CHIEF COMPLAINT: Cholangitis, Biliary obstruction
Choledocholithiasis.
Biliary obstruction.
Postprocedural duodenal perforation.
Retroperitoneal/peritoneal abscess.

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old female who was initially admitted
to [**Hospital3 1280**] hospital with abdominal pain, dark urine, and
fever. The patient had evaluation performed including CT Abdomen
which revealed intra and extrahepatic biliary dilatation with
hyperdensity located within the CBD presumed to be an impacted
stone. The patient was treated with Zosyn for cholangitis. ERCP
there was attempted but unsuccessful for which the patient was
transferred to [**Hospital1 18**]. Attempt at ERCP today was similarly
unsuccessful. Cannulation of the ampulla was performed but the
biliary tree could not subsequently be wired. The patient was
subsequently sent to IR for PTC drainage. Per report the patient
had successful placement of external drain but wiring into the
small bowel was unsuccessful from obstruction. The patient is
now admitted to the medical service for ongoing management.
    The patient confirms history as above. He reports
intermittent symptoms of abdominal pain in his RUQ radiating to
his back, similar to that which first brought him to the
hospital. He reports feeling weak, nauseous, and now with
intermittent pain across his right shoulder and upper chest
since returning from PTC.

MEDICAL HISTORY: s/p ccy
s/p removal of basal cell cancer on chest

MEDICATION ON ADMISSION: B-12 supplementation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 97.8, 160/72, 72, 20, 95% 2L NC (repeat BP after
morphine for pain, 110/66)
General: Patient is an elderly male, appears younger than stated
age. Appears to be in mild discomfort but NAD
HEENT: NCAT, EOMI, sclera mildly icteric
Neck: No JVD
Chest: Small bibasilar crackles, left > right
Cor: RRR, no M/R/G
Abdomen: healed ccy scar. + PTC drain with brown fluid in bag.
Mild/mod RUQ tenderness, no guard or rebound. Remainder of
abdomen Soft, non-tender
Ext: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient lives in [**Location 47**] with his wife. [**Name (NI) **] helps take
care of her as she has many cardiac ailments. He has a home
healthaide twice a week for cleaning. He walks without
assistance, and swims 3-4 times per week. He is independent in
all ADL.
Tobacco: Quit 45 years ago, 20 pack-year previously
ETOH: 1 glass wine/month
Illicits: None
HCP: [**Name (NI) 53767**] [**Name (NI) **] [**Name (NI) 81487**]
Calculus of bile duct without mention of cholecystitis, with obstruction,Peritoneal abscess,Cholangitis,Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified septicemia,Sepsis,Diverticulosis of small intestine (without mention of hemorrhage),Peritoneal adhesions (postoperative) (postinfection),Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other B-complex deficiencies,Esophageal reflux
Choledochlith NOS w obst,Peritoneal abscess,Cholangitis,Accidental op laceration,Septicemia NOS,Sepsis,Dvrtclo sml int w/o hmrg,Peritoneal adhesions,Abn react-surg proc NEC,B-complex defic NEC,Esophageal reflux
Admission Date:  [**2178-11-1**]              Discharge Date:   [**2178-11-14**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Cholangitis, Biliary obstruction
Choledocholithiasis.
Biliary obstruction.
Postprocedural duodenal perforation.
Retroperitoneal/peritoneal abscess.


Major Surgical or Invasive Procedure:
1. Choledochoduodenostomy biliary bypass.
2. Open common bile duct exploration.
3. Extensive lysis of adhesions.
4. Drainage of retroperitoneal abscess.
5. Gastrostomy tube placement.


History of Present Illness:
The patient is a [**Age over 90 **] year old female who was initially admitted
to [**Hospital3 1280**] hospital with abdominal pain, dark urine, and
fever. The patient had evaluation performed including CT Abdomen
which revealed intra and extrahepatic biliary dilatation with
hyperdensity located within the CBD presumed to be an impacted
stone. The patient was treated with Zosyn for cholangitis. ERCP
there was attempted but unsuccessful for which the patient was
transferred to [**Hospital1 18**]. Attempt at ERCP today was similarly
unsuccessful. Cannulation of the ampulla was performed but the
biliary tree could not subsequently be wired. The patient was
subsequently sent to IR for PTC drainage. Per report the patient
had successful placement of external drain but wiring into the
small bowel was unsuccessful from obstruction. The patient is
now admitted to the medical service for ongoing management.
    The patient confirms history as above. He reports
intermittent symptoms of abdominal pain in his RUQ radiating to
his back, similar to that which first brought him to the
hospital. He reports feeling weak, nauseous, and now with
intermittent pain across his right shoulder and upper chest
since returning from PTC.

