had
decreased PO intake for about 1-2 days.  Last night, she noticed
him to be having some difficulty breathing while lying on the
couch.  He also had one loose BM in her presence.  He became
increasing somnlent and unresponse and she took him to the ED.

He was first admitted at [**Hospital6 33**], where inital VS
include Temp 104.7 (rectal), HR 120, RR 48, BP 158/97.  His lab
was notable for CBC 4>42<66 with 22% bands, K 2.7, Cr 1.3, ALT
644, AST 1173, ALP 401, t-bili 5.8, lipase 5405.  CT abd/pelvis
with contrast was notable for findings compatible with mild
acute pancreatitis and acute cholecystitis.  There was concern
of small distal common bile duct calculus.  Pt got fluids,
received potassium repletion and was started empirically on
Zosyn.  He was transferred to [**Hospital1 18**] for further workup and ERCP.
 Before transfer he also underwent an MRCP.

On arrival to the MICU, patient appeared comfortable and was
only complaining of slight epigastric pain.   Patient's VS on
arrival:  97.7 140/95 100 25 95% RA

Past Medical History:
Dementia
hearing loss
CAD s/p stenting in [**2180-12-13**] (1 vessel disease)
prostatic cancer s/p radiation therapy [**2180**]
acute cholecystitis/pancreatitis in [**2180-11-13**] (rx. with abx)
MDS

Social History:
Former smoker, quit 35 years ago. Has 1-2 drinks EtOH/day.
Lives with wife.  Is retired research physicist.  Used to be in
the NAVY.


Family History:
Brother had MI in his 70s.  Sister has [**Name (NI) 11964**].
Sister: gastric cancer.


Physical Exam:
ADMISSION EXAM:
General: Appears jaundiced, in NAD, alert and oriented to person
and place but not date ([**2172**])
HEENT: positive sclera icterus, otherwise MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, +S1/S2, +systolic murmur heard best
left sternal border, otherwise no rubs, gallops
Lungs: + crackles in LLB posteriology, no rales/rhonchi/wheezing

Abdomen: +BS, no tenderness, no rebound/guarding/rigidity,
somewhat distended, hypertympanic in RUQ
GU: has foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

DISCHARGE EXAM:
Anicteric sclera
Non tender, nondistended, +BS
Otherwise unchanged


Pertinent Results:
[**2182-9-7**] 09:01PM BLOOD WBC-11.6* RBC-4.51* Hgb-14.1 Hct-41.3
MCV-92 MCH-31.3 MCHC-34.2 RDW-13.9 Plt Ct-65*
[**2182-9-7**] 09:01PM BLOOD Neuts-89.8* Lymphs-5.7* Monos-4.3 Eos-0.1
Baso-0.1
[**2182-9-8**] 03:00AM BLOOD PT-17.0* PTT-36.4 INR(PT)-1.6*
[**2182-9-7**] 09:01PM BLOOD Glucose-105* UreaN-24* Creat-1.6* Na-142
K-4.0 Cl-111* HCO3-21* AnGap-14
[**2182-9-8**] 03:00AM BLOOD ALT-382* AST-276* AlkPhos-244*
TotBili-6.9*
[**2182-9-7**] 09:01PM BLOOD Albumin-3.3* Calcium-7.4* Phos-4.1 Mg-2.2
[**2182-9-10**] 06:45AM BLOOD WBC-5.1 RBC-3.94* Hgb-12.3* Hct-37.0*
MCV-94 MCH-31.2 MCHC-33.3 RDW-14.6 Plt Ct-77*
[**2182-9-10**] 06:45AM BLOOD PT-11.9 PTT-30.4 INR(PT)-1.1
[**2182-9-10**] 06:45AM BLOOD Glucose-83 UreaN-20 Creat-1.4* Na-143
K-3.8 Cl-111* HCO3-24 AnGap-12
[**2182-9-10**] 06:45AM BLOOD ALT-144* AST-44* AlkPhos-151*
TotBili-1.9*

Blood cx: NGTD

ERCP: Normal major papilla. 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. The common bile duct was 8 mm in size. There were
two filling defects in the CBD consistent with stones. A
sphincterotomy was performed in the 12 o'clock position using a
sphincterotome over an existing guidewire. Two stones were
extracted successfully from the CBD using a balloon catheter.

Brief Hospital Course:
80M with dementia, h/o gallstone pancreatitis, CAD s/p stents
[**2180**], prostate cancer, dementia, presenting with cholangitis and
pancreatitis.

# cholangitis: He was hemodynamically stable. His LFTs were
downtrending without treatment, suggestive of a passed stone.
Given the OSH findings, he underwent ERCP, which showed 2
stones, which were removed with a balloon catheter. He was
continued on antibiotics, IVF and bowel rest. After the
procedure he felt improved. His diet was advanced without
difficulty. He was discharged with 7 more days of cipro and
flagyl. He will follow up with his PCP for repeat labs and
discussion of possible cholecystectomy.

# Acute pancreatitis: Patient with OSH imaging findings
suggesting inflammatory changes and small fluid around pancreas
on abdominal CT.  No signs of necrosis. With bowel rest and IVF
the lipase down trended and he was asymptomatic.

