CHIEF COMPLAINT: Right upper quadrant pain

PRESENT ILLNESS: This is a [**Age over 90 **]M with a history of DM2 presenting with severe
RUQ since last night.  He's actually had intermittent mild pain
x
9 days (~[**1-10**] day each time), but it became worse overnight
without any precipitating factors.  [**10-18**] sharp, RUQ,
non-radiating pain.  No F/C/N/V/D.

MEDICAL HISTORY: diabetes, HTN, GERD, depression, ASA 81, colace

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: enalapril 5mg daily, lactulose [**1-10**] tspns [**Hospital1 **], metformin
1000mg [**Hospital1 **] and 500mg at noon, omeprazole 20mg daily, paroxetine
10mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: (Admit)
VS  99.6 67 180/81 18 99% RA
Gen NAD, AAOx3 but in pain
CV RRR
Pulm CTAB
Abd soft, extremely TTP RUQ, +G, no rebound; well healed
incisions
Ext wwp, no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives alone. No T, very rare EtOH, no IVDU.
Acute cholecystitis,Atrial fibrillation,Other fluid overload,Unspecified essential hypertension,Esophageal reflux,Depressive disorder, not elsewhere classified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes
Acute cholecystitis,Atrial fibrillation,Fluid overload NEC,Hypertension NOS,Esophageal reflux,Depressive disorder NEC,DMII neuro nt st uncntrl,Neuropathy in diabetes
Admission Date:  [**2117-3-4**]              Discharge Date:   [**2117-3-10**]


Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
Right upper quadrant pain

Major Surgical or Invasive Procedure:
[**2117-3-4**]
Laparoscopic cholecystectomy


History of Present Illness:
This is a [**Age over 90 **]M with a history of DM2 presenting with severe
RUQ since last night.  He's actually had intermittent mild pain
x
9 days (~[**1-10**] day each time), but it became worse overnight
without any precipitating factors.  [**10-18**] sharp, RUQ,
non-radiating pain.  No F/C/N/V/D.

Past Medical History:
diabetes, HTN, GERD, depression, ASA 81, colace

PSH: tonsillectomy, jaw surgery, eye surgery, bilateral open
inguinal hernia repairs


Social History:
Lives alone. No T, very rare EtOH, no IVDU.


Family History:
NC


Physical Exam:
(Admit)
VS  99.6 67 180/81 18 99% RA
Gen NAD, AAOx3 but in pain
CV RRR
Pulm CTAB
Abd soft, extremely TTP RUQ, +G, no rebound; well healed
incisions
Ext wwp, no edema

General:  NAD, alert and oriented, sitting in chair [**Location (un) 1131**]
paper

Vital signs:  bp=139/79, hr 77, resp. rate 18, oxygen saturation
98% (2 liters)

CV:  Ns1, 2, -s3, -s4
LUNGS:  Clear upper, diminshed bases
ABDOMEN: soft, slightly distended, non-tender, steri-strips to
port sites
EXT:  no pedal edema bil.

