CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 70 year old
gentleman with chronic pancreatitis who presented early in
[**2195**] with a 23 pound weight loss and jaundice.  At that time
patient was found to have dilated biliary ducts on CT scan.
Patient underwent multiple ERCP procedures and common bile
multiple removals and revisions of stents due to infection.
Patient's washings for cytology from his multiple ERCP
procedures were all negative for malignant cells.  Patient
underwent choledochojejunostomy in [**2196-6-26**] to bypass
biliary obstruction from the common bile duct.  Patient had
multiple pancreatic biopsies at that time that were negative
for malignancy.  Patient did well until several months later
the spring of [**2196**] for nutritional support as well as
undergoing gastrojejunostomy to bypass the duodenum secondary
to gastroparesis.  Patient has had increasing ascites for the
last several months which was tapped at an outside hospital
and found to be exudative.  Patient presented to [**Hospital6 11896**] with several hours of vomiting blood on
[**2197-10-16**].  Patient was found to be hypotensive in the
emergency room with hematocrit of 19.  Patient was
resuscitated with packed red blood cells and propranolol.
Patient was found to have grade 2 varices on EGD on [**10-17**]
that were not acutely bleeding.  Over the next few days
patient was treated with fluids and medicated for anxiety
with large quantities of opiates and benzodiazepines.
Patient became increasing obtunded and was eventually
transferred to [**Hospital1 18**] for liver biopsy.  Of note, patient had
two negative ultrasounds of his right upper quadrant which
ruled out [**Hospital1 32004**] vein thrombosis.  On presentation patient
had developed coagulopathy with increased PT/PTT.

MEDICAL HISTORY: As per HPI.  Also a history of
coronary artery disease status post CABG.  History of
hypertension.  History of type 2 diabetes.  History of
pulmonary nodules.  History of post traumatic stress
disorder.

MEDICATION ON ADMISSION: 

ALLERGIES: Morphine and codeine as well as plastic tape,
nylon tape.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Hepatic encephalopathy,Pneumonitis due to inhalation of food or vomitus,Cirrhosis of liver without mention of alcohol,Infection of gastrostomy,Esophageal varices in diseases classified elsewhere, with bleeding,Chronic pancreatitis,Posttraumatic stress disorder
Hepatic encephalopathy,Food/vomit pneumonitis,Cirrhosis of liver NOS,Gastrostomy infection,Bleed esoph var oth dis,Chronic pancreatitis,Posttraumatic stress dis
Admission Date:  [**2197-10-21**]       Discharge Date:

Date of Birth:   [**2127-3-9**]       Sex:  M

Service:
HISTORY OF PRESENT ILLNESS:  The patient is a 70 year old
gentleman with chronic pancreatitis who presented early in
[**2195**] with a 23 pound weight loss and jaundice.  At that time
patient was found to have dilated biliary ducts on CT scan.
Patient underwent multiple ERCP procedures and common bile
multiple removals and revisions of stents due to infection.
Patient's washings for cytology from his multiple ERCP
procedures were all negative for malignant cells.  Patient
underwent choledochojejunostomy in [**2196-6-26**] to bypass
biliary obstruction from the common bile duct.  Patient had
multiple pancreatic biopsies at that time that were negative
for malignancy.  Patient did well until several months later
the spring of [**2196**] for nutritional support as well as
undergoing gastrojejunostomy to bypass the duodenum secondary
to gastroparesis.  Patient has had increasing ascites for the
last several months which was tapped at an outside hospital
and found to be exudative.  Patient presented to [**Hospital6 11896**] with several hours of vomiting blood on
[**2197-10-16**].  Patient was found to be hypotensive in the
emergency room with hematocrit of 19.  Patient was
resuscitated with packed red blood cells and propranolol.
Patient was found to have grade 2 varices on EGD on [**10-17**]
that were not acutely bleeding.  Over the next few days
patient was treated with fluids and medicated for anxiety
with large quantities of opiates and benzodiazepines.
Patient became increasing obtunded and was eventually
transferred to [**Hospital1 18**] for liver biopsy.  Of note, patient had
two negative ultrasounds of his right upper quadrant which
ruled out [**Hospital1 32004**] vein thrombosis.  On presentation patient
had developed coagulopathy with increased PT/PTT.

