CHIEF COMPLAINT: 

PRESENT ILLNESS: The patient is a 78-year-old
woman with a history of hypertension, depression, anxiety and
dementia who was admitted to the [**Hospital6 3872**] on
[**2101-7-5**] with several day history of nausea, vomiting and
and emesis of coffee ground material.  At the outside
17,000 and was started on initially Levofloxacin and then the
addition of Ampicillin and Flagyl.  A CT scan performed on
[**6-6**] showed dilated common bile duct with gallstones.  She was
thought to have bowel obstruction and was treated with bowel
rest and hydration.  On [**7-9**] she had respiratory distress and
to have new left lower lobe infiltrate on chest x-ray.
Nasogastric tube was placed with return of 2500 cc of bilious
have increased lipase on [**7-7**] which was noted to be trending
downward.  She was transferred to [**Hospital1 190**] for further management and was admitted to the
medical Intensive Care Unit.

MEDICAL HISTORY: Includes hypertension, depression,
history of left hip fracture, anxiety, legally blind,
dementia, remote history of atrial fibrillation.

MEDICATION ON ADMISSION: 

ALLERGIES: Pneumococcal pneumonia vaccine.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Acute pancreatitis,Calculus of gallbladder without mention of cholecystitis, with obstruction,Gallstone ileus,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Unspecified pleural effusion,Senile dementia, uncomplicated,Unspecified protein-calorie malnutrition
Acute pancreatitis,Cholelithias NOS w obstr,Gallstone ileus,Food/vomit pneumonitis,Acute kidney failure NOS,Pleural effusion NOS,Senile dementia uncomp,Protein-cal malnutr NOS
Admission Date:  [**2101-7-11**]       Discharge Date:  [**2101-8-1**]


HISTORY OF PRESENT ILLNESS:  The patient is a 78-year-old
woman with a history of hypertension, depression, anxiety and
dementia who was admitted to the [**Hospital6 3872**] on
[**2101-7-5**] with several day history of nausea, vomiting and
and emesis of coffee ground material.  At the outside
17,000 and was started on initially Levofloxacin and then the
addition of Ampicillin and Flagyl.  A CT scan performed on
[**6-6**] showed dilated common bile duct with gallstones.  She was
thought to have bowel obstruction and was treated with bowel
rest and hydration.  On [**7-9**] she had respiratory distress and
to have new left lower lobe infiltrate on chest x-ray.
Nasogastric tube was placed with return of 2500 cc of bilious
have increased lipase on [**7-7**] which was noted to be trending
downward.  She was transferred to [**Hospital1 190**] for further management and was admitted to the
medical Intensive Care Unit.

PAST MEDICAL HISTORY:  Includes hypertension, depression,
history of left hip fracture, anxiety, legally blind,
dementia, remote history of atrial fibrillation.

ALLERGIES:  Pneumococcal pneumonia vaccine.

MEDICATIONS:  At home, Coumadin, Zoloft, Prinivil and Colace.
On transfer, Ativan 1 mg q 3 hours prn, Morphine 2-5 mg subcu
q 3 hours prn, Tylenol prn, Levaquin 500 mg IV q d since [**7-10**],
TPN, Albuterol nebulizer prn, Flagyl 500 mg IV q 8 hours
since [**7-9**].

PHYSICAL EXAMINATION:  Vitals at the outside hospital on [**7-11**],
temperature 101.0, heart rate 107, blood pressure 140/58,
respirations 24.  On admission to the Intensive Care Unit at
[**Hospital1 69**], temperature was 100.8,
heart rate 101 to 116, respirations 18 to 23, blood pressure
135/51.  In general she is arousable, calling out for her
husband, alert and oriented to self only.  Neck was supple
with no jugular venous distension noted.  HEENT:  Pupils were
equal, round and reactive to light.  Chest: short, shallow
respirations with no crackles, decreased breath sounds at the
left base.  Heart, tachycardic, regular rate, normal S1 and
S2 without murmur.  Abdomen soft, nontender, non distended
with hypoactive bowel sounds.  Extremities were without
edema.  Dorsalis pedis pulses were strong and symmetric.

