CHIEF COMPLAINT: ABD pain

PRESENT ILLNESS: HD 11
Unasyn [**1-1**] (11)
80M acute cholecystitis/cholangitis
PMH: CRI (2.5), FEV1 70% ([**8-9**]), NIDDM, MI [**2138**], s/p LAD and
LCx. [**Last Name (LF) **] , [**First Name3 (LF) **] 30-35%, Hx a-flutter, syncope, CVA x9 w/
cortical blindness
PSH: Partial L. nephrectomy, b/l LE bypass([**Doctor Last Name 1476**])
[**Last Name (un) 1724**]: Lopressor 25", amiodarone 200", asa 81', lipitor 80',
isosorbide mn 30', flogard 2.2", plavix 75", Coumadin 4
t/th/sat/saun, 3 m/w/f, hydralazine 25"', plavix 75'
Plan:
- ERCP chemical pancreatitis improving, clinically stable ->no
plan to re-ERCP at this point
- Cardiology informed of demand ischemia v NSTEMI, tele, BB,
nitro
- NPO for now
- GI rec. f/u in [**2-7**] weeks when [**Date Range 100581**] is performed
- f/u w/[**Date Range **] re: Carot. endart needs to be done

MEDICAL HISTORY: CRI
S/P CVA x 9 w/ prior left PCA infarct with cortical blindness
and [**10-7**] right parietal occipital cerebrovascular accident.
MI x 2
Peripheral bypass bilaterally
Diabetes
Hypertension
Hyperlipidemia
Cyst removed from kidney
Aflutter, s/p ablation [**11-5**] on amio/warfarin
syncope
renal arteries no stenosis by cath [**2154-5-17**]
s/p EPS [**5-8**]
[**5-8**] s/p TTE w/ EF to be newly depressed at 30-35% with left
ventricular hypertrophy and [**12-8**]+MR. [**Name14 (STitle) **] w/ reversible defect
-> cath w/ 60-70% LAD stenosis and an 80% LCX stenosis. The RCA
was occluded with left to right collaterals. s/p [**Name14 (STitle) **] to LAD
and LCx.

MEDICATION ON ADMISSION: lopressor 25"
amiodarone 200"
asa 81'
lipitor 80'
isosorbide mn 30'
flogard 2.2"
plavix 75'
coumadin 4 t/tr/sa/sn
coumadin 3 m/w/f
hydralazine 25'"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals:
wd, wn, nad
supple, no lad
ctab, no w/c/r
rrr, no m/r/g
soft, non-distended, non-ttp, nabs
no c/c/e

FAMILY HISTORY: non-contrib

SOCIAL HISTORY: Patient is married and lives at home with
his wife; retired metal worker. He has had a prior tobacco
history, but no alcohol
use.
Calculus of gallbladder and bile duct with acute cholecystitis, with obstruction,Cholangitis,Acute pancreatitis,Congestive heart failure, unspecified,Atrial flutter,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Abnormal coagulation profile,Abdominal aneurysm without mention of rupture,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified disorder of kidney and ureter,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction
Gall&bil cal w/ac w obs,Cholangitis,Acute pancreatitis,CHF NOS,Atrial flutter,Ocl crtd art wo infrct,Abnrml coagultion prfile,Abdom aortic aneurysm,DMII wo cmp nt st uncntr,Hypertension NOS,Hyperlipidemia NEC/NOS,Renal & ureteral dis NOS,Status-post ptca,Old myocardial infarct
Admission Date:  [**2156-1-1**]              Discharge Date:   [**2156-1-11**]

Date of Birth:  [**2075-5-3**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Doctor First Name 5188**]
Chief Complaint:
ABD pain

