CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: This is an 80 yo F with a history of SVT, AS s/p AVR who
presents with 4 weeks of general malaise and 2 weeks of
intermittent RUQ/epigastric pain, worse with eating. She also
notes intermittent shaking chills since Friday. She kept putting
off having an evaluation because she hoped it would go away or
be indigestion. Today, she finally called 911 when the pain and
chills became more severe today and she noticed her urine had
become dark [**Location (un) 2452**] several days prior. She presented to an OSH
where a RUQ U/S showed a dilated CBD to 1.3cm with 2 1cm
obstructing stones but no evidence of cholecystitis. Initial
temp there was 102. She received IV cipro/flagyl and was
transferred to [**Hospital1 18**] ED for ERCP eval for ? of cholangitis.
.
In the ED, initial vitals wer 98.2, 93, 119/63, 14, 97% 2L. She
received 2mg IV morphine and 1g IV vancomycin. She was admitted
to the [**Hospital Unit Name 153**] for monitoring and ERCP in am.
.
ROS: The patient denies any weight change, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity oedema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.

MEDICAL HISTORY: Aortic Stenosis s/p AVR w/ St. [**Male First Name (un) 923**] Porcine, [**2146-7-4**]
Hepatitis C
PSVT
Varicose veins s/p stripping
Macular degeneration
Osteoporosis
s/p Tonsillectomy
s/p Total abdominal hysterectomy
s/p Umbilical hernia repair and abdominoplasty
s/p Spinal fusion and laminectomy
s/p Bilateral cataract surgery

MEDICATION ON ADMISSION: Aspirin 81 mg once daily,
Toprol XL 100 mg once daily
Calcium Citrate with Vitamin D - 600mg daily
Vitamin E once daily
Vitamin C 1000mg daily
Multivitamin dailyy
Vitamin B6 100mg daily Zinc 50mg daily
Magnesium Oxide 50mg daily
[**Hospital 106379**] every fourth Sunday
Ocuvite Lutein daily
Ibuprofen as needed

ALLERGIES: Ampicillin

PHYSICAL EXAM: Vitals: T: 97.2 BP: 116/56 HR: 81 RR:14 O2Sat:100% 2L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea,
MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, +BS, no HSM, no masses, tender in RUQ, +[**Doctor Last Name 515**]

FAMILY HISTORY: Brother died of CHF at age 75.

SOCIAL HISTORY: Retired lab tech. Denies tobacco use. Also denies ETOH use in 20
yrs.
Cholangitis,Calculus of bile duct without mention of cholecystitis, with obstruction,Paroxysmal supraventricular tachycardia,Chronic hepatitis C without mention of hepatic coma,Osteoporosis, unspecified,Macular degeneration (senile), unspecified,Heart valve replaced by other means,Arthrodesis status
Cholangitis,Choledochlith NOS w obst,Parox atrial tachycardia,Chrnc hpt C wo hpat coma,Osteoporosis NOS,Macular degeneration NOS,Heart valve replac NEC,Arthrodesis status
Admission Date:  [**2146-11-20**]              Discharge Date:   [**2146-11-23**]

Date of Birth:  [**2066-2-24**]             Sex:   F

Service: MEDICINE

Allergies:
Ampicillin

Attending:[**First Name3 (LF) 552**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
ERCP [**11-21**]

History of Present Illness:
This is an 80 yo F with a history of SVT, AS s/p AVR who
presents with 4 weeks of general malaise and 2 weeks of
intermittent RUQ/epigastric pain, worse with eating. She also
notes intermittent shaking chills since Friday. She kept putting
off having an evaluation because she hoped it would go away or
be indigestion. Today, she finally called 911 when the pain and
chills became more severe today and she noticed her urine had
become dark [**Location (un) 2452**] several days prior. She presented to an OSH
where a RUQ U/S showed a dilated CBD to 1.3cm with 2 1cm
obstructing stones but no evidence of cholecystitis. Initial
temp there was 102. She received IV cipro/flagyl and was
transferred to [**Hospital1 18**] ED for ERCP eval for ? of cholangitis.
.
In the ED, initial vitals wer 98.2, 93, 119/63, 14, 97% 2L. She
received 2mg IV morphine and 1g IV vancomycin. She was admitted
to the [**Hospital Unit Name 153**] for monitoring and ERCP in am.
.
ROS: The patient denies any weight change, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity oedema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.


