CHIEF COMPLAINT: transfer for ERCP

PRESENT ILLNESS: 73 yo man with COPD on 3L home O2, CAD s/p CABG ~12 yrs ago,
atrial fibrillation on coumadin, HTN, HL, OSA on CPAP who
presented to [**Hospital1 392**]
on [**4-24**] with abdominal pain that started earlier that day. The
pain was not associated with food and not releived by OTC
antiacids. At the OSH he was found to have a fever to 100.5,
elevated LFT's concerning for cholecystitis. RUQ U/S revealed
distended gallbladder with stones but no evidence of
cholecystitis and dilated common bile and intrahepatic ducts.
MRCP revealed 4 large stones (up to 1 cm) in the common bile
duct, no ductal dilation and periportal edema consistent with
ascending cholangitis. He remained hemodynamically stable, he
received one dose of gentamycin and was subsequently started on
Zosyn/Flagyl, given 2 units of FFP and transfered to [**Hospital1 18**] for
ERCP. Of note, he was found to have a new RBBB at OSH and was
ROMI.
.
On admssion he was found to have WBC 12.1, BUN/Cr 41/2.0, ALT
340, AST 238, AP 253, Tbili 5.5 and amylase 564 and was taken
directly to ERCP. Patient received ampicillin/gentamycin prior
to procedure and was intubated. ERCP revealed two 1 cm stones,
multiple smaller stones, CBD dilation to 12 mm, a stent was
placed and a sphynteromy done. He was succesfully extubated
after the procedure.
.
In the [**Hospital Unit Name 153**], patient denied any pain and stated that he was
feeling well.

MEDICAL HISTORY: CAD s/p CABG
AFib on coumadin
COPD on home O2 at 3L
OSA on CPAP
DM II
HTN
HL
Melanoma s/p resection
Asthma
GERD
? Dementia
Depression

MEDICATION ON ADMISSION: HOME MEDS:

ALLERGIES: Phenergan

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple
Lungs: Pursed lip breathing, clear to auscultation bilaterally,
no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient is retired. He has a 60 pk/yr smoking history, quit in
the [**2109**]. Denies EtOH
Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Acute kidney failure, unspecified,Acute pancreatitis,Cholangitis,Chronic obstructive asthma with (acute) exacerbation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstructive sleep apnea (adult)(pediatric),Dehydration,Other and unspecified hyperlipidemia,Lipoma of intra-abdominal organs,Atrial fibrillation,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Esophageal reflux,Other dependence on machines, supplemental oxygen,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Personal history of malignant melanoma of skin,Personal history of tobacco use
Gall&bil cal w/o ch w ob,Acute kidney failure NOS,Acute pancreatitis,Cholangitis,Ch obst asth w (ac) exac,Hypertension NOS,DMII wo cmp nt st uncntr,Obstructive sleep apnea,Dehydration,Hyperlipidemia NEC/NOS,Lipoma intra-abdominal,Atrial fibrillation,Depressive disorder NEC,Mental disor NEC oth dis,Esophageal reflux,Depend-supplement oxygen,Aortocoronary bypass,Long-term use anticoagul,Hx-malig skin melanoma,History of tobacco use
Admission Date:  [**2139-4-25**]              Discharge Date:   [**2139-4-26**]

Date of Birth:  [**2065-6-3**]             Sex:   M

Service: MEDICINE

Allergies:
Phenergan

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
transfer for ERCP

Major Surgical or Invasive Procedure:
ERCP with sphincterotomy and common bile duct temporary stent
placement.


