CHIEF COMPLAINT: Jaundice.

PRESENT ILLNESS: This very nice 59-year-old woman recently became jaundiced.  A
workup ensued and found her to have biliary obstruction on
account of a mass in the head of her pancreas.  This mass was
ultimately visualized by CAT scan and seemed to be a resectable
lesion.  It was finally analyzed by endoscopic ultrasound and a
biopsy of this proved adenocarcinoma. The patient has been
informed of the diagnosis. She was admitted for planned Whipple
surgery.

MEDICAL HISTORY: Her medical history is significant for hypercholesterolemia,
sleep apnea, asthma, overactive bladder, arthritis, gout, HTN,
borderline hypothyroidism, obesity, and mild GERD.

MEDICATION ON ADMISSION: Protonix 40mg PO daily

ALLERGIES: Grass Pollen-Bermuda, Standard / [**Doctor Last Name **] / Dust & Pollen Filter
Mask

PHYSICAL EXAM: On Admission:
AVSS/afebrile
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B).
COR: RRR
ABD: Protuberant. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
.
At Discharge:
VS: 98.8 PO, 88, 144/88, 20, 94% RA
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B).
COR: RRR
ABD: Subcostal and umbilical incisions with steri-strips OTA
c/d/i. Appropriately tender to palpation along incision,
otherwsie soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Occassion alcohol. No tobacco or illicits.
Malignant neoplasm of head of pancreas,Hemorrhage complicating a procedure,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Acidosis,Obstruction of bile duct,Precipitous drop in hematocrit,Pure hypercholesterolemia,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Gout, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Obesity, unspecified,Esophageal reflux,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic cholecystitis
Mal neo pancreas head,Hemorrhage complic proc,Mal neo lymph intra-abd,Acidosis,Obstruction of bile duct,Drop, hematocrit, precip,Pure hypercholesterolem,Asthma NOS,Hypertension NOS,Gout NOS,Obstructive sleep apnea,Hypothyroidism NOS,Obesity NOS,Esophageal reflux,Abn react-anastom/graft,Chronic cholecystitis
Admission Date:  [**2187-8-22**]              Discharge Date:   [**2187-8-30**]

Date of Birth:  [**2128-5-2**]             Sex:   F

Service: SURGERY

Allergies:
Grass Pollen-Bermuda, Standard / [**Doctor Last Name **] / Dust & Pollen Filter
Mask

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Jaundice.

Major Surgical or Invasive Procedure:
[**2187-8-22**]:
1. Pylorus-preserving pancreaticoduodenectomy.
2. Open cholecystectomy.
3. Staging laparoscopy.
[**2187-8-23**]:
1. Reopening of recent laparotomy and control of intra-abdominal
bleeding.


History of Present Illness:
This very nice 59-year-old woman recently became jaundiced.  A
workup ensued and found her to have biliary obstruction on
account of a mass in the head of her pancreas.  This mass was
ultimately visualized by CAT scan and seemed to be a resectable
lesion.  It was finally analyzed by endoscopic ultrasound and a
biopsy of this proved adenocarcinoma. The patient has been
informed of the diagnosis. She was admitted for planned Whipple
surgery.


Past Medical History:
Her medical history is significant for hypercholesterolemia,
sleep apnea, asthma, overactive bladder, arthritis, gout, HTN,
borderline hypothyroidism, obesity, and mild GERD.

Her surgical history is significant for hysterectomy in [**2178**] as
well as a left knee arthroscopy in [**2183**].  She has had two
pilonidal cyst operations, tonsillectomy, and adenoidectomy in
the distant past.  Her GI procedures include the aforementioned
ERCP and EUS and she is currently stented.


Social History:
Occassion alcohol. No tobacco or illicits.

Family History:
Non-contributory.

Physical Exam:
On Admission:
AVSS/afebrile
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B).
COR: RRR
ABD: Protuberant. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
.
At Discharge:
VS: 98.8 PO, 88, 144/88, 20, 94% RA
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B).
COR: RRR
ABD: Subcostal and umbilical incisions with steri-strips OTA
c/d/i. Appropriately tender to palpation along incision,
otherwsie soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.