PAST MEDICAL HISTORY:  As per HPI.  Also a history of
coronary artery disease status post CABG.  History of
hypertension.  History of type 2 diabetes.  History of
pulmonary nodules.  History of post traumatic stress
disorder.

ALLERGIES:  Morphine and codeine as well as plastic tape,
nylon tape.

MEDICATIONS ON TRANSFER:  Elavil 25 mg p.o. once a day,
Ambien 10 mg p.o. once a day, Duragesic 75 mg q.72 hours,
Risperdal 0.5 mg b.i.d., Ativan p.r.n., tobramycin eyedrops,
Lacri-Lube eyedrops, lactulose 30 cc b.i.d., Inderal 20 mg
t.i.d., Protonix GGT at 8 mg per hour, regular insulin
sliding scale as well as 15 of NPH and 4 units of regular
insulin in the morning.

PHYSICAL EXAMINATION:  On admission temperature was 98.3,
blood pressure 122/70, pulse 80, breathing 30 times a minute,
sating 93% on 2 liters.  Patient was obtunded.  He moved his
extremities spontaneously, but did not respond to sternal
rub.  Pupils were equal, round and reactive to light
bilaterally.  Chest was roughly clear to auscultation,
although patient had minimal inspiratory effort.
Cardiovascular exam revealed regular rate, normal S1, S2, no
murmurs.  Abdomen was distended and firm with caput medusae.
Patient had a recently healed midline incision.  Patient had
normoactive bowel sounds.  Extremities showed trace edema
bilaterally in his lower extremities.  On neurological exam
patient was unable to follow commands.  He did have
withdrawal to painful stimuli on his extremities, but did not
respond to sternal rub and did spontaneously move all four
extremities.

LABORATORY DATA:  Chest x-ray on admission showed patchy
infiltrates diffusely in the right lung versus question of
right sided effusion.  Electrolytes on admission were sodium
139, K 4.0, chloride 108, bicarb 23, BUN 15, creatinine 0.6.
Free calcium was 1.13.  INR was 1.5, PTT 31.9.  Patient had
white count of 9.6, hematocrit 34, platelets 206.  Patient's
t-bili was 1.8, alka phos was markedly elevated at 318, LDH
was elevated at 179, AST and ALT were mildly elevated at 52
and 48 respectively.  Patient's albumin on admission was 2.4.
Patient's ABG on admission was 7.50, 30, 57 on 2 liters nasal
cannula which improved to 7.54, 26 and 198 on 100% face mask.

ASSESSMENT:  In short, this is a 70 year old male with a long
complicated GI history who presented with new ascites in the
last several months and with a large GI bleed at [**Hospital6 11896**] on [**2197-10-16**].  Patient is hemodynamically
stable with stable hematocrit, but completely obtunded and
with new coagulopathy on admission.

HOSPITAL COURSE:
1.  Encephalopathy.  Patient was found to be profoundly
encephalopathic upon admission.  It was not clear whether
this was entirely due to hepatic encephalopathy or due to
excessive sedation.  All sedative medications were held for
the course of the patient's hospitalization.  Patient was
started on lactulose.  Patient's mental status improved with
lactulose throughout the next several days.  Patient was
alert and oriented, able to follow conversation, although did
remain somewhat confused about larger issues.  Patient
remained alert and oriented throughout the rest of his
hospital stay on lactulose.

2.  GI bleed.  Patient had a large GI bleed at the outside
hospital.  Because of this patient was started on octreotide,
Protonix infusion and continued on propranolol.  Serial
hematocrits were checked.  Patient underwent banding of his
varices on [**2197-10-26**].  At that time patient's EGD report noted
grade 3 varices in the lower third of the esophagus that were
not bleeding.