History of Present Illness:
73 yo man with COPD on 3L home O2, CAD s/p CABG ~12 yrs ago,
atrial fibrillation on coumadin, HTN, HL, OSA on CPAP who
presented to [**Hospital1 392**]
on [**4-24**] with abdominal pain that started earlier that day. The
pain was not associated with food and not releived by OTC
antiacids. At the OSH he was found to have a fever to 100.5,
elevated LFT's concerning for cholecystitis. RUQ U/S revealed
distended gallbladder with stones but no evidence of
cholecystitis and dilated common bile and intrahepatic ducts.
MRCP revealed 4 large stones (up to 1 cm) in the common bile
duct, no ductal dilation and periportal edema consistent with
ascending cholangitis. He remained hemodynamically stable, he
received one dose of gentamycin and was subsequently started on
Zosyn/Flagyl, given 2 units of FFP and transfered to [**Hospital1 18**] for
ERCP. Of note, he was found to have a new RBBB at OSH and was
ROMI.
.
On admssion he was found to have WBC 12.1, BUN/Cr 41/2.0, ALT
340, AST 238, AP 253, Tbili 5.5 and amylase 564 and was taken
directly to ERCP. Patient received ampicillin/gentamycin prior
to procedure and was intubated. ERCP revealed two 1 cm stones,
multiple smaller stones, CBD dilation to 12 mm, a stent was
placed and a sphynteromy done. He was succesfully extubated
after the procedure.
.
In the [**Hospital Unit Name 153**], patient denied any pain and stated that he was
feeling well.


Past Medical History:
CAD s/p CABG
AFib on coumadin
COPD on home O2 at 3L
OSA on CPAP
DM II
HTN
HL
Melanoma s/p resection
Asthma
GERD
? Dementia
Depression


Social History:
Patient is retired. He has a 60 pk/yr smoking history, quit in
the [**2109**]. Denies EtOH

Family History:
Non-contributory

Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple
Lungs: Pursed lip breathing, clear to auscultation bilaterally,
no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
Labs:

[**2139-4-25**] 05:58PM   WBC-12.1* RBC-4.43* HGB-11.8* HCT-36.9*
MCV-83 MCH-26.7* MCHC-32.0 RDW-20.7*
[**2139-4-25**] 05:58PM   PT-22.7* PTT-30.0 INR(PT)-2.1*
[**2139-4-25**] 05:58PM   GLUCOSE-223* UREA N-41* CREAT-2.0* SODIUM-138
POTASSIUM-5.1 CHLORIDE-103 TOTAL CO2-19* ANION GAP-21*
ALT(SGPT)-340* AST(SGOT)-238* ALK PHOS-253* AMYLASE-564* TOT
BILI-5.5* CALCIUM-8.6 PHOSPHATE-5.3* MAGNESIUM-2.0
[**2139-4-26**] 05:43AM BLOOD WBC-8.3 RBC-4.04* Hgb-10.7* Hct-33.9*
MCV-84 MCH-26.5* MCHC-31.6 RDW-21.1* Plt Ct-144*
[**2139-4-26**] 05:43AM BLOOD PT-19.2* INR(PT)-1.8*
[**2139-4-26**] 05:43AM BLOOD Glucose-200* UreaN-45* Creat-1.9* Na-141
K-4.3 Cl-106 HCO3-21* AnGap-18 ALT-281* AST-187* AlkPhos-240*
Amylase-312* TotBili-3.9*

ERCP Report:
Date: Saturday, [**2139-4-25**] Endoscopist(s): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52995**],
M.D. (attending)
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD (fellow)

Patient: [**Known firstname **] [**Known lastname 52996**]
 Ref.Phys.: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD
    Anesthesiologists: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 25731**], MD
    Assisting Nurse(s)/
Other Personnel: [**Name6 (MD) 39403**] [**Name8 (MD) **], RN
Birth Date: [**2065-6-3**] (73 years) Instrument: TJF-160VF ([**Numeric Identifier 52997**])

 [**Numeric Identifier 52998**] Indications: A level 4 consult was performed
Fever, RUQ abdominal pain, jaundice, and an abnormal MRCP with
dilated bile ducts and choledocholithiasis all consistent with
cholangitis