Major Surgical or Invasive Procedure:
- ERCP



History of Present Illness:
HD 11
Unasyn [**1-1**] (11)
80M acute cholecystitis/cholangitis
PMH: CRI (2.5), FEV1 70% ([**8-9**]), NIDDM, MI [**2138**], s/p LAD and
LCx. [**Last Name (LF) **] , [**First Name3 (LF) **] 30-35%, Hx a-flutter, syncope, CVA x9 w/
cortical blindness
PSH: Partial L. nephrectomy, b/l LE bypass([**Doctor Last Name 1476**])
[**Last Name (un) 1724**]: Lopressor 25", amiodarone 200", asa 81', lipitor 80',
isosorbide mn 30', flogard 2.2", plavix 75", Coumadin 4
t/th/sat/saun, 3 m/w/f, hydralazine 25"', plavix 75'
Plan:
- ERCP chemical pancreatitis improving, clinically stable ->no
plan to re-ERCP at this point
- Cardiology informed of demand ischemia v NSTEMI, tele, BB,
nitro
- NPO for now
- GI rec. f/u in [**2-7**] weeks when [**Date Range 100581**] is performed
- f/u w/[**Date Range **] re: Carot. endart needs to be done

Past Medical History:
CRI
S/P CVA x 9 w/ prior left PCA infarct with cortical blindness
and [**10-7**] right parietal occipital cerebrovascular accident.
MI x 2
Peripheral bypass bilaterally
Diabetes
Hypertension
Hyperlipidemia
Cyst removed from kidney
Aflutter, s/p ablation [**11-5**] on amio/warfarin
syncope
renal arteries no stenosis by cath [**2154-5-17**]
s/p EPS [**5-8**]
[**5-8**] s/p TTE w/ EF to be newly depressed at 30-35% with left
ventricular hypertrophy and [**12-8**]+MR. [**Name14 (STitle) **] w/ reversible defect
-> cath w/ 60-70% LAD stenosis and an 80% LCX stenosis. The RCA
was occluded with left to right collaterals. s/p [**Name14 (STitle) **] to LAD
and LCx.


Social History:
Patient is married and lives at home with
his wife; retired metal worker. He has had a prior tobacco
history, but no alcohol
use.


Family History:
non-contrib


Physical Exam:
vitals:
wd, wn, nad
supple, no lad
ctab, no w/c/r
rrr, no m/r/g
soft, non-distended, non-ttp, nabs
no c/c/e