# Thrombocytopenia: This is consistent with his diagnosis of
MDS. They were near baseline.

# [**Last Name (un) **]: Cr was 1.6 on admission. After IVF his creatinine
returned to baseline.

# AMS: He returned to his baseline with treatment of his
cholangitis.

Transitional issues:
- f/u labs
- discussion of CCY

Medications on Admission:
- Aspirin 81 mg qd
- Lisinopril 20 mg qd
- Simvastatin 20 mg qd
- Omeprazole 40 mg qd
- Celexa 10 mg qd
- Flomax 0.4 mg qd
- Ferrous Sulfate 65 mg [**Hospital1 **]
- Razadyne 8 mg [**Hospital1 **]
- Vitamin D 1000 u qd



Discharge Medications:
1. Lisinopril 20 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice per day Disp
#*14 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times per
day Disp #*21 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
please do not take this medication until [**2182-9-15**]
6. Citalopram 10 mg PO DAILY
7. Ferrous Sulfate 325 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. Razadyne *NF* (galantamine) 8 mg Oral [**Hospital1 **]
10. Vitamin D 1000 UNIT PO DAILY


Discharge Disposition:
Home With Service

Facility:
[**Hospital3 **] VNA

Discharge Diagnosis:
cholangitis
cholelithiasis


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


Discharge Instructions:
You were admitted from an outside hospital for an infection in
your gallbadder. You underwent a procedure, called ERCP, with
removal of multile gall stones. Also, you were treated with
antibiotics. With this you felt much improved.

You will need to continue the antibiotics for another 7 days.
Please complete the course as prescribed. You will also need to
follow up with your primary care doctor. At that time you should
have repeat labs to make sure your LFTs have returned to [**Location 213**].
Also, you should discuss whether cholecystectomy is worth
undergoing.

Followup Instructions:
Name:[**Name6 (MD) 92437**] [**Last Name (NamePattern4) 112168**],MD
Specialty: Primary Care
Address: 21 [**Doctor Last Name **] HWY [**Apartment Address(1) 24578**], [**Hospital1 **],[**Numeric Identifier 20089**]
Phone: [**Telephone/Fax (1) 9489**]
When: [**9-17**] at 11:30am
{"Unspecified septicemia,Acute pancreatitis,Cholangitis,Acute kidney failure, unspecified,Acidosis,Calculus of bile duct without mention of cholecystitis, with obstruction,Sepsis,Unspecified hearing loss,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Personal history of malignant neoplasm of prostate,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Thrombocytopenia, unspecified,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified"}


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: ascending cholangitis

PRESENT ILLNESS: 80 M with h/o gallstone pancreatitis, CAD s/p stent, Alzheimer's
dementia, presenting with somnolence and AMS.  Most of his
history is relayed per his wife as the patient is intermittently
attentive and hard of hearing.  As per wife, patient has been
less active than usual for about the past week.  He has also had
decreased PO intake for about 1-2 days.  Last night, she noticed
him to be having some difficulty breathing while lying on the
couch.  He also had one loose BM in her presence.  He became
increasing somnlent and unresponse and she took him to the ED.

MEDICAL HISTORY: Dementia
hearing loss
CAD s/p stenting in [**2180-12-13**] (1 vessel disease)
prostatic cancer s/p radiation therapy [**2180**]
acute cholecystitis/pancreatitis in [**2180-11-13**] (rx. with abx)
MDS

MEDICATION ON ADMISSION: - Aspirin 81 mg qd
- Lisinopril 20 mg qd
- Simvastatin 20 mg qd
- Omeprazole 40 mg qd
- Celexa 10 mg qd
- Flomax 0.4 mg qd
- Ferrous Sulfate 65 mg [**Hospital1 **]
- Razadyne 8 mg [**Hospital1 **]
- Vitamin D 1000 u qd

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
General: Appears jaundiced, in NAD, alert and oriented to person
and place but not date ([**2172**])
HEENT: positive sclera icterus, otherwise MMM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, +S1/S2, +systolic murmur heard best
left sternal border, otherwise no rubs, gallops
Lungs: + crackles in LLB posteriology, no rales/rhonchi/wheezing

FAMILY HISTORY: Brother had MI in his 70s.  Sister has [**Name (NI) 11964**].
Sister: gastric cancer.

SOCIAL HISTORY: Former smoker, quit 35 years ago. Has 1-2 drinks EtOH/day.
Lives with wife.  Is retired research physicist.  Used to be in
the NAVY. 

### Response:
{"Unspecified septicemia,Acute pancreatitis,Cholangitis,Acute kidney failure, unspecified,Acidosis,Calculus of bile duct without mention of cholecystitis, with obstruction,Sepsis,Unspecified hearing loss,Coronary atherosclerosis of native coronary artery,Percutaneous transluminal coronary angioplasty status,Personal history of malignant neoplasm of prostate,Alzheimer's disease,Dementia in conditions classified elsewhere without behavioral disturbance,Thrombocytopenia, unspecified,Chronic kidney disease, Stage III (moderate),Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified"}