Medications: General Anesthesia
Ampicillin 2 gm IV
Gentamycin 60 mg IV

Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
General anesthesia. The patient was placed in the supine
position and an endoscope was introduced through the mouth and
advanced under direct visualization until the third part of the
duodenum was reached. Careful visualization was performed. The
procedure was not difficult. The quality of the preparation was
good. The patient tolerated the procedure well. There were no
complications.
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: A single periampullary diverticulum with a medium
opening was found at the major papilla. There was also a
medium-sized peri-ampullary lipoma.
Cannulation:  On the first attempt, cannulation of the biliary
duct was successful and deep with a sphincterotome after a
guidewire was placed. Contrast medium was injected resulting in
complete opacification. The procedure was not difficult. The
pancreatic duct was not cannulated.

Biliary Tree: Two 10 mm piston-like stones that were causing
partial obstruction were seen at the lower third of the common
bile duct. There was post-obstructive dilation of the mid and
distal CBD to 12 mm with a mild dilation of the upper CBD and
CHD to 8-9 mm. A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire. Two
large 1 cm stones and a copious amount of small stones, stone
fragments, and thick sludge were extracted successfully using a
9-12mm Rx balloon catheter. A 9cm by 10FR plastic biliary stent
was placed successfully in the CBD using a Microvasive 10FR
stent introducer kit. Multiple stones were seen in the
gallbladder. The cystic duct did opacify with contrast and did
not appear to be obstructed.
Impression: A single periampullary diverticulum with a medium
opening was found at the major papilla.
There was also a medium-sized peri-ampullary lipoma.
On the first attempt, cannulation of the biliary duct was
successful and deep with a sphincterotome after a guidewire was
placed. Contrast medium was injected resulting in complete
opacification. The procedure was not difficult.
The pancreatic duct was not cannulated.
Two 10 mm piston-like stones that were causing partial
obstruction were seen at the lower third of the common bile
duct. There was post-obstructive dilation of the mid and distal
CBD to 12 mm with a mild dilation of the upper CBD and CHD to
8-9 mm.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Two large 1 cm stones and a copious amount of small stones,
stone fragments, and thick sludge were extracted successfully
using a 9-12mm Rx balloon catheter.
A 9cm by 10FR plastic biliary stent was placed successfully in
the CBD using a Microvasive 10FR stent introducer kit.
Multiple stones were seen in the gallbladder. The cystic duct
did opacify with contrast and did not appear to be obstructed.

Recommendations: Return to [**Hospital1 18**] ICU overnight.
NPO overnight with aggressive IV hydration. He will need several
liters of NS upfront and then a high infusion rate of
250-300cc/hr for cholangitis and gallstone pancreatitis.
Continue IV antibiotics for cholangitis.
Transfuse 2 units of FFP and please give 2.5 mg of vitamin K.
No coumadin, ASA, plavix, or NSAIDs for 5-7 days.
Repeat ERCP with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10532**] in 4 weeks for
stent removal. He will need to hold coumadin for 5 days prior to
this procedure.
Additional notes: The procedure was performed by the ERCP fellow
and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 52995**].