LABORATORY DATA:  From the outside hospital, blood cultures
drawn on [**7-5**] were sterile.  Urinalysis was clean and culture
was sterile.  White blood count on [**7-5**] was 17.4, down to
14.7 on [**7-11**] and then on admission to [**Hospital1 190**] 17.8.  Hematocrit on [**7-5**] was 43.8.  On [**7-11**]
31.8 and on admission to [**Hospital1 69**]
31.6.  Platelet count on admission was 393,000.  Chem 7 on
admission, sodium 135, potassium 4.4, chloride 98, CO2 25,
BUN 16, creatinine 0.6 and glucose 118.  PT 13.2, PTT 30.3,
INR 1.2.  ALT 22, AST 26, alkaline phosphatase 70, total
bilirubin 0.4, albumin 2.5, calcium 8.5, phosphorus 4.6,
magnesium 1.9, blood cultures and urine cultures were without
growth.  The patient's amylase and lipase fluctuated
throughout her hospital course.  On [**7-11**] her lipase was 37 and
her amylase was 64.  On [**7-20**] her lipase was 810 and her
amylase was 209.  On [**7-28**] her lipase was 218 and her amylase
was 68.  On [**7-30**] the lipase was 289 and amylase was 79.

Chest x-ray on admission showed extensive left lower lobe and
possibly lingular pneumonia as well as probable effusions.
Repeat chest x-ray on [**7-15**] performed to evaluate PICC line
placement showed PICC in the middle superior vena cava with
no pneumothorax as well as improvement in the left sided
infiltrate.  Another chest x-ray performed on [**7-21**] in the
setting of fever and hypotension showed further resolution of
the left lower lobe consolidation with some persistent
consolidation in this region.

CAT scan on [**7-12**] showed cholelithiasis without cholecystitis,
dilated common bile duct measuring up to 1.5 cm in diameter,
tapering to normal caliber at the level of the ampulla.  No
stones were seen within the common or cystic duct.  Normal
appearing pancreas without evidence of pancreatitis.  Mildly
dilated loops of small bowel without obstruction.  Bilateral
pleural effusion with associated consolidation or atelectasis,
left greater than right.  Follow-up abdominal CT performed on
[**7-21**] showed abrupt common bile duct narrowing with focal proximal
dilatation of uncertain etiology.  Given the presence of
gallstones and a pancreatic cyst, the most likely etiology is
a benign stricture from prior stone passage and/or
pancreatitis.  An obstructing stone was not visualized.

Abdominal ultrasound performed at the outside hospital on [**7-6**]
showed numerous fluid filled loops of bowel in the right
upper quadrant with small amount of free fluid around the
liver.  There was a 2 cm cyst seen in the head of the
pancreas.  Common duct was dilated to 1 cm.  An 8 by 5 by 7
mm cyst was seen in the body of the pancreas.  It should be
noted that on the second CT mentioned above, there was a cyst
in the body of the pancreas noted that is consistent with the
ultrasound findings, however, there was no finding noted in
the head of the pancreas on CT.  EKG showed normal sinus
rhythm notable only for nonspecific ST-T changes in leads 3
and AVF.

IMPRESSION:  This is a 78-year-old woman with hypertension
and dementia, presenting from an outside hospital with
original presentation of several days of nausea and vomiting
with coffee ground emesis.  She presented to the [**Hospital1 346**] for further management in the
context of increased oxygen demands.