Pertinent Results:
[**2156-1-6**] 06:35AM BLOOD WBC-9.2 RBC-3.94* Hgb-12.8* Hct-36.1*
MCV-92 MCH-32.6* MCHC-35.5* RDW-14.8 Plt Ct-285
[**2156-1-4**] 07:40AM BLOOD WBC-10.4 RBC-3.91* Hgb-12.6* Hct-35.6*
MCV-91 MCH-32.3* MCHC-35.5* RDW-14.7 Plt Ct-309
[**2156-1-3**] 03:36AM BLOOD WBC-10.8 RBC-3.74* Hgb-12.0* Hct-33.7*
MCV-90 MCH-32.0 MCHC-35.5* RDW-14.7 Plt Ct-258
[**2156-1-2**] 09:56AM BLOOD WBC-14.7* RBC-3.96* Hgb-12.8* Hct-35.8*
MCV-90 MCH-32.4* MCHC-35.8* RDW-14.7 Plt Ct-290
[**2156-1-2**] 06:25AM BLOOD WBC-14.0* RBC-4.26* Hgb-13.4* Hct-38.5*
MCV-91 MCH-31.5 MCHC-34.8 RDW-14.8 Plt Ct-319
[**2156-1-1**] 06:50AM BLOOD WBC-12.6* RBC-4.12* Hgb-12.7* Hct-35.9*
MCV-87 MCH-30.9 MCHC-35.5* RDW-14.6 Plt Ct-268
[**2155-12-31**] 10:30PM BLOOD WBC-14.8* RBC-4.36* Hgb-13.4* Hct-37.9*
MCV-87 MCH-30.7 MCHC-35.3* RDW-14.7 Plt Ct-306
[**2156-1-3**] 03:36AM BLOOD Neuts-80.3* Lymphs-11.3* Monos-3.5
Eos-4.2* Baso-0.6
[**2156-1-2**] 09:56AM BLOOD Neuts-90* Bands-3 Lymphs-2* Monos-3 Eos-2
Baso-0 Atyps-0 Metas-0 Myelos-0
[**2155-12-31**] 10:30PM BLOOD Neuts-62 Bands-5 Lymphs-16* Monos-6
Eos-11* Baso-0 Atyps-0 Metas-0 Myelos-0
[**2156-1-2**] 09:56AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL
[**2156-1-6**] 06:35AM BLOOD Plt Ct-285
[**2156-1-6**] 06:35AM BLOOD PT-12.7 INR(PT)-1.1
[**2156-1-4**] 07:40AM BLOOD Plt Ct-309
[**2156-1-4**] 07:40AM BLOOD PT-12.7 PTT-22.5 INR(PT)-1.1
[**2156-1-3**] 03:36AM BLOOD Plt Ct-258
[**2156-1-3**] 03:36AM BLOOD PT-15.4* PTT-24.5 INR(PT)-1.4*
[**2156-1-2**] 09:56AM BLOOD Plt Smr-NORMAL Plt Ct-290
[**2156-1-2**] 09:56AM BLOOD PT-17.9* PTT-25.2 INR(PT)-1.7*
[**2156-1-2**] 06:25AM BLOOD Plt Ct-319
[**2156-1-2**] 06:25AM BLOOD PT-19.1* INR(PT)-1.8*
[**2156-1-1**] 03:48PM BLOOD PT-21.3* INR(PT)-2.1*
[**2156-1-1**] 06:50AM BLOOD Plt Ct-268
[**2156-1-1**] 06:50AM BLOOD PT-30.9* PTT-29.2 INR(PT)-3.3*
[**2155-12-31**] 10:30PM BLOOD Plt Ct-306
[**2155-12-31**] 10:30PM BLOOD PT-28.3* PTT-28.0 INR(PT)-2.9*
[**2156-1-6**] 06:35AM BLOOD Glucose-124* UreaN-36* Creat-1.9* Na-146*
K-3.8 Cl-110* HCO3-24 AnGap-16
[**2156-1-4**] 07:40AM BLOOD Glucose-80 UreaN-48* Creat-2.3* Na-147*
K-3.6 Cl-107 HCO3-26 AnGap-18
[**2156-1-3**] 03:36AM BLOOD Glucose-99 UreaN-42* Creat-2.6* Na-142
K-3.3 Cl-104 HCO3-30 AnGap-11
[**2156-1-2**] 09:56AM BLOOD Glucose-136* UreaN-35* Creat-2.3* Na-141
K-5.1 Cl-103 HCO3-27 AnGap-16
[**2156-1-2**] 06:25AM BLOOD Glucose-133* UreaN-34* Creat-2.1* Na-142
K-4.2 Cl-103 HCO3-24 AnGap-19
[**2156-1-1**] 06:50AM BLOOD Glucose-151* UreaN-43* Creat-2.2* Na-139
