CHIEF COMPLAINT: Duodenal perforation, choledocholithiasis

PRESENT ILLNESS: Mrs. [**Known lastname 1263**] is a [**Age over 90 **] year old woman with history of paroxysmal
atrial fibrillation on coumadin, s/p pacemaker placement for
sick sinus syndrome, hypertension, gallstones and
choledocholithiasis has underwent ERCP for removal of stones in
common bile duct. She underwent ERCP on [**2184-5-11**]. Bile duct was
found to be dilated to 12 mm distally. Several stones were found
in proximal duct causing complete obstruction. The largest one
was 2 cm in size. Cholangioscopy was performed with a SpyGlass.
Large stones noted in common hepatic duct. The duct wall was
inflamed due to prior stent/stones. Stones were fragmented with
[**Last Name (un) 938**] and several fragments were removed with a balloon catheter.
Majority of the stone was fragmented and removed but not all of
the stones could be removed. A 5cm by 10FR double pigtail
biliary stent was placed successfully. The last ERCP was done on
[**2184-6-22**]. It was found that the biliary tree was severely
dilated with evidence of large 2 cm stone in the common hepatic
duct. There were also multiple smaller filling defects in the
CBD
consistent with stones and sludge.  Multiple small stones and
sludge were extracted successfully using a balloon.
Cholangioscopy was performed using the Spyglass Spyscope and
extensive sludge and debris were found in the bile ducts.
Copious irrigation was performed. The large 2 cm stone was
encountered
and [**Last Name (un) 938**] was attempted. Some fragmentation was achieved. However,
due to [**Last Name (un) 938**] machine malfunction, we were unable to completely
fragment the stone. A 5cm by 10FR single pigtail biliary stent
was placed successfully.
Today she presented for repeat ERCP with discontinuation of
coumadin of 5 days. The regular side-viewing ERCP scope was
used. The mucosa of stomach appeared edematous and friable. Mild
bleeding was noted when advancing the scope. The scope was
advanced to reach the duodenal bulb. Multiple ulcers were found
and one of the ulcers appeared deep. Given the unknown nature of
the ulcer, the scope was withdrawn. A regular gastroscope was
inserted with no difficulty. In the stomach, some heme was seen.
There was no evidence of active bleeding. Multiple ulcers were
found in the duodenal bulb. One ulcer on the posterior wall of
the duodenal bulb appeared deep. Given the unknown nature of the
ulcer, the decision was made to abort the procedure.
In the recovery, patient noticed severe diffuse abdominal pain.
STAT CT scan with gastrograffin was ordered. It was found to
have marked pneumoperitoneum suggestive of perforation. Patient
was started on Zosyn and Metronidazole. Urgent consultation with
pancreas surgeon was requested. The decision was made to proceed
with emergent surgery for repair. Patient was transported
straight to Operation room.

MEDICAL HISTORY: Paroxysmal atrial fibrillation on warfarin (known since [**2180**])
s/p pacer (dual chamber) [**6-/2182**], with sick sinus syndrome
Hypertension (> 40 years)
Gallstones, choledocholithiasis

MEDICATION ON ADMISSION: nadolol 40', simvastatin 10', warfarin 2.5'

ALLERGIES: morphine / Ciprofloxacin

PHYSICAL EXAM: On Transfer:
T 96.8, HR 63, BP 167/67, RR 20, O2Sat 99%2L
GEN: in acute distress from the pain; awake and alert and
responding to questions
HEENT: PERRLA, no scleral icterus, dry mucous membranes
CC: irregular rhythms, s1, s2,
Chest: clear to ausculation bilaterally, no wheezing or crackles
Abdomen: mildly to moderately distended, diffusely tenderness on
palpation.
Extremities: no pedal edema

FAMILY HISTORY: 2 children with gallstones, and/or removal of gallbaldder.