3.  Hepatic decompensation.  Patient had elevated LFTs upon
admission and no clear cause for his liver failure.
Ultrasound of the right upper quadrant was repeated in-house
which did show nonocclusive [**Date Range 32004**] vein thrombosis.  Patient
was transferred, as noted above, for transjugular liver
biopsy which patient underwent.  Unfortunately, there was not
enough sample tissue obtained to make a definitive diagnosis.
However, the tissue that was present was suggestive of
cirrhosis.  Patient's LFTs trended down and were within
normal limits upon the time of discharge with the exception
of his coagulation factors and his albumin which remained
markedly elevated and depressed respectively.  Patient did
have difficulty with ascites during his hospitalization.  He
was started on spironolactone to try to mobilize fluid with
some success.  However, patient continued to develop
progressive ascites and lower extremity edema.  Patient had a
diagnostic tap upon admission which was consistent with
transudative ascitic fluid secondary to [**Date Range 32004**] hypertension,
grew no organisms and gram stain was unremarkable.  At the
time of this dictation therapeutic tap of patient's ascites
was being considered.

4.  Infectious disease.  Patient was thought to have
aspiration pneumonia upon admission and was started on levo
and Flagyl of which he was supposed to finish a 10 day
course.  Unfortunately, patient lost the GJ-tube that had
been placed at the outside hospital and had a new tube
replaced which, unfortunately, became infected and began to
show purulent discharge.  Because of this patient was
continued on levo and Flagyl and started on vanco.  At the
time of this dictation patient has been afebrile with a
steady white blood cell count.  He is currently on vanc, levo
and Flagyl.  However, he will likely continue to be treated
with vancomycin alone since he has a history of MSSA.
Cultures are pending at the time of this dictation.

5.  Hematology.  Patient's hematocrit remained roughly stable
throughout the course of his admission, between 28 and 32.
Patient's hematocrit was monitored frequently.  Patient had
no evidence of acute bleeding during the course of his
hospital stay.  Patient's platelets were 206 on admission.
They trended down to a nadir of 96.  Heparin antibodies were
checked and found to be negative.  Patient's platelets were
continued to be followed.  They remained stable in the low
100s at the time of this dictation.  Patient's INR and PTT
remained elevated throughout the course of his
hospitalization.  He had minimal response to p.o. vitamin K.
His INR was as high as 2.2.  PTT was as elevated as 45.
Patient had been switched from p.o. to subcu vitamin K and
his coagulation factors were trending down at the time of
this dictation.

6.  Endocrine.  Patient had a history of type 2 diabetes
requiring insulin.  While patient was NPO, he was maintained
on regular insulin sliding scale.  When patient was fed p.o.
and/or taking tube feeds, he was maintained on NPH standing
dose as well as regular insulin sliding scale with good
glycemic control.

7.  Fluids, electrolytes and nutrition.  Nutrition was a
[**Last Name 16423**] problem during the patient's admission.  His G-tube
fell out and needed to be replaced, which was done under
fluoroscopy in interventional radiology.  Patient tolerated
tube feeds well, however, his tube began to show purulent
discharge several days after it was placed surrounding the
opening site.  Patient had marked tenderness around the site.
Feeds were stopped and patient was started on antibiotics.
The discharge around the site resolved after treatment with
vancomycin as did the tenderness and erythema.  At this
dictation it is still being decided whether patient should be
fed with tube feeds versus TPN.  Another issue with his
GJ-tube is that as his ascites has expanded, patient has
begun to develop leakage of stool around the GJ-tube site.
Tube placement was checked again by IR.  It was not found to
be leaking into the peritoneum.  It was thought that the
stool is likely small bowel contents refluxing into patient's
gastric space.  It should be noted again that patient has
gastrojejunostomy secondary to gastroparesis and the tube
itself is a GJ-tube.  Patient required frequent repletion of
his calcium, potassium and magnesium while in-house.

8.  Cardiovascular.  Patient had a history of coronary artery
disease.  This issue was not active during the course of his
hospitalization.  Patient had no signs of heart failure or
ischemia.