Past Medical History:
Aortic Stenosis s/p AVR w/ St. [**Male First Name (un) 923**] Porcine, [**2146-7-4**]
Hepatitis C
PSVT
Varicose veins s/p stripping
Macular degeneration
Osteoporosis
s/p Tonsillectomy
s/p Total abdominal hysterectomy
s/p Umbilical hernia repair and abdominoplasty
s/p Spinal fusion and laminectomy
s/p Bilateral cataract surgery


Social History:
Retired lab tech. Denies tobacco use. Also denies ETOH use in 20
yrs.

Family History:
Brother died of CHF at age 75.

Physical Exam:
Vitals: T: 97.2 BP: 116/56 HR: 81 RR:14 O2Sat:100% 2L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea,
MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, +BS, no HSM, no masses, tender in RUQ, +[**Doctor Last Name 515**]

EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses.



Pertinent Results:
=========
Labs
=========

[**2146-11-21**] 03:20AM BLOOD WBC-4.7 RBC-3.45* Hgb-10.8* Hct-31.7*
MCV-92 MCH-31.5 MCHC-34.2 RDW-16.9* Plt Ct-266
[**2146-11-20**] 05:43PM BLOOD WBC-8.4# RBC-4.04*# Hgb-12.4# Hct-35.7*
MCV-88# MCH-30.6 MCHC-34.7 RDW-16.6* Plt Ct-329#
[**2146-11-21**] 03:20AM BLOOD Neuts-71.9* Lymphs-17.2* Monos-8.4
Eos-2.2 Baso-0.2
[**2146-11-20**] 05:43PM BLOOD Neuts-81.0* Lymphs-12.5* Monos-5.9
Eos-0.4 Baso-0.2
[**2146-11-21**] 03:20AM BLOOD PT-14.1* PTT-30.4 INR(PT)-1.2*
[**2146-11-20**] 05:43PM BLOOD PT-14.4* PTT-27.2 INR(PT)-1.3*
[**2146-11-21**] 03:20AM BLOOD Glucose-83 UreaN-8 Creat-0.4 Na-140 K-3.5
Cl-110* HCO3-19* AnGap-15
[**2146-11-20**] 05:43PM BLOOD Glucose-91 UreaN-10 Creat-0.5 Na-135
K-3.4 Cl-103 HCO3-21* AnGap-14
[**2146-11-21**] 03:20AM BLOOD ALT-38 AST-75* LD(LDH)-179 AlkPhos-288*
TotBili-11.1* DirBili-9.5* IndBili-1.6
[**2146-11-20**] 05:43PM BLOOD ALT-52* AST-92* AlkPhos-370*
TotBili-12.7* DirBili-10.8* IndBili-1.9
[**2146-11-21**] 03:20AM BLOOD Albumin-2.4* Calcium-7.1* Phos-2.2*
Mg-2.2
[**2146-11-20**] 05:43PM BLOOD Albumin-3.1* Calcium-8.0* Phos-2.5*
Mg-2.1
[**2146-11-20**] 05:45PM BLOOD Glucose-85 Lactate-1.1 Na-135 K-3.4*
Cl-102
[**2146-11-20**] 05:45PM BLOOD Hgb-12.9 calcHCT-39

==========
GI
==========
ERCP - [**11-21**]
"Impression: Choledocho-duodenal fistula with pus discharging
from the fistula.
Otherwise normal major papilla.
Normal pancreatic duct .
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized.
The common bile duct was dilated to 14mm with multiple stones
noted within the distal common bile duct up to 12mm.
Successful biliary sphincterotomy extended to the
choledochoduodenal fistula performed in the 12 o'clock position
using a sphincterotome over an existing guidewire.
Successful extraction of stone fragments and sludge using a 15
mm balloon.
Successful extraction of stone fragments using a spiral basket.

Successful placement of a  5cm by 10FR double pig tail biliary
stent into the left intrahepatic system because of pus draining
from the common bile duct and possible retained stone fragments.

Free flow of bile noted after stent placement.


Recommendations: Return to [**Hospital Unit Name 153**].
No aspirin/plavix/anticoagulants for 72 hrs.
Juices today when awake, alert and at baseline
Remain on antibiotics for a total of 7 days
Return in 8 weeks for plastic stent removal and re-evaluation
for any remaining stone fragments.  "