HOSPITAL COURSE:
1.  Gastrointestinal:  A) The patient was found to have
dilated loops of small bowel with the differential diagnosis
being ileus vs small bowel obstruction.  An NG tube was
placed and a large amount of bilious fluid was returned.  CAT
scan was performed that demonstrated there was no source of
obstruction and it was felt that patient had an ileus
secondary to pancreatitis.  The patient was placed on a bowel
regimen and after two weeks of constipation she voided large
amounts of stool.  She did not have further evidence of ileus
after this initial void.  B) Probable gallstone pancreatitis.
Although there was no gallstone seen in the common bile duct
and on multiple imaging studies obtained, the dilatation of
the common bile duct was suspicious for post obstructive
syndrome, especially in light of her increased lipase and
amylase at the outside hospital.  Her lipase and amylase were
coming down at the time of admission so on the [**8-12**]
the ERCP service was consulted.  They felt that she would be
a good candidate for ERCP but that in the setting of her
pneumonia as well as her impaired mental status, she would
probably require intubation for the procedure.  This was not
acceptable according to the health care proxy who was the
patient's daughter, [**Name (NI) **] [**Name (NI) **].  However, in the next week
and a half the patient's amylase and lipase again trended
upwards, reaching their peak on the [**8-20**].  It
became clear that given the patient's documented gallstones,
that she would probably continue to have flares of
pancreatitis as a result of stone obstructing the pancreatic
duct.  As a result of the patient's discomfort with this, the
option of ERCP was revisited with the health care proxy and
it was decided that she would proceed with ERCP.  The patient
had ERCP on [**7-25**].  She, in fact, did not need intubation for
the procedure due to her good pulmonary status since
pneumonia had resolved.  A sphincterotomy was performed and
sludge was extracted from the bile duct.  There were no
complications with the procedure.  The gastroenterologist was
[**Name6 (MD) **] [**Name8 (MD) **], M.D.  The patient tolerated the procedure well
and had downward trend of amylase to normal levels by
discharge and the lipase was trending down.  The patient was
started on Actigall 300 mg [**Hospital1 **] to reduce bowel sludging.  She
was also given Protonix 40 mg po q d for GI prophylaxis.

2.  Pulmonary:  The patient presented with low oxygen
saturation secondary to pneumonia.  It was thought that her
pneumonia was an aspiration pneumonia given her history of
emesis.  The patient did well on Levofloxacin and Flagyl.
Oxygen was provided per nasal cannula but intubation was not
required.  She was successfully weaned off her oxygen and had
good oxygen saturation for the final two weeks of her
hospital stay.  In addition, resolution of the pneumonia was
seen on follow-up chest films.

3.  Infectious Disease:  The patient arrived to the [**Hospital1 1444**] on Levofloxacin, Flagyl and
Ampicillin.  The Levofloxacin and Flagyl were instituted to
treat the aspiration pneumonia.  The Ampicillin was added for
further GI prophylaxis in case of cholangitis.  However, CAT
scan failed to document cholangitis.  It was felt that
patient's elevated white count was secondary to her
pneumonia.

4.  Renal:  The patient had an episode of acute renal failure
that was probably prerenal in etiology at the outside
hospital.  This apparently resolved with hydration.  She had
no renal issues during her stay at the [**Hospital1 190**].

5.  Hematology:  On initial presentation to the outside
hospital the patient had a hematocrit of 43.8.  On arrival to
the [**Hospital1 69**] she had a hematocrit
of 31.6.  Iron studies were performed and it was found that
her anemia was consistent with that of chronic disease.  No
transfusions were necessary and her hematocrit was stable
throughout her hospital stay.  In addition, the patient was
found to have thrombocytosis on admission.  This resolved
slowly throughout her hospitalization although she was
discharged with higher than normal platelet count.  We
attributed this to reactive thrombocytosis.

6.  Cardiovascular:  The patient has a history of atrial
fibrillation although she was in normal sinus rhythm during
her hospital stay.  This was discussed with her primary care
physician and it was decided to hold her Coumadin.  She was
not discharged on Coumadin.