Brief Hospital Course:
73 yo M with multiple medical problems who was transfered from
OSH for ERCP after developing acute ascending cholangitis with
obstructing stones. On admission to [**Hospital1 18**] found to have acute
renal failure.
.
#. Ascending cholangitis: Patient presented to OSH with acute
onset abdominal pain. Found to have acute ascending cholangitis
and transfered to [**Hospital1 18**] for ERCP. Patient underwent procedure
w/o complications, found to have two 1 cm stones, multiple small
ones, a dilated CBD.  Sphincterotomy was performed and a
temporary stent was placed. His LFT's improved after procedure
and Zosyn IV was continued. His pain was well controlled with
morphine. He remained afebrile and hemodynamically stable
throughout admission
.
#. Acute renal failure: Patient's BUN/Cr was WNL at the OSH. On
admission labs found to have BUN/Cr 41/2.0. This was thought to
be due to pre-renal azotemia due to dehydration as patient was
NPO and FeNa was found to be 0.2%. He received IVF hydration and
his renal function improved slightly. His lisinopril, lasix and
digoxin were held due to ARF. Patient received gentamycin at the
OSH and at prior to ERCP which could cause renal toxicity. Due
to this renal function needs to be closely monitored.
.
#. CAD s/p CABG: Patient was found to have new RBBB at OSH and
was ROMI. On admission EKG RBBB had resolved, but it did show
atrial fibrillation and low voltage. Atenolol and verapamil were
continued. Other meds held as above.
.
#. Atrial fibrillation: Patient currently in rate controlled
atrial fibrillation in the 60's. Atenolol and verapamil were
continued. He received 2 units of FFP and 5 mg of vitamin K for
reversal of INR post-procedure as there was a risk for bleeding.
Coumadin was held.
.
#. COPD/OSA: Patient with known COPD and was able to be
extubated post-ERCP w/o complications. Home meds were continued.
He has sats in the mid 90's on 5 L NC. He was on CPAP overnight
for OSA.
.
#. GERD: He received IV pantoprazole while NPO and transitioned
to PO pantoprazole one a diet was resumed.
.
#. DM II: Metformin and lantus were held due to ARF and NPO
status respectively. Patient continued on humalog SS.
.
#. HTN: Patient was normotensive. Meds continued or held as
above.
.
#. HL: Simvastatin was held due to liver injury.
.
#. Depression: Home meds continued.
.
#. ?Dementia: Home meds continued.
.
#. CODE STATUS: Full Code

Medications on Admission:
HOME MEDS:

Malatonin 5/lorazepam 0.5mg QHS
Advair 500/50 [**Hospital1 **]
Spiriva 1 inhalation daily
Proair IH prn
Atenolol 50 mg daily
Digoxin 0.25 mg daily
Lisinopril 10 mg daily
Metformin 1000 mg [**Hospital1 **]
Verapamil 240 mg qam, 120 mg qpm
Paroxetine 20 mg daily
Omeprazole 20 mg daily
Furosemide 80 mg daily
Simvastatin 80 mg daily
Coumadin 5 mg daily
Aricept 10 mg daily
Lantus Unknown dose
Humalog SS
....


Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
3. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

5. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
6. Ferrous Sulfate 300  mg (60 mg Iron) Tablet Sig: One (1)
Tablet PO BID (2 times a day).
7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for SOB.
8. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
9. Verapamil 120 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)).
10. Verapamil 120 mg Tablet Sig: One (1) Tablet PO QPM (once a
day (in the evening)).
11. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1)
Recon Soln Intravenous Q6H (every 6 hours) for 7 days.
12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1)  Inhalation once a day.
13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
14. Lantus 100 unit/mL Cartridge Sig: unknown  Subcutaneous once
a day.
15. Humalog 100 unit/mL Cartridge Sig: 2-10 units Subcutaneous
four times a day: per sliding scale.


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary Diagnosis:
Choledocholithiasis
Ascending cholangitis

Secondary diagnosis:
Coronary artery disease
Atrial fibrillation
COPD
OSA
Hypertension
Hyperlipidemia
Dementia


Discharge Condition:
Mental Status: Clear and coherent
Level of Consciousness: Alert and interactive
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)


Discharge Instructions:
You were transfered from [**First Name5 (NamePattern1) 392**] [**Last Name (NamePattern1) **] to [**Hospital1 18**] for ERCP. You
underwent this procedure and a temporary stent was placed in
your bile duct. You stayed in the ICU overnight for monitoring
and you did well.

DO NOT take coumadin (warfarin), aspirin, plavix (clopidogrel),
or non steroidal anti inflammatory drugs (such as ibuprofen or
naproxen) for the next 5-7 days.  You will need to schedule
another ERCP in 4 weeks to remove the stent that was placed.
You will need to hold your coumadin 5 days before this
procedure.