K-4.5 Cl-106 HCO3-22 AnGap-16
[**2155-12-31**] 10:30PM BLOOD Glucose-192* UreaN-48* Creat-2.4* Na-137
K-4.4 Cl-101 HCO3-22 AnGap-18
[**2156-1-6**] 09:45AM BLOOD CK(CPK)-86
[**2156-1-6**] 06:35AM BLOOD ALT-91* AST-113* LD(LDH)-217 AlkPhos-535*
Amylase-267* TotBili-1.4
[**2156-1-6**] 02:21AM BLOOD CK(CPK)-90
[**2156-1-5**] 06:30PM BLOOD CK(CPK)-83
[**2156-1-5**] 06:25AM BLOOD CK(CPK)-84 Amylase-263*
[**2156-1-4**] 07:40AM BLOOD ALT-95* AST-103* AlkPhos-408*
Amylase-721* TotBili-2.0*
[**2156-1-3**] 08:10PM BLOOD Amylase-1388*
[**2156-1-3**] 11:39AM BLOOD CK(CPK)-96
[**2156-1-3**] 03:36AM BLOOD ALT-110* AST-116* LD(LDH)-177 CK(CPK)-120
AlkPhos-398* Amylase-1643* TotBili-3.3*
[**2156-1-2**] 10:14PM BLOOD CK(CPK)-175*
[**2156-1-2**] 09:56AM BLOOD CK(CPK)-214*
[**2156-1-2**] 06:25AM BLOOD ALT-125* AST-150* LD(LDH)-223
AlkPhos-501* Amylase-91 TotBili-3.7*
[**2156-1-1**] 06:50AM BLOOD ALT-110* AST-180* AlkPhos-402*
Amylase-104* TotBili-2.4*
[**2155-12-31**] 10:30PM BLOOD ALT-70* AST-122* AlkPhos-328*
Amylase-141* TotBili-1.4
[**2156-1-6**] 06:35AM BLOOD Lipase-684*
[**2156-1-5**] 06:25AM BLOOD Lipase-477*
[**2156-1-4**] 07:40AM BLOOD Lipase-741*
[**2156-1-3**] 08:10PM BLOOD Lipase-1797*
[**2156-1-3**] 03:36AM BLOOD Lipase-3806*
[**2156-1-2**] 06:25AM BLOOD Lipase-43
[**2156-1-1**] 06:50AM BLOOD Lipase-54
[**2155-12-31**] 10:30PM BLOOD Lipase-108*
[**2156-1-6**] 09:45AM BLOOD CK-MB-NotDone cTropnT-0.25*
[**2156-1-6**] 02:21AM BLOOD CK-MB-NotDone cTropnT-0.27*
[**2156-1-5**] 06:30PM BLOOD CK-MB-NotDone cTropnT-0.24*
[**2156-1-5**] 06:25AM BLOOD CK-MB-NotDone cTropnT-0.23*
[**2156-1-4**] 07:40AM BLOOD CK-MB-3 cTropnT-0.18*
[**2156-1-3**] 08:10PM BLOOD CK-MB-3 cTropnT-0.17*
[**2156-1-3**] 11:39AM BLOOD CK-MB-NotDone cTropnT-0.19*
[**2156-1-3**] 03:36AM BLOOD CK-MB-5 cTropnT-0.24*
[**2156-1-2**] 10:14PM BLOOD CK-MB-7 cTropnT-0.25*
[**2156-1-2**] 09:56AM BLOOD CK-MB-6 cTropnT-0.08*
[**2156-1-6**] 06:35AM BLOOD Albumin-3.2* Calcium-8.8 Phos-2.4* Mg-2.0
[**2156-1-4**] 07:40AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1
[**2156-1-3**] 03:36AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.2
[**2156-1-2**] 09:56AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.0
[**2156-1-2**] 06:25AM BLOOD Calcium-8.9 Phos-2.9 Mg-1.9
[**2156-1-1**] 06:50AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-2.1
[**2156-1-2**] 08:53AM BLOOD Type-ART Rates-/24 pO2-58* pCO2-41
pH-7.43 calHCO3-28 Base XS-2 Intubat-NOT INTUBA
Comment-NON-REBREA