9.  Renal.  Patient had good urine output while he had a
Foley in.  However, once the Foley was discontinued, patient
had some difficulty urinating and needed to be straight
cathed several times for urine output.  Patient's urine was
checked and sent for culture.  Cultures were negative two
days prior to discharge.  Patient's BUN and creatinine
remained stable throughout the course of his hospitalization.

10. Psych.  Patient has a history of post traumatic stress
disorder secondary to having been imprisoned in a Japanese
war camp in the [**Country 31115**] as a child.  Patient has a great
deal of anxiety and claustrophobia secondary to this.
Patient was evaluated by psychiatry in-house who felt patient
would benefit from Risperdal.  Patient was treated with
Risperdal throughout the course of his hospitalization with
good control of his anxiety.  Patient's family also brought
patient a VCR on which he watched movies which also helped
soothe patient's anxiety.  Psychiatry felt patient likely had
some element of reversible dementia and should have formal
neurocognitive evaluation as an outpatient.

11. Disposition.  At this time patient is awaiting rehab
placement or transfer back to [**Hospital6 **] to be cared
for by [**First Name8 (NamePattern2) 4457**] [**Last Name (NamePattern1) 3100**] who is his primary gastroenterologist.
At this time patient is in stable condition.

MEDICATIONS AT TIME OF DICTATION:
1.  Regular insulin sliding scale.
2.  Propranolol 20 mg p.o. or per NG t.i.d. with parameters
to hold for systolic blood pressure less than 100.
3.  Protonix 40 mg p.o. b.i.d.
4.  Risperdal 1.5 mg p.o. b.i.d. as well as 1 mg p.o. b.i.d.
p.r.n. agitation.
5.  Levofloxacin 500 mg p.o. q.24 hours.
6.  Flagyl 500 mg t.i.d.
7.  Vancomycin 1 gm q.12 hours.
8.  Vitamin K 10 mg subcutaneously q.day.
9.  Lacri-Lube ointment ophthalmologic as well as tobramycin
ophthalmologic solutions.
10. Lactulose 30 mg p.o. q.eight hours p.r.n. titrated to
four bowel movements a day.

DISCHARGE DIAGNOSES:
1.  Cirrhosis, etiology unclear.
2.  [**Name2 (NI) **] vein thrombosis, nonocclusive.
3.  Esophageal varices, status post banding.
4.  Hepatic encephalopathy.
5.  Coronary artery disease, status post CABG.
6.  Type 2 diabetes mellitus.
7.  Hypertension.
8.  Post traumatic stress disorder.
9.  Anxiety.
10. Status post open cholecystectomy.
11. Status post choledochojejunostomy.
12. Status post gastrojejunostomy.
13. Status post GJ-tube placement.

An addendum to this discharge summary will be added at such
as the patient is discharged.






                            [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(2) 21723**]

Dictated By:[**Name8 (MD) 8330**]
MEDQUIST36

D:  [**2197-11-3**]  19:52
T:  [**2197-11-3**]  20:31
JOB#:  [**Job Number 106625**]


Admission Date:  [**2197-10-21**]     Discharge Date:  [**2197-11-14**]

Date of Birth:   [**2127-3-9**]     Sex:  M

Service:

HISTORY OF THE PRESENT ILLNESS:  The patient is a 70-year-old
male transferred from an outside hospital with a history of
chronic pancreatitis.  The patient initially presented to
medical attention early in [**2195**] with a 23 pound weight loss
and jaundice.  Workup for this found that he had dilated
biliary ducts on CT.  The patient underwent multiple ERCP
procedures with common bile duct stenting starting in [**2196-3-27**].  The patient had multiple removals and revisions of
his stents.  The patient also had multiple washings for
cytology which had been negative for malignant cells.