Past Medical History:
s/p ccy
s/p removal of basal cell cancer on chest

Social History:
The patient lives in [**Location 47**] with his wife. [**Name (NI) **] helps take
care of her as she has many cardiac ailments. He has a home
healthaide twice a week for cleaning. He walks without
assistance, and swims 3-4 times per week. He is independent in
all ADL.
Tobacco: Quit 45 years ago, 20 pack-year previously
ETOH: 1 glass wine/month
Illicits: None
HCP: [**Name (NI) 53767**] [**Name (NI) **] [**Name (NI) 81487**]

Family History:
NC

Physical Exam:
Vitals: 97.8, 160/72, 72, 20, 95% 2L NC (repeat BP after
morphine for pain, 110/66)
General: Patient is an elderly male, appears younger than stated
age. Appears to be in mild discomfort but NAD
HEENT: NCAT, EOMI, sclera mildly icteric
Neck: No JVD
Chest: Small bibasilar crackles, left > right
Cor: RRR, no M/R/G
Abdomen: healed ccy scar. + PTC drain with brown fluid in bag.
Mild/mod RUQ tenderness, no guard or rebound. Remainder of
abdomen Soft, non-tender
Ext: no edema

Pertinent Results:
Admission labs: Labs:
[**Age over 90 **]|103| 9 < 100
3.4| 31|0.7
Ca: 8.2 Mg: 1.9 P: 2.1
ALT: 126 AP: 279 Tbili: 2.9
AST: 38

8.2 > 33.5 < 251

INR 1.2 PT  13.7  PTT 23.7
CK MB 3  Trop .03 ([**11-2**])

Pathology: pigment type calculi

Cultures:
[**2178-11-12**]  C diff : neg
[**2178-11-11**]  Cath Tip No sig growth (prelim)
[**2178-11-10**]  URINE Cx NG
[**2178-11-10**]  BLOOD Cx P
[**2178-11-10**]  BLOOD Cx P
[**2178-11-4**]  SWAB E COLI pan [**Last Name (un) 36**]

[**11-10**] CTA:
1. No drainable fluid collection, definable abscess or biloma.
Extensive
fat stranding in RUQ likely secondary ro recent surgery.
2. Status post choledochoduodenostomy biliary bypass with
expected
pneumobilia.
3. Persistent right greater than left pleural effusions with
associated
compressive atelectasis, moderate-sized hiatal hernia, colonic
diverticulosis,
vascular calcifications, and prostatic enlargement.



Brief Hospital Course:
11/16-18/08: The patient failed multiple ERCP events and was
unable to
[**2178-11-4**]: The patient underwent a choledochoduodenostomy biliary
bypass, open common bile duct exploration, extensive lysis of
adhesions, drainage of retroperitoneal abscess and a gastrostomy
tube placement. He tolerated the procedure well. He was
empirically started on an 8 day course of Zosyn for EColi in
bile. The patient was transferred to the SICU post-op for fluid
management and observation.
[**2178-11-5**]: The patient was started on TPN. Transferred to the
floor
[**11-6**]: Pt kept NPO, IVF with NGT in place.
[**11-7**]: Foley dc'd without problems voiding.  G tube to gravity.
TPN  continued with sips for comfort.
[**11-8**]:Pt consulted.  PTC fell out with follow up LFTs without
elevation.  No evidence of bleeding from site.
[**11-9**]; G tube clamped.  Normal follow up LFTs after PTC pulled
out.  Slight leakage of site monitored and dressed with small
ostomy bag around former PTC site.
[**11-10**]:  Spiked to 101.4, pain c/w diaphragmatic irritation on R;
CTA - no obvious collection; CXR-bibasilar atelectasis; UA neg.
Vancomycin and Cipro stated empirically.Pt advanced to clears in
am.  NPO for fever workup and CT scan then brought back to sips.

[**11-11**]: Afebrile for 24 hours.  Advanced from sips to clears.
Ambulating with physical therapy. JP amylase of 7, drain
removed. CVL removed with no growth from catheter tip. C Diff
sent [**Doctor Last Name **] to 5 loose BM, returned negative.
[**11-12**]: Advanced from clears to fulls.  Well tolerated.
Ambulating regularly. Afebrile. Discussion with family regarding
home services and importance of help at home to help pt care for
wife> [**Name (NI) 1094**] niece to stay with him for help around the house.
[**11-13**]: Advanced to regular diet.  Staples removed. Pt discharged
home with VNA, HHA and home PT services.