   RADIOLOGY  Final Report

CT ABDOMEN W/O CONTRAST  [**2155-12-31**] 10:42 PM

CT ABDOMEN W/O CONTRAST; CT PELVIS W/O CONTRAST

Reason: eval for leaking AAA

[**Hospital 93**] MEDICAL CONDITION:
80 year old man with ab pain, known AAA
REASON FOR THIS EXAMINATION:
eval for leaking AAA
CONTRAINDICATIONS for IV CONTRAST: None.

INDICATION: 80-year-old man with abdominal pain and known
abdominal aortic aneurysm.

COMPARISONS: Prior abdominal ultrasound from [**2154-5-9**]. At that
time, the abdominal aortic aneurysm measured 43 x 35 cm
(transverse x AP).

TECHNIQUE: Axial non-contrast CT images of the abdomen and
pelvis were obtained without intravenous contrast, and sagittal
and coronal reconstructions were also performed. No oral
contrast was administered.
Intravenous contrast was not administered because of renal
insufficiency.

CT OF THE ABDOMEN WITH IV CONTRAST: There is subsegmental
atelectasis in the right lower lobe, but no effusions. There are
coronary artery calcifications. The hepatic density is rather
elevated, consistent with amiodarone therapy for example. The
gallbladder is somewhat distended with dependent gallstones.
There is no surrounding stranding. There is no intra- or
extrahepatic biliary ductal dilatation. The distal common duct
measures approximately 8 mm in diameter without evidence of
stones.

There are some scattered pancreatic calcifications. [**Year (4 digits) **]
calcifications in the aorta and splenic artery. The spleen
appears normal and is not enlarged. The adrenal glands are
unremarkable. Of note, there are enlarged periportal lymph
nodes. The largest measures 19 x 14 mm.

There is a 25 mm hypoattenuating focus in the right kidney,
which has previously been ascertained as a simple cyst by
ultrasound. There is also a tiny 5 mm hyperdense cyst in the
upper pole. There is a calcification, probably [**Year (4 digits) 1106**] in the
left kidney. Both kidneys are atrophic.

The maximum dimensions of the abdominal aortic aneurysm are 45 x
41 mm in axial dimensions (AP x transverse), and the maximum
diameter is 40 cm. The appearance is likely unchanged allowing
for differences in technique, and there is no evidence of a
surrounding hematoma. There is also a common iliac artery
aneurysm on the right measuring 27 mm in diameter.

The stomach, small and large bowel are within normal limits.
There is no retroperitoneal or mesenteric lymphadenopathy, or
free air or fluid.

CT OF THE PELVIS WITH IV CONTRAST: There are prostate
calcifications. The sigmoid, rectum, seminal vesicles are
unremarkable, and the bladder appears normal. There is a normal
appearance appendix, with its tip herniating into the right
inguinal ring.

BONE WINDOWS: There are marked degenerative changes of
thoracolumbar spine, but no suspicious lytic or blastic lesions.

IMPRESSION:
1. Likely similar appearance of abdominal aortic aneurysm,
allowing for differences in technique, with maximum diameter of
40 mm.
2. Moderately distended gallbladder, with stones.
3. No intra- or extrahepatic biliary ductal dilatation.
4. Prominent periportal lymph nodes.
5. Elevated density of the hepatic parenchyma, which could be
seen in amiodarone therapy for example.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: [**First Name8 (NamePattern2) **] [**2156-1-1**] 2:51 PM

   RADIOLOGY  Final Report

LIVER OR GALLBLADDER US (SINGLE ORGAN)  [**2156-1-1**] 12:47 AM

LIVER OR GALLBLADDER US (SINGL

Reason: eval for cholecystis, stones

[**Hospital 93**] MEDICAL CONDITION:
80 year old man with diffuse ab pain, R>L; elevated LFTs
REASON FOR THIS EXAMINATION:
eval for cholecystis, stones
INDICATIONS: 80-year-old man with diffuse abdominal pain.

COMPARISONS: CT of the same day.

TECHNIQUE: Right upper quadrant ultrasound.

FINDINGS: The echotexture of the liver appears normal, and no
focal lesions are identified. There is no intra- or
extra-hepatic biliary ductal dilatation. The visualized proximal
portion of the pancreas appears normal. The main portal vein
demonstrates appropriate hepatopetal flow.