You were noted to be in renal failure, so your lasix, digoxin,
and lisinopril were held.  These can be resumed when your renal
function returns to normal.

Due to your elevated liver function tests, simvastatin and
metformin were stopped.  You may resume these when your liver
function returns to normal.

No other changes were made in your medications.

Followup Instructions:
Please schedule a follow up appointment with your primary care
doctor within a week of discharge from the hospital.

Please schedule a repeat ERCP with Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 10532**]
in 4 weeks for stent removal. You will need to stop taking
coumadin for 5 days prior to this procedure.


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]
{'Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Acute kidney failure, unspecified,Acute pancreatitis,Cholangitis,Chronic obstructive asthma with (acute) exacerbation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstructive sleep apnea (adult)(pediatric),Dehydration,Other and unspecified hyperlipidemia,Lipoma of intra-abdominal organs,Atrial fibrillation,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Esophageal reflux,Other dependence on machines, supplemental oxygen,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Personal history of malignant melanoma of skin,Personal history of tobacco 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: transfer for ERCP

PRESENT ILLNESS: 73 yo man with COPD on 3L home O2, CAD s/p CABG ~12 yrs ago,
atrial fibrillation on coumadin, HTN, HL, OSA on CPAP who
presented to [**Hospital1 392**]
on [**4-24**] with abdominal pain that started earlier that day. The
pain was not associated with food and not releived by OTC
antiacids. At the OSH he was found to have a fever to 100.5,
elevated LFT's concerning for cholecystitis. RUQ U/S revealed
distended gallbladder with stones but no evidence of
cholecystitis and dilated common bile and intrahepatic ducts.
MRCP revealed 4 large stones (up to 1 cm) in the common bile
duct, no ductal dilation and periportal edema consistent with
ascending cholangitis. He remained hemodynamically stable, he
received one dose of gentamycin and was subsequently started on
Zosyn/Flagyl, given 2 units of FFP and transfered to [**Hospital1 18**] for
ERCP. Of note, he was found to have a new RBBB at OSH and was
ROMI.
.
On admssion he was found to have WBC 12.1, BUN/Cr 41/2.0, ALT
340, AST 238, AP 253, Tbili 5.5 and amylase 564 and was taken
directly to ERCP. Patient received ampicillin/gentamycin prior
to procedure and was intubated. ERCP revealed two 1 cm stones,
multiple smaller stones, CBD dilation to 12 mm, a stent was
placed and a sphynteromy done. He was succesfully extubated
after the procedure.
.
In the [**Hospital Unit Name 153**], patient denied any pain and stated that he was
feeling well.

MEDICAL HISTORY: CAD s/p CABG
AFib on coumadin
COPD on home O2 at 3L
OSA on CPAP
DM II
HTN
HL
Melanoma s/p resection
Asthma
GERD
? Dementia
Depression

MEDICATION ON ADMISSION: HOME MEDS:

ALLERGIES: Phenergan

PHYSICAL EXAM: General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, DMM, oropharynx clear
Neck: supple
Lungs: Pursed lip breathing, clear to auscultation bilaterally,
no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Patient is retired. He has a 60 pk/yr smoking history, quit in
the [**2109**]. Denies EtOH 

### Response:
{'Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Acute kidney failure, unspecified,Acute pancreatitis,Cholangitis,Chronic obstructive asthma with (acute) exacerbation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obstructive sleep apnea (adult)(pediatric),Dehydration,Other and unspecified hyperlipidemia,Lipoma of intra-abdominal organs,Atrial fibrillation,Depressive disorder, not elsewhere classified,Other persistent mental disorders due to conditions classified elsewhere,Esophageal reflux,Other dependence on machines, supplemental oxygen,Aortocoronary bypass status,Long-term (current) use of anticoagulants,Personal history of malignant melanoma of skin,Personal history of tobacco use'}