Pertinent Results:
[**2117-3-8**] 04:35AM BLOOD WBC-6.7 RBC-3.22* Hgb-9.6* Hct-29.7*
MCV-92 MCH-29.9 MCHC-32.4 RDW-12.7 Plt Ct-212
[**2117-3-7**] 03:46AM BLOOD WBC-7.3 RBC-3.04* Hgb-9.1* Hct-27.7*
MCV-91 MCH-29.9 MCHC-32.9 RDW-12.7 Plt Ct-179
[**2117-3-6**] 07:55PM BLOOD WBC-9.3 RBC-3.50* Hgb-10.5* Hct-32.1*
MCV-92 MCH-29.9 MCHC-32.6 RDW-12.7 Plt Ct-182
[**2117-3-4**] 08:20AM BLOOD Neuts-83.9* Lymphs-11.5* Monos-3.9
Eos-0.3 Baso-0.4
[**2117-3-8**] 04:35AM BLOOD Plt Ct-212
[**2117-3-7**] 03:46AM BLOOD Plt Ct-179
[**2117-3-9**] 05:05AM BLOOD Glucose-116* UreaN-20 Creat-0.8 Na-145
K-4.0 Cl-109* HCO3-27 AnGap-13
[**2117-3-8**] 04:35AM BLOOD Glucose-156* UreaN-23* Creat-0.9 Na-138
K-3.4 Cl-104 HCO3-26 AnGap-11
[**2117-3-7**] 03:46AM BLOOD Glucose-133* UreaN-21* Creat-1.1 Na-139
K-3.8 Cl-103 HCO3-27 AnGap-13
[**2117-3-6**] 04:35AM BLOOD ALT-22 AST-31 AlkPhos-71 Amylase-15
TotBili-1.4
[**2117-3-4**] 11:23PM BLOOD CK(CPK)-127
[**2117-3-4**] 08:20AM BLOOD ALT-13 AST-25 AlkPhos-90 Amylase-38
TotBili-1.0
[**2117-3-6**] 04:35AM BLOOD Lipase-10
[**2117-3-4**] 08:20AM BLOOD Lipase-27
[**2117-3-4**] 11:23PM BLOOD CK-MB-4 cTropnT-<0.01
[**2117-3-9**] 05:05AM BLOOD Calcium-8.4 Phos-2.4* Mg-1.9
[**2117-3-8**] 04:35AM BLOOD Calcium-8.1* Phos-2.3* Mg-1.9
[**2117-3-4**] 10:53AM BLOOD Lactate-2.1*

[**2117-3-4**]:  EKG:

Artifact is present. Sinus rhythm. Ventricular ectopy. Low
voltage in the
limb leads. Non-specific ST-T wave changes. Compared to the
previous tracing  of [**2117-3-4**] ventricular ecopy and low voltage
are new.
TRACING #2

[**2117-3-4**]:  Liver/gallbladder ultrasound:

 IMPRESSION:
Findings concerning for acute cholecystitis in the appropriate
clinical
setting with a positive son[**Name (NI) 493**] [**Name2 (NI) 515**] sign in a distended
gallbladder containing stones and sludge.

[**2117-3-6**]:  chest x-ray:

FRONTAL CHEST RADIOGRAPH: Interstitial edema is not
significantly changed;
however, there is increasing opacification at the right lung
base which may represent atelectasis, although superimposed
infection cannot be excluded.
There are small bilateral pleural effusions. There is no
pneumothorax.
Azygos fissure is again noted. The cardiomediastinal silhouette
is stable. A small amount of free air underneath the
hemidiaphragms is again noted
consistent with recent laparotomy.

[**2117-3-8**]:  EKG:

Normal sinus rhythm. Non-specific ST-T wave changes. Compared to
tracing #1
the rate is slightly faster. Other findings are similar.
TRACING #2

[**2117-3-9**]:  chest x-ray:


FINDINGS: In comparison with the study of [**3-7**], there is little
change in the amount of free intraperitoneal gas beneath the
hemidiaphragm, consistent with prior surgery. Some residual
opacification at the left base is consistent with atelectasis
and possible effusion, though in the appropriate clinical
setting, the possibility of supervening pneumonia would have to
be considered.
No evidence of pulmonary vascular congestion at this time.









Brief Hospital Course:
  The patient was seen in the emergency department and was
determined to have acute cholecystitis. He was taken to the
operating room for a laparoscopic cholecystectomy. Due to the
patients severe disease, this was noted to be a very difficult
dissection, and the cystic duct was taken using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3224**] stapler
rather than the classic clips. The remainder of the procedure
was prolonged, but otherwise uncomplicated. The patient
tolerated the procedure well and was taken to the PACU for
further recovery.  He recovered from anesthesia without
difficulty and was transferred to the floor for observation. His
initial recovery was uneventful and on the normal course for a
difficult cholecystectomy. On POD 2, however, the patient was
noted to have desaturations to 81% ad was found to be in new
onset Afib. This was controlled with lopressor and the patient
was transferred to the intensive care unit. A CT PE protocol was
negative for PE, and the patient was loaded with diltiazem and a
drip was maintained overnight. The patient converted back to
normal sinus rhythm and his oxygen saturations recovered to his
normal preop levels. He was given lasix for his fluid overload
and to assist in prevention of continued afib. Following this,
the patient was transferred back to the floor for the remainder
of his recovery.
  He returned to the regular floor on [**3-7**].  He continued to
have episodes of rapid heart rate which were controlled with
metoprolol.  His regular diet was resumed.  His foley catheter
was discontinued on POD #4 and he has been voiding without
difficulty.  He was evaluated by physical therapy who
recommended a rehabilitation facility to improve his overall
conditioning in hopes of him attaining optimal recovery. Today
he will complete his final day of unasyn.
  He is preparing for discharge to a rehabilitation facility.
His vital signs are stable and his episodes of rapid heart rate
have diminished.  He is tolerating a regular diet.  He is
voiding without difficulty.  He will follow-up with the Acute
Care service in 2 weeks.