The gallbladder is moderately distended. Some tenderness is
present about the gallbladder, more so than in adjacent areas.
There is layering sludge within the gallbladder and multiple
shadowing stones. Although much of the wall is normal in
thickness, there are areas of focal wall thickening, with
intramural edema in some areas, particularly along the mid and
fundal portions up to a maximum thickness of 6 mm. There is no
ascites.

IMPRESSION: High suspicion for cholecystitis.

The study and the report were reviewed by the staff radiologist.
DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1507**]
DR. [**First Name (STitle) 3934**] [**Name (STitle) 3935**]
Approved: [**First Name8 (NamePattern2) **] [**2156-1-1**] 2:51 PM

PATIENT/TEST INFORMATION:
Indication: Coronary artery disease.
Height: (in) 70
Weight (lb): 193
BSA (m2): 2.06 m2
BP (mm Hg): 154/89
HR (bpm): 58
Status: Inpatient
Date/Time: [**2156-1-6**] at 12:11
Test: TTE (Complete)
Doppler: Full Doppler and color Doppler
Contrast: None
Tape Number: 2006W011-0:00
Test Location: West Echo Lab
Technical Quality: Adequate




REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]

MEASUREMENTS:
Left Atrium - Long Axis Dimension: 3.8 cm (nl <= 4.0 cm)
Left Atrium - Four Chamber Length: *5.8 cm (nl <= 5.2 cm)
Right Atrium - Four Chamber Length: 4.6 cm (nl <= 5.0 cm)
Left Ventricle - Septal Wall Thickness: 1.0 cm (nl 0.6 - 1.1 cm)

Left Ventricle - Inferolateral Thickness: 1.0 cm (nl 0.6 - 1.1
cm)
Left Ventricle - Diastolic Dimension: 5.2 cm (nl <= 5.6 cm)
Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%)
Aorta - Valve Level: 3.4 cm (nl <= 3.6 cm)
Aorta - Ascending: 3.3 cm (nl <= 3.4 cm)
Aortic Valve - Peak Velocity: *2.3 m/sec (nl <= 2.0 m/sec)
Aortic Valve - Peak Gradient: 21 mm Hg
Aortic Valve - Mean Gradient: 10 mm Hg
Mitral Valve - E Wave: 0.8 m/sec
Mitral Valve - A Wave: 0.8 m/sec
Mitral Valve - E/A Ratio: 1.00
Mitral Valve - E Wave Deceleration Time: 139 msec

INTERPRETATION:

Findings:

LEFT ATRIUM: Normal LA size.

RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.

LEFT VENTRICLE: Normal LV cavity size. Moderately depressed
LVEF.

RIGHT VENTRICLE: Normal RV chamber size and free wall motion.

AORTA: Normal aortic root diameter.

AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild
(1+) AR.

MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild
thickening of
mitral valve chordae. Mild (1+) MR.

PERICARDIUM: No pericardial effusion.

GENERAL COMMENTS: Compared with the findings of the prior study,
there has
been no significant change.

Conclusions:
1. The left ventricular cavity size is normal. Overall left
ventricular
systolic function is moderately depressed. Posterior akinesis
and lateral and
distal septal hypokinesis are present.
2. The aortic valve leaflets (3) are mildly thickened. Mild (1+)
aortic
regurgitation is seen.
3. The mitral valve leaflets are mildly thickened. Mild (1+)
mitral
regurgitation is seen.
4. Compared with the findings of the prior study of [**2153-4-23**],
there has been
probably no significant change.

Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1445**], MD on [**2156-1-6**] 12:44.
[**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **].




