CHIEF COMPLAINT: abdominal pain

PRESENT ILLNESS: Ms. [**Known lastname 11215**] is a 78 yo female who developed right upper quandrant
pain and vomiting a few days ago. She denied hematemasis. She
went to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she was noted to be jaundiced. Although
patient had not noticed this, she states her urine became tea
colored a few weeks ago. She was found to have at common bile
duct stone by ultrasound at [**Hospital1 **] and was trasnferred here for
ERCP. At [**Hospital1 **], she was given zofran, dilaudid 0.5 IV, ativan
0.5 mg IV, and 500 cc of NS. She denies fevers, chills,
lightheadedness, nausea, vomiting.
.
In the ED, vitals were T 97.7, HR 71, BP 133/77, RR 16, 97% on
RA. At present, Surgery and ERCP were consulted with a plan to
undergo ERCP at some point. She got a dose of unasyn in the ED.

MEDICAL HISTORY: GERD
Depression
Anxiety
S/p hysterectomy

MEDICATION ON ADMISSION: Effexor 75 mg daily
Omeprazole 20 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.4, HR 71, BP 144/61, RR 14, 96% on RA
General: somnolent but arousable, jaundiced
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Patient denies family history of hepatic, pancreatic, or biliary
conditions

SOCIAL HISTORY: Patient recently suffered the loss of a friend to cancer. She
denies tobacco or alcohol use. Patient is independent and lives
alone.
Calculus of bile duct without mention of cholecystitis, with obstruction,Esophageal reflux,Dysthymic disorder
Choledochlith NOS w obst,Esophageal reflux,Dysthymic disorder
Admission Date:  [**2197-4-8**]              Discharge Date:   [**2197-4-9**]

Date of Birth:  [**2119-2-28**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2485**]
Chief Complaint:
abdominal pain

Major Surgical or Invasive Procedure:
ERCP with placement of [**First Name3 (LF) **] [**2197-4-8**]

History of Present Illness:
Ms. [**Known lastname 11215**] is a 78 yo female who developed right upper quandrant
pain and vomiting a few days ago. She denied hematemasis. She
went to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she was noted to be jaundiced. Although
patient had not noticed this, she states her urine became tea
colored a few weeks ago. She was found to have at common bile
duct stone by ultrasound at [**Hospital1 **] and was trasnferred here for
ERCP. At [**Hospital1 **], she was given zofran, dilaudid 0.5 IV, ativan
0.5 mg IV, and 500 cc of NS. She denies fevers, chills,
lightheadedness, nausea, vomiting.
.
In the ED, vitals were T 97.7, HR 71, BP 133/77, RR 16, 97% on
RA. At present, Surgery and ERCP were consulted with a plan to
undergo ERCP at some point. She got a dose of unasyn in the ED.

.
On the [**Hospital Unit Name 153**], she denies abdominal pain. She has persistent
nausea and vomiting. Further history is limited by somnolence
secondary to sedating meds received in the ED.
.
Review of sytems: unable to obtain due to sedation secondary to
sedating meds


Past Medical History:
GERD
Depression
Anxiety
S/p hysterectomy


Social History:
Patient recently suffered the loss of a friend to cancer. She
denies tobacco or alcohol use. Patient is independent and lives
alone.

Family History:
Patient denies family history of hepatic, pancreatic, or biliary
conditions

Physical Exam:
Vitals: T: 98.4, HR 71, BP 144/61, RR 14, 96% on RA
General: somnolent but arousable, jaundiced
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
.. \ 12.4 /
10.0 ---- 266
.. / 36.8 \
.
Diff: 88.4%N, 7.3%L, 3.7%M, 0.2%E, 0.4%B
.
141 | 101 | 14 /
--------------- 175
3.9 | 30  | 0.6 \
.
ALT 197
AST 112
AP 432
T. bili - 9.0
Alb 3.8
Lipase 40
.
.
PT 11.1
PTT 21.2
INR 0.9
.
OSH LFTS:
T. bili 3.6
ALT 228
AST 128
Alk Phos 492
WBC 10
.
Micro:
Blood cultures x 1 - NGT
.

.
Images:
OSH [**Name (NI) 5283**] sono - [**Name2 (NI) 86185**]s with intrahepatic and
extrahepatic biliary dilitation.  gallbladder sludge and right
renal cyst.  Common bile duct is dilated to 1.2 cm.

.
[**4-8**] ERCP
ERCP performed under MAC: Two large stones and copious amount of
stone fragments and debris were extracted, biliary [**Month/Year (2) **] was
placed.  Abrupt termination of the duct at the ampulla was
noted, thought to represent edema vs. ampullary neoplasm. Plan
to repeat ERCP in 4 weeks for [**Month/Year (2) **] removal and biopsies of the
ampulla.