Medications on Admission:
[**Last Name (un) 1724**]: enalapril 5mg daily, lactulose [**1-10**] tspns [**Hospital1 **], metformin
1000mg [**Hospital1 **] and 500mg at noon, omeprazole 20mg daily, paroxetine
10mg daily

Discharge Medications:
1. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): hold for blood pressure <110, hr <60.
2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO TID (3 times
a day): as neeeded for pain.
3. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
4. paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
6. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.

7. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
8. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc
Injection TID (3 times a day).
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3
times a day): hold for blood pressure <110, hr <60.


Discharge Disposition:
Extended Care

Facility:
Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**]

Discharge Diagnosis:
Acute cholecystitis


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - with additional person for
assistance


Discharge Instructions:
* You were admitted to the hospital with abdominal pain from
inflammation of your gallbladder.  During surgery the
gallbladder was noted to be very diseased.
* You have done well and should continue to eat well and stay
well hydrated.
Follow the general direction below:

You are being discharged on medications to treat the pain from
your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST  refrain from such activities while
taking these medications.

Please call your doctor or return to the emergency room if you
have 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.


* 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.

Activity:
No heavy lifting of items [**10-23**] pounds for 6 weeks. You may
resume moderate
exercise at your discretion, no abdominal exercises.

Wound Care:
You may shower, no tub baths or swimming.

If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips 7-10 days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.


Followup Instructions:
Call the Acute Care Clinic at [**Telephone/Fax (1) 600**] for a follow up
appointment in 2 weeks.  Please follow-up with your primary care
provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5444**], in 1 week.  The telephone number is
#[**Telephone/Fax (1) 250**].

Provider: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**]
Date/Time:[**2117-3-8**] 4:10

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5447**], M.D. Date/Time:[**2117-5-21**] 10:40



Completed by:[**2117-3-9**]
{'Acute cholecystitis,Atrial fibrillation,Other fluid overload,Unspecified essential hypertension,Esophageal reflux,Depressive disorder, not elsewhere classified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes'}


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: Right upper quadrant pain

PRESENT ILLNESS: This is a [**Age over 90 **]M with a history of DM2 presenting with severe
RUQ since last night.  He's actually had intermittent mild pain
x
9 days (~[**1-10**] day each time), but it became worse overnight
without any precipitating factors.  [**10-18**] sharp, RUQ,
non-radiating pain.  No F/C/N/V/D.

MEDICAL HISTORY: diabetes, HTN, GERD, depression, ASA 81, colace

MEDICATION ON ADMISSION: [**Last Name (un) 1724**]: enalapril 5mg daily, lactulose [**1-10**] tspns [**Hospital1 **], metformin
1000mg [**Hospital1 **] and 500mg at noon, omeprazole 20mg daily, paroxetine
10mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: (Admit)
VS  99.6 67 180/81 18 99% RA
Gen NAD, AAOx3 but in pain
CV RRR
Pulm CTAB
Abd soft, extremely TTP RUQ, +G, no rebound; well healed
incisions
Ext wwp, no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Lives alone. No T, very rare EtOH, no IVDU. 

### Response:
{'Acute cholecystitis,Atrial fibrillation,Other fluid overload,Unspecified essential hypertension,Esophageal reflux,Depressive disorder, not elsewhere classified,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes'}