SOCIAL HISTORY: Tobacco, former (quit [**2145**], 1ppdx30 years). Son [**Name (NI) **] [**Known lastname **]
([**Telephone/Fax (1) 88880**]. Patient is widowed.
Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Unspecified septicemia,Severe sepsis,Septic shock,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Unspecified pleural effusion,Pulmonary congestion and hypostasis,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Accidents occurring in residential institution,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Other specified disorders of peritoneum,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Unspecified essential hypertension,Diverticulosis of small intestine (without mention of hemorrhage),Polyp of corpus uteri
Gall&bil cal w/o ch w ob,Septicemia NOS,Severe sepsis,Septic shock,Accidental op laceration,Acute kidney failure NOS,Pleural effusion NOS,Pulm congest/hypostasis,Acc cut/hem in surgery,Accid in resident instit,Duodenal ulcer NOS,Peritoneal disorder NEC,Atrial fibrillation,Long-term use anticoagul,Status cardiac pacemaker,Hypertension NOS,Dvrtclo sml int w/o hmrg,Polyp of corpus uteri
Admission Date:  [**2184-7-30**]              Discharge Date:   [**2184-8-11**]


Service: SURGERY

Allergies:
morphine / Ciprofloxacin

Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Duodenal perforation, choledocholithiasis


Major Surgical or Invasive Procedure:
[**2184-7-30**]: ERCP
.
[**2184-7-30**]:
1. Repair of duodenal perforation.
2. Repair of colotomy.
3. Placement of feeding gastrojejunostomy tube.


History of Present Illness:
Mrs. [**Known lastname 1263**] is a [**Age over 90 **] year old woman with history of paroxysmal
atrial fibrillation on coumadin, s/p pacemaker placement for
sick sinus syndrome, hypertension, gallstones and
choledocholithiasis has underwent ERCP for removal of stones in
common bile duct. She underwent ERCP on [**2184-5-11**]. Bile duct was
found to be dilated to 12 mm distally. Several stones were found
in proximal duct causing complete obstruction. The largest one
was 2 cm in size. Cholangioscopy was performed with a SpyGlass.
Large stones noted in common hepatic duct. The duct wall was
inflamed due to prior stent/stones. Stones were fragmented with
[**Last Name (un) 938**] and several fragments were removed with a balloon catheter.
Majority of the stone was fragmented and removed but not all of
the stones could be removed. A 5cm by 10FR double pigtail
biliary stent was placed successfully. The last ERCP was done on
[**2184-6-22**]. It was found that the biliary tree was severely
dilated with evidence of large 2 cm stone in the common hepatic
duct. There were also multiple smaller filling defects in the
CBD
consistent with stones and sludge.  Multiple small stones and
sludge were extracted successfully using a balloon.
Cholangioscopy was performed using the Spyglass Spyscope and
extensive sludge and debris were found in the bile ducts.
Copious irrigation was performed. The large 2 cm stone was
encountered
and [**Last Name (un) 938**] was attempted. Some fragmentation was achieved. However,
due to [**Last Name (un) 938**] machine malfunction, we were unable to completely
fragment the stone. A 5cm by 10FR single pigtail biliary stent
was placed successfully.
Today she presented for repeat ERCP with discontinuation of
coumadin of 5 days. The regular side-viewing ERCP scope was
used. The mucosa of stomach appeared edematous and friable. Mild
bleeding was noted when advancing the scope. The scope was
advanced to reach the duodenal bulb. Multiple ulcers were found
and one of the ulcers appeared deep. Given the unknown nature of
the ulcer, the scope was withdrawn. A regular gastroscope was
inserted with no difficulty. In the stomach, some heme was seen.
There was no evidence of active bleeding. Multiple ulcers were
found in the duodenal bulb. One ulcer on the posterior wall of
the duodenal bulb appeared deep. Given the unknown nature of the
ulcer, the decision was made to abort the procedure.
In the recovery, patient noticed severe diffuse abdominal pain.
STAT CT scan with gastrograffin was ordered. It was found to
have marked pneumoperitoneum suggestive of perforation. Patient
was started on Zosyn and Metronidazole. Urgent consultation with
pancreas surgeon was requested. The decision was made to proceed
with emergent surgery for repair. Patient was transported
straight to Operation room.


Past Medical History:
Paroxysmal atrial fibrillation on warfarin (known since [**2180**])
s/p pacer (dual chamber) [**6-/2182**], with sick sinus syndrome
Hypertension (> 40 years)
Gallstones, choledocholithiasis


Social History:
Tobacco, former (quit [**2145**], 1ppdx30 years). Son [**Name (NI) **] [**Known lastname **]
([**Telephone/Fax (1) 88880**]. Patient is widowed.


Family History:
2 children with gallstones, and/or removal of gallbaldder.