Brief Hospital Course:
Pt was monitored post ERCP and treated with ABX
ERCP Report  [**Hospital1 **]
[**Hospital Ward Name 517**]

Date: [**Last Name (LF) 2974**], [**2156-1-2**] Endoscopist(s): [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],
MD
[**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 28439**], MD (fellow)

Patient: [**Known firstname 122**] [**Known lastname 100582**]
 Ref.Phys.: [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) 2472**], M.D.; Per-[**Name6 (MD) **] [**Name8 (MD) 5182**], MD PhD

Birth Date: [**2075-5-3**] (80 years) Instrument: TJF 160
 048 40 25 Indications: Cholecystitis and concern for
cholangitis. ERCP to evaluate further.

Medications: general anesthesia

ASA Class: P2
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated his
understanding and signed the corresponding consent forms. The
patient was placed in the prone position and an endoscope was
introduced through the mouth and advanced under direct
visualization until the second 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 non-bleeding diverticulum with small
opening was found on the rim of the major papilla.
Cannulation:  Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification. The
procedure was not difficult. Cannulation of the pancreatic duct
was not attempted.
Biliary Tree: A moderate diffuse dilation was seen at the common
bile duct. These findings are compatible with biliary
obstruction.
Procedures: A 9cm by 10 f Cotton [**Doctor Last Name **] biliary [**Doctor Last Name **] was placed
successfully in the common bile duct.
Impression: Papilla major diverticulum

Biliary dilation compatible with biliary obstruction

CBD [**Doctor Last Name **] placement


Recommendations: Continue ICU management
Consider cholecystectomy
Repeat ERCP in 1 month to remove [**Doctor Last Name **] and clear CBD - will need
[**Doctor Last Name 100581**].
Additional notes: Images sub-optimal in the ICU with a C arm.
CBD dilatation probable CBD stone. Given coagulopathy
[**Doctor Last Name 100581**] not possible. Stnet placed. Will require
definitive ERCP in [**3-11**] weeks.

_________________________________
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD

_________________________________
[**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) 28439**], MD (fellow)

Pt is to F/U with Dr. [**Last Name (STitle) **] for [**Last Name (STitle) **] removal and
Spincterotomy

Medications on Admission:
lopressor 25"
amiodarone 200"
asa 81'
lipitor 80'
isosorbide mn 30'
flogard 2.2"
plavix 75'
coumadin 4 t/tr/sa/sn
coumadin 3 m/w/f
hydralazine 25'"

Discharge Medications:
1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QAM (once a day
(in the morning)).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).

1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2
times a day).
Disp:*90 Tablet(s)* Refills:*0*
4. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO QAM (once a day
(in the morning)).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
9. Warfarin 3 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday
-Wednesday-[**Last Name (STitle) 2974**]).
Disp:*30 Tablet(s)* Refills:*0*
10. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO QTUTHSASU ().
Disp:*30 Tablet(s)* Refills:*0*
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*10 Tablet(s)* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2558**] - [**Location (un) **]

Discharge Diagnosis:
- acute cholecystitis
- ERCP pancreatitis


Discharge Condition:
- good


Discharge Instructions:
- Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs.
- Adhere to 2 gm sodium diet
- Fluid Restriction:
- You may resume all home medications with the changes that have
been made during your hospitalization
- You may resume your regular, salt restricted diet
- You may shower
- [**Name8 (MD) **] MD or return to ER if T>101.5, chills, nausea, vomiting,
chest pain, shortness of breath, severe abdominal pain, or any
other concern.

Pt had ABD pain and a chemical pancreatitis, it is very
important for the patient to return if he complains of any ABD.
pain at all or if there are any signs of complications related
to his Gallbladder

Followup Instructions:
- You need to follow up with the Gastro-Intestinal doctors [**First Name (Titles) **] [**Name5 (PTitle) 100583**] and [**Name5 (PTitle) 100581**]. You had a plastic [**Last Name (un) 2435**] placed
and will need to have that removed in 3 weeks time you will
likely need to stop your coumadin prior to spincterotomy at time
of ERCP
- You should follow-up with Dr. [**Last Name (STitle) 5182**] in 3 weeks.  Please
call his office at ([**Telephone/Fax (1) 15350**] to schedule an appointment.
- Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**]
Date/Time:[**2156-1-29**] 8:30
- Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB)
Date/Time:[**2156-6-29**] 11:00.  Please call to confirm this/or an
earlier appointment.
- You should also follow-up with your primary doctor for a blood
pressure check and further monitoring of your blood pressure.