The patient underwent choledochojejunostomy in [**2196-6-26**]
to bypass his biliary obstruction.  He had multiple
pancreatic biopsies at that time which were negative for
malignancy.  The patient did well until several months later
when he developed nausea and vomiting again, thought to be
due to gastroparesis.  He had a G tube placed in the spring
of [**2196**] for nutritional support as well as a repeat
gastrojejunostomy to bypass his duodenum.  The patient had
increased ascites which has been tapped several times and
been negative for cytology.

The patient presented to an outside hospital on [**2197-10-16**] with
several hours of vomiting blood.  He was found to be
hypotensive in their ED with a hematocrit of 19.  He was
resuscitated with packed red blood cells and found to have
grade II varices on a [**2197-10-17**] EGD.  However, they were not
banded at that time.

Over the next few days, the patient became increasingly
obtunded and was transferred to [**Hospital6 2018**] for liver biopsy.  Of note, the patient had an
ultrasound which showed normal [**Hospital6 32004**] vein flow and no
evidence of [**Hospital6 32004**] vein thrombosis.  The patient developed
coagulopathy at the outside hospital.

PAST MEDICAL HISTORY:
1.  GI history, as above.
2.  Coronary artery disease, status post CABG.
3.  Hypertension.
4.  Type 2 diabetes.
5.  Multiple pulmonary nodules.
6.  Post-traumatic stress disorder.

MEDICATIONS ON TRANSFER:
1.  Elavil 25 mg p.o. q.h.s.
2.  Ambien 10 mg p.o. q.h.s.
3.  Protonix 8 micrograms per hour.
4.  Regular insulin sliding scale with 16 of NPH and 4 units
of regular in the morning.
5.  Inderal 20 mg t.i.d.
6.  Lactulose 30 cc b.i.d.
7.  Duragesic patch 75 micrograms q. 72 hours.
8.  Risperdal 0.5 mg b.i.d.
9.  Tobramycin eyedrops.
10. Lacrilube.
11. Ativan p.r.n.

PHYSICAL EXAMINATION ON ADMISSION:  Vital signs:  Temperature
98.3, blood pressure 122/70, pulse 80, saturating 92% on 2
liters.  General:  The patient was obtunded.  Would move
extremities to sternal rub and withdrawal from painful
stimuli but did not open his eyes spontaneously.  The pupils
were equal, round and reactive.  The chest was clear to
auscultation bilaterally.  Cardiovascular:  Regular rate.
Abdomen:  Distended, firm, with a noticeable caput medusae
and a recently healed midline incision.  The patient had
normoactive bowel sounds.  The patient had trace bilateral
edema in his lower extremities.  Neurologically, the patient
would not follow commands.

LABORATORY DATA/OTHER STUDIES:  The chest x-ray was notable
for patchy infiltrates diffusely in the right lung.

The laboratories on admission revealed a sodium of 139,
potassium 4.0, chloride 108, bicarbonate 23, BUN 15,
creatinine 0.6.  The patient's INR was 1.5, PTT 31.9.  The
patient's hematocrit was 34.  His total bilirubin was 1.8,
albumin 2.4, alkaline phosphatase 318, LD 179, AST 48, ALT
62.  The patient had ABGs which showed him to be 7.50, PC02
30, P02 57 on 2 liters nasal cannula.  The patient then had a
repeat ABG which showed a pH of 7.54, PC02 26, P02 198 on
100% face mask.

HOSPITAL COURSE:  In short, this was a 70-year-old man with a
long GI history who presented with new ascites in [**2197-6-26**] and with a GI bleed on [**2197-10-16**].  He presented
hemodynamically stable and with a stable hematocrit but
completely obtunded and with a new coagulopathy.

1.  GASTROINTESTINAL BLEED:  The patient was started on a
Protonix drip as well as Octreotide.  His Inderal was also
continued.  The patient remained hemodynamically stable.  He
underwent EGD with initial banding of his varices while
in-house.  The patient had no further evidence of GI bleed.

While he was hospitalized, the patient had a re-look which
showed his bands to still be in place prior to discharge.
The patient was scheduled to follow-up with GI for repeat
banding on [**2197-12-1**].