Physical Exam:
On Transfer:
T 96.8, HR 63, BP 167/67, RR 20, O2Sat 99%2L
GEN: in acute distress from the pain; awake and alert and
responding to questions
HEENT: PERRLA, no scleral icterus, dry mucous membranes
CC: irregular rhythms, s1, s2,
Chest: clear to ausculation bilaterally, no wheezing or crackles
Abdomen: mildly to moderately distended, diffusely tenderness on
palpation.
Extremities: no pedal edema

On Discharge:
VS: 96.6, 60, 110/60, 14, 98%RA
GEN: NAD, Comfortable, AAO x 3
CV: irregularly irregular rhythm, pacing
PULM: Diminished lung sounds bilateraly
Extr: Warm, no c/c/e


Pertinent Results:
[**2184-8-10**] 07:10AM BLOOD WBC-6.6 RBC-3.08* Hgb-10.5* Hct-30.8*
MCV-100* MCH-34.0* MCHC-34.0 RDW-16.8* Plt Ct-189
[**2184-8-10**] 07:10AM BLOOD Glucose-117* UreaN-23* Creat-0.7 Na-132*
K-4.6 Cl-101 HCO3-27 AnGap-9
[**2184-8-5**] 04:30AM BLOOD ALT-24 AST-35 AlkPhos-134* Amylase-107*
TotBili-1.3
[**2184-8-10**] 07:10AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.1

[**2184-7-31**] 5:17 am MRSA SCREEN      Source: Nasal swab.
                **FINAL REPORT [**2184-8-1**]**
MRSA SCREEN (Final [**2184-8-1**]):
      POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.

[**2184-7-30**] CT ABD:
IMPRESSION:
1. Marked retroperitoneal as well as omental and mesenteric air,
suggesting duodenal perforation.
2. Most of the stomach is seen in the left thoracic cavity,
compatible with the documented large hiatal hernia in the Atrius
note.
3. No evidence of extraluminal oral contrast.
4. Biliary stent in place. Moderate left pneumobilia.
5. Moderate bilateral effusions. Small-to-moderate pelvic fluid.

6. Severe L1 compression fracture, of uncertain chronicity.
Recommend
clinical correlations.

[**2184-8-2**] ECG:
Baseline artifact. Low voltage throughout. Atrial activity is
difficult to
discern - possibly atrial fibrillation. On the previous tracing
of [**2184-5-5**]
atrial pacing was seen. QRS complexes are quite similar.
Pacemaker
interrogation may be helpful.

[**2184-8-6**] UGI SGL:
IMPRESSION: No evidence of duodenal leak. Small diverticulum in
second
portion of the duodenum and a larger diverticulum of the
proximal jejunum were observed.

[**2184-8-6**] KUB:
IMPRESSION: Non-specific bowel gas pattern. Nn evidence of ileus
or
obstruction. No contrast leakage into abdominal cavity.

[**2184-8-9**] CT ABD:
IMPRESSION:
1. An intra-abdominal fluid collection with enhancing rim is
seen anterior to the liver extending medial to the gallbladder
measuring 10 x 4 mm (2:22) and containing air which is
concerning for abscess.
2. Normal appendix.
3. Scattered colonic diverticulosis without evidence of
diverticulitis.
4. No extravasation of oral contrast to suggest leakage or
perforation.
5. Pneumobilia consistent with prior ERCP.
6. Residual retroperitoneal air with the largest collection seen
inferior to the left kidney.
7. Moderate bilateral pleural effusions.
8. Intrathoracic herniation of the superior stomach and
pancreatic tail into the chest.
9. The uterus is enlarged with heterogeneous material filling
the endometrial canal which is concerning for malignancy. A
followup pelvic and transvaginal ultrasound would be recommended
for further evaluation if clinically indicated.
10. Severe compression fracture at L1.