[**2197-4-8**] 06:20AM BLOOD WBC-10.0 RBC-3.97* Hgb-12.4 Hct-36.8
MCV-93 MCH-31.3 MCHC-33.8 RDW-13.3 Plt Ct-266
[**2197-4-9**] 05:22AM BLOOD WBC-4.8# RBC-3.95* Hgb-12.2 Hct-37.2
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.0 Plt Ct-226
[**2197-4-8**] 07:02AM BLOOD PT-11.1 PTT-21.2* INR(PT)-0.9
[**2197-4-8**] 06:20AM BLOOD Glucose-175* UreaN-14 Creat-0.6 Na-141
K-3.9 Cl-101 HCO3-30 AnGap-14
[**2197-4-9**] 05:22AM BLOOD Glucose-102* UreaN-10 Creat-0.6 Na-143
K-3.6 Cl-106 HCO3-30 AnGap-11
[**2197-4-8**] 06:20AM BLOOD ALT-197* AST-112* AlkPhos-432*
TotBili-9.0*
[**2197-4-9**] 05:22AM BLOOD ALT-174* AST-112* LD(LDH)-194
AlkPhos-413* TotBili-9.0*
[**2197-4-8**] 06:20AM BLOOD Lipase-40
[**2197-4-9**] 05:22AM BLOOD Albumin-3.6 Calcium-8.8 Phos-2.6* Mg-2.1

Brief Hospital Course:
Ms. [**Known lastname 11215**] is a 78 yo female who developed right upper quadrant
pain and vomiting a few days prior to presenting to the ED. She
was admitted on [**4-8**] for ERCP for choledocholithiasis after an
OSH [**Month/Year (2) 5283**] ultrasound showed intra and extra duct dilatation. She
was given a dose of unasyn in the ED and again prior to ERCP.

An ERCP was performed under MAC on [**4-8**]: two large stones and
copious amounts of stone fragments and debris were extracted,
and biliary [**Month/Year (2) **] was placed.  Abrupt termination of the duct at
the ampulla was noted, thought to represent edema but concern
was raised for possible ampullary neoplasm. The plan by the ERCP
team is to repeat ERCP in 4 weeks for [**Month/Year (2) **] removal and biopsies
of the ampulla. She did well post-ERCP without symptoms of
abdominal pain, no nausea or vomiting.

General Surgery was consulted regarding need for
cholecystectomy.  [**Hospital1 18**] General Surgery will contact patient to
schedule cholecystectomy after repeat ERCP.

She was discharged from the ICU to home after tolerating a
regular diet. Upon discharge, her LFTs and Total Bilirubin were
still elevated but stable, and she remained icteric.  She had no
complaints of nausea, vomiting or abdominal pain and had no
fevers.  She was instructed to follow up with her primary care
physician the day after discharge for followup labs which should
be faxed to the GI team at [**Hospital1 18**].

Her code status was confirmed as FULL CODE this admission.

Medications on Admission:
Effexor 75 mg daily
Omeprazole 20 mg daily

Discharge Medications:
1. Outpatient Lab Work
Please draw AST, ALT, Alk phos, Tbili in [**3-16**] days and fax
results to Dr. [**Last Name (STitle) **], GI department, [**Hospital1 18**] [**Telephone/Fax (1) 86186**]
2. Venlafaxine 75 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO DAILY (Daily).
3. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
4. Compazine 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for nausea for 4 days.
Disp:*5 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnosis:
Cholelithiasis

Secondary Diagnosis:
Gastroesophageal Reflux Disease


Discharge Condition:
Stable, tolerating regular diet, stable hemodynamics, afebrile.


Discharge Instructions:
Dear Ms. [**Known lastname 11215**],
You were admitted to the hospital with gallstones. You underwent
a procedure called ERCP to remove the gallstones. They saw
inflammation of the junction between the bile ducts and the
bowel, so the GI doctors placed a [**Name5 (PTitle) **] that is keeping your
ducts in your gallbladder open. You will need this [**Name5 (PTitle) **] removed
in 4 weeks.
.
If you have fever, chills, rigors, nausea, vomiting, abdominal
pain, changes in the color of your urine (dark-[**Location (un) 2452**]), [**Doctor Last Name 352**]
stools or anything else that concerns you please call your
primary care physician right away.
.
Your medications were left unchanged.

Followup Instructions:
Please follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], next
week. He should draw labs to test your liver
(AST/ALT/TBILI/APHos) and fax them to Dr. [**Last Name (STitle) **] in the GI
department here at [**Hospital1 18**]. Dr.[**Name (NI) 15832**] fax number is:
[**Telephone/Fax (1) 86186**].
{'Calculus of bile duct without mention of cholecystitis, with obstruction,Esophageal reflux,Dysthymic disorder'}


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: Ms. [**Known lastname 11215**] is a 78 yo female who developed right upper quandrant
pain and vomiting a few days ago. She denied hematemasis. She
went to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] where she was noted to be jaundiced. Although
patient had not noticed this, she states her urine became tea
colored a few weeks ago. She was found to have at common bile
duct stone by ultrasound at [**Hospital1 **] and was trasnferred here for
ERCP. At [**Hospital1 **], she was given zofran, dilaudid 0.5 IV, ativan
0.5 mg IV, and 500 cc of NS. She denies fevers, chills,
lightheadedness, nausea, vomiting.
.
In the ED, vitals were T 97.7, HR 71, BP 133/77, RR 16, 97% on
RA. At present, Surgery and ERCP were consulted with a plan to
undergo ERCP at some point. She got a dose of unasyn in the ED.

MEDICAL HISTORY: GERD
Depression
Anxiety
S/p hysterectomy

MEDICATION ON ADMISSION: Effexor 75 mg daily
Omeprazole 20 mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.4, HR 71, BP 144/61, RR 14, 96% on RA
General: somnolent but arousable, jaundiced
HEENT: Sclera icteric, MMM, oropharynx clear
Neck: supple
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: Patient denies family history of hepatic, pancreatic, or biliary
conditions

SOCIAL HISTORY: Patient recently suffered the loss of a friend to cancer. She
denies tobacco or alcohol use. Patient is independent and lives
alone. 

### Response:
{'Calculus of bile duct without mention of cholecystitis, with obstruction,Esophageal reflux,Dysthymic disorder'}