2.  LIVER FAILURE:  The patient's liver failure is of an
unclear etiology.  He was evaluated by the Liver Service.  He
underwent a right upper quadrant ultrasound which showed that
there was some evidence of [**Date Range 32004**] vein thrombosis.  The
patient also underwent an MRI/MRCP which showed him to have
some element of thrombosis also in his [**Date Range 32004**] vein but not in
any of his other [**Date Range 32004**] vasculature.  The patient's MRI/MRA
was poor quality given to the patient's inability to lie flat
due to shortness of breath.

The patient underwent a liver biopsy which was nondiagnostic
secondary to inadequate sample.  However, it did appear to be
consistent with cirrhosis.

3.  ASCITES:  The patient continued to develop progressive
ascites during his hospitalization.  The patient initially
underwent diagnostic paracentesis which showed no evidence of
spontaneous bacterial peritonitis.  The patient underwent
therapeutic paracentesis in which 6 liters was drained and
the patient had subsequent albumin infusion.  The patient was
started on Lasix and Aldactone as his blood pressures and
renal function could tolerate.

4.  MENTAL STATUS:  The patient came in on an enormous number
of sedatives.  All of these were discontinued upon admission.
The patient was given Lactulose which was titrated to his
bowel movements.  The patient became awake and alert, able to
converse.  The patient was evaluated by the Psychiatry
Service for management of his post-traumatic stress disorder
and agitation.  The patient was started on Risperdal which he
tolerated well.

The patient was also evaluated by Psychiatry to discuss his
competence to make decisions for himself and found to be
completely competent.

5.  NUTRITION:  The patient had a G tube on admission.
Placement of this G tube was confirmed by Gastrografin.  This
G tube eventually fell out, however, and needed to be
replaced.  The patient had a new G tube replaced in
Interventional Radiology, however, with expanding ascites,
the patient experienced a large amount of leakage around the
site of the G tube as well as some purulent discharge.  Feeds
were stopped through the tube.  The patient was treated with
vancomycin for coagulase-positive Staphylococcus which grew
from a swab taken from around his G tube.

The patient had a seven day course of vancomycin and no
positive blood cultures.

6.  INFECTIOUS DISEASE:  The patient was initially started on
levofloxacin for infiltrates on his admission chest x-ray.
The patient completed a ten day course of levofloxacin.  The
patient also began to complain of pain and swelling in his
testicles.  He had pyuria and was thought to have
epididymitis.  The patient was started on ciprofloxacin for a
seven to ten day course and treated with analgesia.

7.  HEMATOLOGY:  The patient's hematocrit remained roughly
stable throughout the course of his admission.  It did drop
somewhat and the patient received three units of packed red
blood cells throughout the course of his admission.  The
patient remained Guaiac negative.  The patient also had
elevated INR and PTT.  The patient was started on vitamin K
10 mg subcutaneously q.d.  His INR and PTT remained stable.

8.  CARDIOVASCULAR:  The patient had a history of
cardiovascular disease.  He had an element of chest pain that
resolved with sublingual nitroglycerin.  Question of an
elevated ST in V2 on EKG compared to admission.  The patient
was ruled out for MI uneventfully.

9.  PSYCHIATRY:  The patient had a history of post-traumatic
stress disorder secondary to being in a prison camp as a
child.  He was seen by Psychiatry who started him on
Risperdal which the patient tolerated well.  The patient was
also brought in a television from home and watched movies to
soothe his anxiety.  The patient was also started on Remeron
q.h.s. which he tolerated well.

10.  CODE STATUS: This was an issue of much discussion
throughout the [**Hospital 228**] hospital stay.  The patient's family
wished for him to be DNR/DNI given his poor prognosis.
However, the patient was not clear that this is what he
wanted.  The patient fluctuated, occasionally saying that he
wished to be resuscitated and other times stating that he
wished for us to euthanize him.

The patient was evaluated by Psychiatry for issues of
competency and deemed competent.  The patient then stated
firmly that he did not wish to be resuscitated and the
patient was discharged to home with hospice level care.