[**2146-11-23**] 07:05AM BLOOD WBC-6.9 RBC-3.87* Hgb-11.9* Hct-36.3
MCV-94 MCH-30.7 MCHC-32.8 RDW-17.1* Plt Ct-449*
[**2146-11-22**] 06:05AM BLOOD WBC-6.5 RBC-3.46* Hgb-11.0* Hct-32.5*
MCV-94 MCH-31.7 MCHC-33.7 RDW-16.7* Plt Ct-313
[**2146-11-21**] 03:20AM BLOOD WBC-4.7 RBC-3.45* Hgb-10.8* Hct-31.7*
MCV-92 MCH-31.5 MCHC-34.2 RDW-16.9* Plt Ct-266
[**2146-11-23**] 07:05AM BLOOD Glucose-82 UreaN-8 Creat-0.6 Na-137 K-4.0
Cl-106 HCO3-26 AnGap-9
[**2146-11-22**] 06:05AM BLOOD Glucose-75 UreaN-8 Creat-0.6 Na-137 K-4.7
Cl-106 HCO3-25 AnGap-11
[**2146-11-20**] 05:43PM BLOOD ALT-52* AST-92* AlkPhos-370*
TotBili-12.7* DirBili-10.8* IndBili-1.9
[**2146-11-21**] 03:20AM BLOOD ALT-38 AST-75* LD(LDH)-179 AlkPhos-288*
TotBili-11.1* DirBili-9.5* IndBili-1.6
[**2146-11-22**] 06:05AM BLOOD ALT-38 AST-70* LD(LDH)-182 AlkPhos-285*
TotBili-10.9*
[**2146-11-23**] 07:05AM BLOOD ALT-44* AST-95* AlkPhos-298* Amylase-21
TotBili-6.5* DirBili-4.5* IndBili-2.0

Brief Hospital Course:
Patient is an 80 yo Female with history of AS s/p AVR who
presents with biliary obstruction complicated by cholangitis,
now s/p successful stone extraction and biliary decompression
with ERCP.
.
#. Cholangitis, Bacterial: Secondary to biliary obstruction from
stones. Patient hemodynamically stable, now decompressed. Blood
Cx from [**Hospital **] hospital neg todate. Blood Cx here neg so far
too.
- Afebrile, nl wbc, and clinically improved after abx and ERCP.
- LFTs were downtrending at dc
- continue Cipro/Flagyl for a total 10 day course, additional
7days at dc
- Pt told to resume aspirin on friday
- pt's diet was advanced and tolerated it well. Day of
discharge, pt complained of "gas pain" in lower abdomen, not
severe, not significant on exam - lipase/amylase were checked to
eval for post-ercp pancreatitis. Pt ate meal and tolerated it
well.
This may be related to antibiotics but pt was able to keep them
down and only had a few more days of abx left, so decision was
made to continue them. Pt was told that if she noticed worsening
abdominal pain, diarrhea, fever, she should talk to her pcp or
go to local ED
-Pt will be called for repeat ERCP
-Pt was seen by surgery inpt and they recommended that she fu in
clinic for elective cholecystectomy in near future
.
.
#. Aortic Stenosis s/p porcine AVR - Patient currently
euvolemic, not anti-coagulated as an outpatient
- she was on toprol xl as outpt, initially held, then metoprolol
was restarted. Pt told to resume toprol xl at discharge
.
#. Hepatitis C, Chronic - no active issues
- outpatient follow up
.
#. FEN - regular diet.

#. Dispo - pt was ambulating well and discharged home w home PT
eval (given hx of foot drop/brace not available in hospital)
.


Medications on Admission:
Aspirin 81 mg once daily,
Toprol XL 100 mg once daily
Calcium Citrate with Vitamin D - 600mg daily
Vitamin E once daily
Vitamin C 1000mg daily
Multivitamin dailyy
Vitamin B6 100mg daily Zinc 50mg daily
Magnesium Oxide 50mg daily
[**Hospital 106379**] every fourth Sunday
Ocuvite Lutein daily
Ibuprofen as needed


Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
3. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day: please start this on friday. do not take aspirin
or any blood thinners until then.
5. [**Hospital 106379**] 150 mg Tablet Sig: One (1) Tablet PO once a month.
6. Calcium Citrate + D 315-200 mg-unit Tablet Sig: One (1)
Tablet PO twice a day.
7. Ocuvite Lutein     Capsule Sig: One (1) Capsule PO once a
day.
8. Magnesium Oxide 500 mg Tablet Sig: One (1) Tablet PO once a
day.
9. Vitamin B-6 100 mg Tablet Sig: One (1) Tablet PO once a day.

10. Zinc 50 mg Tablet Sig: One (1) Tablet PO once a day.
11. Multivitamin     Tablet Sig: One (1) Tablet PO once a day.
12. Vitamin E 400 unit Tablet Sig: One (1) Tablet PO once a day.