Pertinent Results:
On Admission:
[**2187-8-22**] 07:21PM   GLUCOSE-185* UREA N-12 CREAT-0.9 SODIUM-144
POTASSIUM-4.6 CHLORIDE-110* TOTAL CO2-21* ANION GAP-18
[**2187-8-22**] 07:21PM   CK(CPK)-314*
[**2187-8-22**] 07:21PM   CK-MB-5 cTropnT-<0.01
[**2187-8-22**] 07:21PM   CALCIUM-8.4 PHOSPHATE-4.4 MAGNESIUM-2.1
[**2187-8-22**] 07:21PM   WBC-11.9*# RBC-4.47 HGB-12.0 HCT-37.6 MCV-84
MCH-26.9* MCHC-32.0 RDW-15.7*
[**2187-8-22**] 07:21PM   PLT COUNT-307
[**2187-8-22**] 07:21PM   PT-12.5 INR(PT)-1.1
[**2187-8-22**] 04:54PM   GLUCOSE-157* LACTATE-3.4* NA+-141 K+-4.6
CL--105 TCO2-23
[**2187-8-22**] 04:54PM   HGB-13.3 calcHCT-40
[**2187-8-22**] 04:54PM   freeCa-1.18
[**2187-8-22**] 04:54PM   freeCa-1.18
.
At Discharge:
[**2187-8-26**] 04:42AM BLOOD WBC-11.8* RBC-3.20* Hgb-9.1* Hct-28.4*
MCV-89 MCH-28.5 MCHC-32.1 RDW-16.1* Plt Ct-172
[**2187-8-23**] 10:50AM BLOOD Neuts-73.4* Lymphs-22.0 Monos-3.9 Eos-0.1
Baso-0.6
[**2187-8-26**] 04:42AM BLOOD Plt Ct-172
[**2187-8-30**] 06:10AM BLOOD K-3.9
[**2187-8-23**] 10:50AM BLOOD ALT-649* AST-719* AlkPhos-83 Amylase-40
TotBili-2.0*
[**2187-8-30**] 06:10AM BLOOD Mg-1.9
.
Imaging:
[**2187-8-22**] Abdominal x-ray:
FINDINGS: Study is suboptimal secondary to patient body habitus
and patient motion. Nasogastric tube is seen extending into the
expected location of the stomach. There is a line.catheter
extending along the the right abdomen to the level of the T11
vertebral body. A horizontal line of surgical staples is seen
extending across the abdomen. Horizontal linear density in the
left upper quadrant is felt to most likely be artifactual.
Otherwise, no definite evidence of a radiopaque needle or other
surgical foreign body. Surgical staples also noted overlying the
upper left pelvis.
.
[**2187-8-22**] CXR:
Elevation of the right hemidiaphragm may be due to right lower
lobe atelectasis, common postoperative finding. Upper lungs are
clear. Pleural effusion is minimal if any. No pneumothorax.
Normal cardiomediastinal silhouette. Right jugular line tip
projects over the low SVC and a nasogastric tube passes into the
stomach.
.
Pathology:
SPECIMEN SUBMITTED: Jejunum, Whipple specimen, Gallbladder,
Whipple's node.

DIAGNOSIS:
1.  Gallbladder (A): Chronic cholecystitis.
2.  Lymph node, "Whipple," (B-C): One lymph node with no
carcinoma seen.
3.  Jejunum, segment (D): Unremarkable small intestine.
4.  Pancreas and duodenum, Whipple procedure (E-T):
Adenocarcinoma, moderately differentiated, 2.5 cm, See Synoptic
Report.
Pancreas (Exocrine): Resection Synopsis

MACROSCOPIC

Specimen Type:  Pancreaticoduodenectomy, partial pancreatectomy.
Tumor Site:  Pancreatic head.
Tumor Size
    Greatest dimension:  2.5 cm.  Additional dimensions:  1.8 cm
x 1.6 cm.
Other organs/Tissues Received:  Gallbladder, Jejunum. Whipple's
lymph node.

MICROSCOPIC

Histologic Type:  Ductal adenocarcinoma.
Histologic Grade:  G2:  Moderately differentiated.

EXTENT OF INVASION

Primary Tumor:  pT3:  Tumor extends beyond the pancreas but
without involvement of the celiac axis or the superior
mesenteric artery.
Regional Lymph Nodes:  pN1b:  Metastasis in multiple regional
lymph nodes.
Lymph Nodes
    Number examined:  20.
    Number involved:  4.
Distant metastasis:  pMX:  Cannot be assessed.
Margins:
    Margins uninvolved by invasive carcinoma:
        Distance from closest margin:  5 mm.  Specified margin:
Posterior retroperitoneal.
Venous/Lymphatic vessel invasion:  Absent.
Perineural invasion:  Present.
Additional Pathologic Findings:  Chronic pancreatitis.
Comments:  Adenocarcinoma extends into peripancreatic fat and
into the duodenal mucosa.

Clinical: Pancreatic cancer.
Gross:

The specimen is received fresh in four parts, each labeled with
the patient's name, "[**Known lastname 60542**], [**Known firstname **]" and the medical record
number.

Part 1 is additionally labeled "gallbladder." It consists of a
gallbladder measuring 12.0 x 2.7 x 2.3 cm. The gallbladder is
opened to reveal velvety pink mucosa.  There are no stones and
approximately 10 cc of residual, green sludgy bile.   Part 1 is
represented in cassette A.

Part 2 is additionally labeled "Whipple's node." It consists of
a lymph node, measuring 2.3 1.7 x 0.5 cm.  The lymph node is
bisected and submitted entirely in B-C.