The patient was tachycardic and had hypertension so she was
treated with Lopressor initially at low dose and ultimately
at 50 mg po tid.  She had several episodes of hypotension
that were responsive to IV fluid boluses.

7.  Fluids, Electrolytes & Nutrition:  The patient was
treated with IV fluids, initially with partial peripheral
nutrition and ultimately with total peripheral nutrition via
PICC line.  During this time she was npo.  One week prior to
discharge we tried her on sips of clears but she experienced
abdominal pain with this so we again made her npo for another
day, retried her on sips of clears and she tolerated this
well.  We continued to advance her diet while continuing the
TPN and on [**7-30**] she pulled out her own PICC line and since
she was tolerating po feeds well, there was no need to put in
another PICC line.

8.  Psychiatry:  The patient was treated initially with
Ativan prn for agitation.  Later we tried a course of Haldol,
however, she developed extrapyramidal side effects with this,
specifically she became somewhat Parkinsonian with
cogwheeling, masked facies and hypertonia.  The Haldol was
discontinued and we changed her to Risperdal for management
of her agitation.  The extrapyramidal side effects from the
Haldol resolved after 48 hours.  She did well on Risperdal.

9.  Prophylaxis:  The patient received Heparin initially
subcutaneously, later in the TPN and finally after the TPN
was discontinued, she again received Heparin subcutaneously
for DVT prophylaxis.

CONDITION ON DISCHARGE:  Good.

DISCHARGE STATUS:  She was discharged to [**Location (un) 29789**] Country Manor
in [**Location (un) 29789**], Mass.

DISCHARGE DIAGNOSIS:
1.  Pancreatitis.
2.  Cholelithiasis.
3.  Aspiration pneumonia.
4.  Dementia.
5.  Hypertension.

DISCHARGE MEDICATIONS:
1.  Ursodiol 300 mg po BID
2.  Lopressor 50 mg po TID
3.  Colace 100 mg po BID
4.  Senna I-II tablets po QD prn
5.  Risperdal 0.5 mg PO BID



                              DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-983

Dictated By:[**Doctor Last Name 34991**]
MEDQUIST36

D:  [**2101-8-1**]  13:16
T:  [**2101-8-1**]  16:24
JOB#:  [**Job Number 34992**]

cc:[**Location (un) 34993**]
{'Acute pancreatitis,Calculus of gallbladder without mention of cholecystitis, with obstruction,Gallstone ileus,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Unspecified pleural effusion,Senile dementia, uncomplicated,Unspecified protein-calorie malnutrition'}


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 78-year-old
woman with a history of hypertension, depression, anxiety and
dementia who was admitted to the [**Hospital6 3872**] on
[**2101-7-5**] with several day history of nausea, vomiting and
and emesis of coffee ground material.  At the outside
17,000 and was started on initially Levofloxacin and then the
addition of Ampicillin and Flagyl.  A CT scan performed on
[**6-6**] showed dilated common bile duct with gallstones.  She was
thought to have bowel obstruction and was treated with bowel
rest and hydration.  On [**7-9**] she had respiratory distress and
to have new left lower lobe infiltrate on chest x-ray.
Nasogastric tube was placed with return of 2500 cc of bilious
have increased lipase on [**7-7**] which was noted to be trending
downward.  She was transferred to [**Hospital1 190**] for further management and was admitted to the
medical Intensive Care Unit.

MEDICAL HISTORY: Includes hypertension, depression,
history of left hip fracture, anxiety, legally blind,
dementia, remote history of atrial fibrillation.

MEDICATION ON ADMISSION: 

ALLERGIES: Pneumococcal pneumonia vaccine.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Acute pancreatitis,Calculus of gallbladder without mention of cholecystitis, with obstruction,Gallstone ileus,Pneumonitis due to inhalation of food or vomitus,Acute kidney failure, unspecified,Unspecified pleural effusion,Senile dementia, uncomplicated,Unspecified protein-calorie malnutrition'}