DISCHARGE MEDICATIONS:
1.  Remeron 7.5 mg q.h.s.
2.  Insulin NPH 8 units subcutaneously q.a.m. and with
dinner.
3.  Sliding scale of regular insulin.
4.  Spironolactone 25 mg p.o. q.d.
5.  Protonix 40 mg p.o. q. 12 hours.
6.  Risperdal 0.5 mg p.o. b.i.d.
7.  Vitamin K 10 mg subcutaneously q.d.
8.  Ciprofloxacin 500 mg p.o. q. 12 hours for 14 days.
9.  Lactulose 20 cc q. eight hours p.r.n.
10. Oxycodone IR 10 mg one to two tablets q. four hours
p.r.n. pain.
11. Magnesium oxide 250 mg p.o. b.i.d.

DISPOSITION:  The patient was discharged home with hospice to
follow-up with his primary care doctor at [**Hospital6 **]
as well as with our Gastroenterology Department for repeat
banding of varices on [**2197-12-1**].




                          [**Name6 (MD) **] [**Name8 (MD) **], M.D.  [**MD Number(2) 21723**]

Dictated By:[**Name8 (MD) 8330**]

MEDQUIST36

D:  [**2198-1-6**]  01:49
T:  [**2198-1-9**]  06:54
JOB#:  [**Job Number **]
{'Hepatic encephalopathy,Pneumonitis due to inhalation of food or vomitus,Cirrhosis of liver without mention of alcohol,Infection of gastrostomy,Esophageal varices in diseases classified elsewhere, with bleeding,Chronic pancreatitis,Posttraumatic stress disorder'}


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: 

PRESENT ILLNESS: The patient is a 70 year old
gentleman with chronic pancreatitis who presented early in
[**2195**] with a 23 pound weight loss and jaundice.  At that time
patient was found to have dilated biliary ducts on CT scan.
Patient underwent multiple ERCP procedures and common bile
multiple removals and revisions of stents due to infection.
Patient's washings for cytology from his multiple ERCP
procedures were all negative for malignant cells.  Patient
underwent choledochojejunostomy in [**2196-6-26**] to bypass
biliary obstruction from the common bile duct.  Patient had
multiple pancreatic biopsies at that time that were negative
for malignancy.  Patient did well until several months later
the spring of [**2196**] for nutritional support as well as
undergoing gastrojejunostomy to bypass the duodenum secondary
to gastroparesis.  Patient has had increasing ascites for the
last several months which was tapped at an outside hospital
and found to be exudative.  Patient presented to [**Hospital6 11896**] with several hours of vomiting blood on
[**2197-10-16**].  Patient was found to be hypotensive in the
emergency room with hematocrit of 19.  Patient was
resuscitated with packed red blood cells and propranolol.
Patient was found to have grade 2 varices on EGD on [**10-17**]
that were not acutely bleeding.  Over the next few days
patient was treated with fluids and medicated for anxiety
with large quantities of opiates and benzodiazepines.
Patient became increasing obtunded and was eventually
transferred to [**Hospital1 18**] for liver biopsy.  Of note, patient had
two negative ultrasounds of his right upper quadrant which
ruled out [**Hospital1 32004**] vein thrombosis.  On presentation patient
had developed coagulopathy with increased PT/PTT.

MEDICAL HISTORY: As per HPI.  Also a history of
coronary artery disease status post CABG.  History of
hypertension.  History of type 2 diabetes.  History of
pulmonary nodules.  History of post traumatic stress
disorder.

MEDICATION ON ADMISSION: 

ALLERGIES: Morphine and codeine as well as plastic tape,
nylon tape.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Hepatic encephalopathy,Pneumonitis due to inhalation of food or vomitus,Cirrhosis of liver without mention of alcohol,Infection of gastrostomy,Esophageal varices in diseases classified elsewhere, with bleeding,Chronic pancreatitis,Posttraumatic stress disorder'}