Medications on Admission:
B-12 supplementation

Discharge Medications:
1. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet
PO Q6H (every 6 hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 1110**] VNA

Discharge Diagnosis:
1. Choledocholithiasis.
2. Biliary obstruction.
3. Postprocedural duodenal perforation.
4. Retroperitoneal/peritoneal abscess.


Discharge Condition:
VSS, tolerating a regular diet, Pain well controlled on PO pain
meds, Ambulating.


Discharge Instructions:
Incision Care:  Keep clean and dry.
-You may shower, and wash surgical incisions.
-Avoid swimming and baths until your follow-up appointment.
-Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
.
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons.
* Signs of dehydration include dry mouth, rapid heartbeat or
feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication.  You may have constipation when taking


narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to ambulate several times per day.
* No heavy ([**9-30**]  lbs) until your follow up appointment.


Followup Instructions:
Please call Dr.[**Doctor Last Name **] office for follow up in [**12-17**] weeks
([**Telephone/Fax (1) 14347**].



Completed by:[**2178-11-14**]
{'Calculus of bile duct without mention of cholecystitis, with obstruction,Peritoneal abscess,Cholangitis,Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified septicemia,Sepsis,Diverticulosis of small intestine (without mention of hemorrhage),Peritoneal adhesions (postoperative) (postinfection),Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other B-complex deficiencies,Esophageal reflux'}


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: Cholangitis, Biliary obstruction
Choledocholithiasis.
Biliary obstruction.
Postprocedural duodenal perforation.
Retroperitoneal/peritoneal abscess.

PRESENT ILLNESS: The patient is a [**Age over 90 **] year old female who was initially admitted
to [**Hospital3 1280**] hospital with abdominal pain, dark urine, and
fever. The patient had evaluation performed including CT Abdomen
which revealed intra and extrahepatic biliary dilatation with
hyperdensity located within the CBD presumed to be an impacted
stone. The patient was treated with Zosyn for cholangitis. ERCP
there was attempted but unsuccessful for which the patient was
transferred to [**Hospital1 18**]. Attempt at ERCP today was similarly
unsuccessful. Cannulation of the ampulla was performed but the
biliary tree could not subsequently be wired. The patient was
subsequently sent to IR for PTC drainage. Per report the patient
had successful placement of external drain but wiring into the
small bowel was unsuccessful from obstruction. The patient is
now admitted to the medical service for ongoing management.
    The patient confirms history as above. He reports
intermittent symptoms of abdominal pain in his RUQ radiating to
his back, similar to that which first brought him to the
hospital. He reports feeling weak, nauseous, and now with
intermittent pain across his right shoulder and upper chest
since returning from PTC.

MEDICAL HISTORY: s/p ccy
s/p removal of basal cell cancer on chest

MEDICATION ON ADMISSION: B-12 supplementation

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: 97.8, 160/72, 72, 20, 95% 2L NC (repeat BP after
morphine for pain, 110/66)
General: Patient is an elderly male, appears younger than stated
age. Appears to be in mild discomfort but NAD
HEENT: NCAT, EOMI, sclera mildly icteric
Neck: No JVD
Chest: Small bibasilar crackles, left > right
Cor: RRR, no M/R/G
Abdomen: healed ccy scar. + PTC drain with brown fluid in bag.
Mild/mod RUQ tenderness, no guard or rebound. Remainder of
abdomen Soft, non-tender
Ext: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: The patient lives in [**Location 47**] with his wife. [**Name (NI) **] helps take
care of her as she has many cardiac ailments. He has a home
healthaide twice a week for cleaning. He walks without
assistance, and swims 3-4 times per week. He is independent in
all ADL.
Tobacco: Quit 45 years ago, 20 pack-year previously
ETOH: 1 glass wine/month
Illicits: None
HCP: [**Name (NI) 53767**] [**Name (NI) **] [**Name (NI) 81487**] 

### Response:
{'Calculus of bile duct without mention of cholecystitis, with obstruction,Peritoneal abscess,Cholangitis,Accidental puncture or laceration during a procedure, not elsewhere classified,Unspecified septicemia,Sepsis,Diverticulosis of small intestine (without mention of hemorrhage),Peritoneal adhesions (postoperative) (postinfection),Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Other B-complex deficiencies,Esophageal reflux'}