                             [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]

Completed by:[**2156-1-11**]
{'Calculus of gallbladder and bile duct with acute cholecystitis, with obstruction,Cholangitis,Acute pancreatitis,Congestive heart failure, unspecified,Atrial flutter,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Abnormal coagulation profile,Abdominal aneurysm without mention of rupture,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified disorder of kidney and ureter,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction'}


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: ABD pain

PRESENT ILLNESS: HD 11
Unasyn [**1-1**] (11)
80M acute cholecystitis/cholangitis
PMH: CRI (2.5), FEV1 70% ([**8-9**]), NIDDM, MI [**2138**], s/p LAD and
LCx. [**Last Name (LF) **] , [**First Name3 (LF) **] 30-35%, Hx a-flutter, syncope, CVA x9 w/
cortical blindness
PSH: Partial L. nephrectomy, b/l LE bypass([**Doctor Last Name 1476**])
[**Last Name (un) 1724**]: Lopressor 25", amiodarone 200", asa 81', lipitor 80',
isosorbide mn 30', flogard 2.2", plavix 75", Coumadin 4
t/th/sat/saun, 3 m/w/f, hydralazine 25"', plavix 75'
Plan:
- ERCP chemical pancreatitis improving, clinically stable ->no
plan to re-ERCP at this point
- Cardiology informed of demand ischemia v NSTEMI, tele, BB,
nitro
- NPO for now
- GI rec. f/u in [**2-7**] weeks when [**Date Range 100581**] is performed
- f/u w/[**Date Range **] re: Carot. endart needs to be done

MEDICAL HISTORY: CRI
S/P CVA x 9 w/ prior left PCA infarct with cortical blindness
and [**10-7**] right parietal occipital cerebrovascular accident.
MI x 2
Peripheral bypass bilaterally
Diabetes
Hypertension
Hyperlipidemia
Cyst removed from kidney
Aflutter, s/p ablation [**11-5**] on amio/warfarin
syncope
renal arteries no stenosis by cath [**2154-5-17**]
s/p EPS [**5-8**]
[**5-8**] s/p TTE w/ EF to be newly depressed at 30-35% with left
ventricular hypertrophy and [**12-8**]+MR. [**Name14 (STitle) **] w/ reversible defect
-> cath w/ 60-70% LAD stenosis and an 80% LCX stenosis. The RCA
was occluded with left to right collaterals. s/p [**Name14 (STitle) **] to LAD
and LCx.

MEDICATION ON ADMISSION: lopressor 25"
amiodarone 200"
asa 81'
lipitor 80'
isosorbide mn 30'
flogard 2.2"
plavix 75'
coumadin 4 t/tr/sa/sn
coumadin 3 m/w/f
hydralazine 25'"

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals:
wd, wn, nad
supple, no lad
ctab, no w/c/r
rrr, no m/r/g
soft, non-distended, non-ttp, nabs
no c/c/e

FAMILY HISTORY: non-contrib

SOCIAL HISTORY: Patient is married and lives at home with
his wife; retired metal worker. He has had a prior tobacco
history, but no alcohol
use. 

### Response:
{'Calculus of gallbladder and bile duct with acute cholecystitis, with obstruction,Cholangitis,Acute pancreatitis,Congestive heart failure, unspecified,Atrial flutter,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Abnormal coagulation profile,Abdominal aneurysm without mention of rupture,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Unspecified disorder of kidney and ureter,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction'}