Brief Hospital Course:
The patient was transferred to the West 2A Surgical Service for
emergent laparotomy and duodenal perforation repair. On [**2184-7-30**],
the patient underwent repair of duodenal perforation, repair of
colotomy and placement of feeding gastrojejunostomy tube, which
went well without complication (reader referred to the Operative
Note for details). Post op, the patient was transferred in ICU,
on IV fluids and antibiotics, with a foley catheter, and IV
Dilaudid for pain control. The patient was started on
Phenylephrine gtt for hypotension and low urine output. The
patient received one unit of pRBC on [**7-31**] and one unit of RBC on
[**2184-8-2**], and albumin on [**2184-8-1**]. The blood pressure and urine
output improved on [**2184-8-2**] , Neo gtt was discontinued and
patient was transferred on the floor.
Neuro: The patient received IV Dilaudid with good effect and
adequate pain control.  When tolerating oral intake, the patient
was transitioned to oral pain medications.
CV: The patient has a history of  paroxysmal atrial
fibrillation. She was started back on her regular dose of
Coumadin on POD # 8. INR was monitored and still subtherapeutic
prior discharge. The patient remained stable from a
cardiovascular standpoint; vital signs were routinely monitored
with telemetry device.
Pulmonary: The patient was extubated postoperatively and
remained stable from a pulmonary standpoint. CRX revealed
bilateral pleural effusion, thought to be [**1-14**] fluid overload.
The patient received several doses of Lasix for diureses. Repeat
CT scan demonstrated improvement of pleural effusions. Good
pulmonary toilet, early ambulation and incentive spirrometry
were encouraged throughout hospitalization.
GI: Post-operatively, the patient was made NPO. Tube feed was
started on POD # 3. On POD # 6, the patient underwent upper GI
test for leak and test was negative. The patient's diet was
advanced to clears. Diet was advanced when appropriate, which
was well tolerated.  Patient's intake and output were closely
monitored, and IV fluid was adjusted when necessary.
Electrolytes were routinely followed, and repleted when
necessary. The patient has two JP drains placed
intraoperatively, they both continue to have large output (R>L).
Repeat CT scan on POD # 9 demonstrated intra-abdominal fluid
collection and  residual retroperitoneal air. The patient was
discharged in rehab tolerating regular diet her TF was
discontinued.
GU: Immediately post op the patient developed acute kidney
injury [**1-14**] prolong hypotension. Patient's Cr increased to 1.5 on
POD # 2 and her urine output decreased. She was treated with
fluid boluses. Cr and UOP improved to normal on POD # 3 and
remained stable.
GYN: The CT scan on admission revealed endometrial thickening.
Repeat CT on POD # 9 demonstrated enlarged uterus with
heterogeneous material filling the endometrial
canal. Pelvic ultrasound was done and final read wasn't
available prior discharge. Radiology reviewed the study and
thinks that findings most likely a hypoplastic endometrial
polyps than malignancies. The patient was scheduled to follow up
with Dr. [**First Name (STitle) **] (OB/GYN Oncology) on [**2184-8-20**].
ID: The patient underwent empirical treatment with IV Zosyn x 7
days. Her peritoneal fluid and urine were negative for any
growth. The patient's white blood count and fever curves were
closely watched for signs of infection.  Wound was evaluated
daily and no signs and symptoms of infection were noticed.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely. She received 2 units of RBC while in ICU for HCT 22.3
and to treat her hypotension. Patient's HCT remained stable low
and was 32 on day of discharge.
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:
nadolol 40', simvastatin 10', warfarin 2.5'

Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
3. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. nadolol 40 mg Tablet Sig: One (1) Tablet PO once a day.


Discharge Disposition:
Extended Care

Facility:
Life Care Center of [**Location (un) 2199**]

Discharge Diagnosis:
1. Choledocholithiasis
2. Duodenal perforation
3. Hypotension
4. Acure kidney injury
5. Bilateral pleural effusions


Discharge Condition:
Condition: Good.
Mental Status: AAOx3
Ambulatory: able to ambulate with help/walker


Discharge Instructions:
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 staples, they will be removed at your follow-up
appointment.
*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 x 2:
*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:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3000**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2184-8-27**]
10:15 [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]. At time of followup, will review
plans for GI follow up once recovery completed.
.
Please follow up with Dr. [**First Name (STitle) **] (PCP) at 2-3 weeks after
discharge. Call [**Telephone/Fax (1) 31019**] to schedule a follow up appointment
with Dr. [**First Name (STitle) **].
.
Please continue to follow up with [**Hospital 197**] clinic to monitor
your INR
.
Provider: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], [**First Name3 (LF) **] Phone:[**Telephone/Fax (1) 5777**]
Date/Time:[**2184-8-20**] 2:00 OB/GYN [**Hospital Ward Name 23**] 8, [**Hospital Ward Name **]



Completed by:[**2184-8-11**]
{'Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Unspecified septicemia,Severe sepsis,Septic shock,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Unspecified pleural effusion,Pulmonary congestion and hypostasis,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Accidents occurring in residential institution,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Other specified disorders of peritoneum,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Unspecified essential hypertension,Diverticulosis of small intestine (without mention of hemorrhage),Polyp of corpus uteri'}


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: Duodenal perforation, choledocholithiasis