13. Vitamin C 1,000 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Home With Service

Facility:
VNA of Central & [**Hospital3 29991**] [**Hospital3 **]

Discharge Diagnosis:
Cholangitis [**1-22**] obstructed gallstones


Discharge Condition:
Good


Discharge Instructions:
You were admitted to the hospital with fevers and jaundice
caused by multiple gallstones causing obstruction of bile. You
were placed on antibiotics and an ERCP was done which showed
many stones in your bile duct, most have been removed and a
repeat ERCP needs to take place in a few weeks. You were also
seen by surgery in the hospital and they want you to call the
clinic to set up an appointment as soon as possible.
Please return to ED for fevers, chills, severe abdominal pain,
bleeding

Followup Instructions:
1. Dr. [**First Name (STitle) **] [**Name (STitle) 2696**], ph: [**Telephone/Fax (1) 2697**], [**12-1**], thurs, 1:30pm
2. Gen surgery, Dr. [**Last Name (STitle) **] ph: [**Telephone/Fax (1) 5189**], please call
clinic to schedule an appt within next week.
3. ERCP scheduling, ph: [**Telephone/Fax (1) 2799**]. You should be getting a
call about scheduling ERCP.Please call this number if you do not
hear from them by next week.
{'Cholangitis,Calculus of bile duct without mention of cholecystitis, with obstruction,Paroxysmal supraventricular tachycardia,Chronic hepatitis C without mention of hepatic coma,Osteoporosis, unspecified,Macular degeneration (senile), unspecified,Heart valve replaced by other means,Arthrodesis status'}


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: abdominal pain

PRESENT ILLNESS: This is an 80 yo F with a history of SVT, AS s/p AVR who
presents with 4 weeks of general malaise and 2 weeks of
intermittent RUQ/epigastric pain, worse with eating. She also
notes intermittent shaking chills since Friday. She kept putting
off having an evaluation because she hoped it would go away or
be indigestion. Today, she finally called 911 when the pain and
chills became more severe today and she noticed her urine had
become dark [**Location (un) 2452**] several days prior. She presented to an OSH
where a RUQ U/S showed a dilated CBD to 1.3cm with 2 1cm
obstructing stones but no evidence of cholecystitis. Initial
temp there was 102. She received IV cipro/flagyl and was
transferred to [**Hospital1 18**] ED for ERCP eval for ? of cholangitis.
.
In the ED, initial vitals wer 98.2, 93, 119/63, 14, 97% 2L. She
received 2mg IV morphine and 1g IV vancomycin. She was admitted
to the [**Hospital Unit Name 153**] for monitoring and ERCP in am.
.
ROS: The patient denies any weight change, nausea, vomiting,
diarrhea, constipation, melena, hematochezia, chest pain,
shortness of breath, orthopnea, PND, lower extremity oedema,
cough, urinary frequency, urgency, dysuria, lightheadedness,
gait unsteadiness, focal weakness, vision changes, headache,
rash or skin changes.

MEDICAL HISTORY: Aortic Stenosis s/p AVR w/ St. [**Male First Name (un) 923**] Porcine, [**2146-7-4**]
Hepatitis C
PSVT
Varicose veins s/p stripping
Macular degeneration
Osteoporosis
s/p Tonsillectomy
s/p Total abdominal hysterectomy
s/p Umbilical hernia repair and abdominoplasty
s/p Spinal fusion and laminectomy
s/p Bilateral cataract surgery

MEDICATION ON ADMISSION: Aspirin 81 mg once daily,
Toprol XL 100 mg once daily
Calcium Citrate with Vitamin D - 600mg daily
Vitamin E once daily
Vitamin C 1000mg daily
Multivitamin dailyy
Vitamin B6 100mg daily Zinc 50mg daily
Magnesium Oxide 50mg daily
[**Hospital 106379**] every fourth Sunday
Ocuvite Lutein daily
Ibuprofen as needed

ALLERGIES: Ampicillin

PHYSICAL EXAM: Vitals: T: 97.2 BP: 116/56 HR: 81 RR:14 O2Sat:100% 2L
GEN: Well-appearing, well-nourished, no acute distress
HEENT: EOMI, PERRL, sclera icteric, no epistaxis or rhinorrhea,
MMM, OP Clear
NECK: No JVD, carotid pulses brisk, no bruits, no cervical
lymphadenopathy, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, ND, +BS, no HSM, no masses, tender in RUQ, +[**Doctor Last Name 515**]

FAMILY HISTORY: Brother died of CHF at age 75.

SOCIAL HISTORY: Retired lab tech. Denies tobacco use. Also denies ETOH use in 20
yrs. 

### Response:
{'Cholangitis,Calculus of bile duct without mention of cholecystitis, with obstruction,Paroxysmal supraventricular tachycardia,Chronic hepatitis C without mention of hepatic coma,Osteoporosis, unspecified,Macular degeneration (senile), unspecified,Heart valve replaced by other means,Arthrodesis status'}