PRESENT ILLNESS: Mrs. [**Known lastname 1263**] is a [**Age over 90 **] year old woman with history of paroxysmal
atrial fibrillation on coumadin, s/p pacemaker placement for
sick sinus syndrome, hypertension, gallstones and
choledocholithiasis has underwent ERCP for removal of stones in
common bile duct. She underwent ERCP on [**2184-5-11**]. Bile duct was
found to be dilated to 12 mm distally. Several stones were found
in proximal duct causing complete obstruction. The largest one
was 2 cm in size. Cholangioscopy was performed with a SpyGlass.
Large stones noted in common hepatic duct. The duct wall was
inflamed due to prior stent/stones. Stones were fragmented with
[**Last Name (un) 938**] and several fragments were removed with a balloon catheter.
Majority of the stone was fragmented and removed but not all of
the stones could be removed. A 5cm by 10FR double pigtail
biliary stent was placed successfully. The last ERCP was done on
[**2184-6-22**]. It was found that the biliary tree was severely
dilated with evidence of large 2 cm stone in the common hepatic
duct. There were also multiple smaller filling defects in the
CBD
consistent with stones and sludge.  Multiple small stones and
sludge were extracted successfully using a balloon.
Cholangioscopy was performed using the Spyglass Spyscope and
extensive sludge and debris were found in the bile ducts.
Copious irrigation was performed. The large 2 cm stone was
encountered
and [**Last Name (un) 938**] was attempted. Some fragmentation was achieved. However,
due to [**Last Name (un) 938**] machine malfunction, we were unable to completely
fragment the stone. A 5cm by 10FR single pigtail biliary stent
was placed successfully.
Today she presented for repeat ERCP with discontinuation of
coumadin of 5 days. The regular side-viewing ERCP scope was
used. The mucosa of stomach appeared edematous and friable. Mild
bleeding was noted when advancing the scope. The scope was
advanced to reach the duodenal bulb. Multiple ulcers were found
and one of the ulcers appeared deep. Given the unknown nature of
the ulcer, the scope was withdrawn. A regular gastroscope was
inserted with no difficulty. In the stomach, some heme was seen.
There was no evidence of active bleeding. Multiple ulcers were
found in the duodenal bulb. One ulcer on the posterior wall of
the duodenal bulb appeared deep. Given the unknown nature of the
ulcer, the decision was made to abort the procedure.
In the recovery, patient noticed severe diffuse abdominal pain.
STAT CT scan with gastrograffin was ordered. It was found to
have marked pneumoperitoneum suggestive of perforation. Patient
was started on Zosyn and Metronidazole. Urgent consultation with
pancreas surgeon was requested. The decision was made to proceed
with emergent surgery for repair. Patient was transported
straight to Operation room.

MEDICAL HISTORY: Paroxysmal atrial fibrillation on warfarin (known since [**2180**])
s/p pacer (dual chamber) [**6-/2182**], with sick sinus syndrome
Hypertension (> 40 years)
Gallstones, choledocholithiasis

MEDICATION ON ADMISSION: nadolol 40', simvastatin 10', warfarin 2.5'

ALLERGIES: morphine / Ciprofloxacin

PHYSICAL EXAM: On Transfer:
T 96.8, HR 63, BP 167/67, RR 20, O2Sat 99%2L
GEN: in acute distress from the pain; awake and alert and
responding to questions
HEENT: PERRLA, no scleral icterus, dry mucous membranes
CC: irregular rhythms, s1, s2,
Chest: clear to ausculation bilaterally, no wheezing or crackles
Abdomen: mildly to moderately distended, diffusely tenderness on
palpation.
Extremities: no pedal edema

FAMILY HISTORY: 2 children with gallstones, and/or removal of gallbaldder.

SOCIAL HISTORY: Tobacco, former (quit [**2145**], 1ppdx30 years). Son [**Name (NI) **] [**Known lastname **]
([**Telephone/Fax (1) 88880**]. Patient is widowed. 

### Response:
{'Calculus of gallbladder and bile duct without cholecystitis, with obstruction,Unspecified septicemia,Severe sepsis,Septic shock,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute kidney failure, unspecified,Unspecified pleural effusion,Pulmonary congestion and hypostasis,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Accidents occurring in residential institution,Duodenal ulcer, unspecified as acute or chronic, without hemorrhage or perforation, without mention of obstruction,Other specified disorders of peritoneum,Atrial fibrillation,Long-term (current) use of anticoagulants,Cardiac pacemaker in situ,Unspecified essential hypertension,Diverticulosis of small intestine (without mention of hemorrhage),Polyp of corpus uteri'}