Part 3 is additionally labeled "jejunum." It consists of a
segment of jejunum measuring 14.5 cm in length and 5.8 cm in
circumference. The serosal surface is smooth and shiny. The
resection margins are stapled.  The bowel is opened to reveal
unremarkable tan and pink mucosa.  The resection margins are
submitted in cassette D.

Part 4 is additionally labeled "Whipple." It consists of a
pancreaticoduodenectomy specimen that measures 12.8 x 5.2 x 4.5
cm in overall dimension. The pancreatic portion is composed of
the head and measures 5.2 x 4.5 x 2.6 cm.  The duodenal segment
measures 12.8 cm in length and 6.4 cm in circumference.  Both
proximal and distal resection margins are stapled with staple
lines at each measuring 4.5 cm. It is oriented by the surgeon
with a black silk suture indicating bile duct, a blue suture
indicating the pancreatic neck margin and a green suture
indicating the superior mesenteric artery. The posterior
retroperitoneal margin is identified and is inked [**Location (un) 2452**].  The
pancreatic parenchymal margin is inked in blue. The uncinate
margin is inked black. The duodenum is opened to reveal a
prominent fold, 1.2 cm from the proximal  resection margin. The
bile duct segment measures 8.5 cm from ampulla to the distal
end. A segment of the cystic duct is present and joins the
common bile duct.  The bile duct is patent. The bile duct is
opened to reveal unremarkable mucosa. The pancreas is serially
sliced to reveal a tumor that measures 2.5 x 1.8 x 1.6 cm and
that lies 0.5 cm from the posterior retroperitoneal margin.  The
uninvolved pancreatic parenchyma is unremarkable.  The
peripancreatic adipose tissue is dissected to reveal several
potential lymph nodes.   It is represented as follows: E =
common bile duct margin and cystic duct, F = pancreatic
parenchymal margin, G = uncinate/SMA margin, H = distal duodenal
resection margin, I = proximal duodenal resection margin, J =
duodenum with prominent fold,  K = ampulla, L = chronic
pancreatitis, M = tumor, N = tumor in relation to posterior
retroperitoneal margin, O-P = tumor, Q-R = lymph nodes submitted
whole, S-T = remainder of peri-pancreatic fat.

Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2187-8-22**] for treatment of a pancreatic mass causing obstructive
jaundice.  On [**2187-8-22**], the patient underwent pylorus-preserving
pancreaticoduodenectomy (Whipple), open cholecystectomy and
staging laparoscopy. In the PACU, the patient was noted to be
tachycardic with a SBP in the 90's and a urine output averaging
10-15mL/Hr. Immediate post-operative HCT was 37. Serial
hematocrits were followed, which progressively declined to a low
of 24.1 by 1am on POD#1. She remained hypotensive and oliguric.
EKGs and cardiac enzymes were negative x2. She was transferred
to the SICU for closer monitoring.  She received 2units of PRBCs
and her HCT improved to 31. Her pressures, however, remained in
the 80s to mid 90s, despite being on two pressors. She also
became progressively acidemic, with her pH going from 7.2 to
7.13, with a base defecit of -12 and lactate of 9.  Later in the
AM, she again dropped her HCT to 28 and remained acidemic. At
this point, given that she did not responded to transfusions,
and remained hypotensive with a significant concern for
postoperative bleeding, the patient was taken back to the OR for
exploratory laparotomy that revealed a clot by the SMA, which
was successfully evacuated and post-operative bleeding
controlled (reader referred to the Operative Notes for details).
Overnight, she was placed on CPAP. She received three dose
peri-operative IV Cipro and Cefazolin. She remained in the SICU
until POD#3, during which time she remained hemodynamically
stable.
.
Later on POD#3, the patient was transferred to the floor.  She
arrived on the floor NPO except medications, on IV fluids, with
a foley catheter and a JP drain in place, and Dilaudid PCA for
pain control. Once on the floor, the [**Hospital 228**] hospital course
was otherwise uneventful and followed the Whipple Clinical
Pathway.  Post-operative pain was initially well controlled with
the Dilaudid PCA, which was converted to oral pain medication
when tolerating clear liquids. The NG tube was discontinued on
POD#3 prior to transfer to the floor, and the foley catheter
discontinued at midnight of POD#4. The patient subsequently
voided without problem. The patient was started on sips of
clears on POD#4, which was progressively advanced as tolerated
to a regular diet by POD#7.  JP amylase was sent in the evening
of  POD#6; the JP was discontinued on POD#7 as the output and
amylase level were low.
.
On the floor, the patient ambulated early and frequently, was
adherent with respiratory toilet and incentive spirrometry, and
actively participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay. The patient's blood sugar was monitored regularly
throughout the stay; sliding scale insulin was administered when
indicated, but the patient did not require insulin for home
discharge.
.
At the time of discharge on [**2187-8-30**], the patient was doing
well, afebrile with stable vital signs.  The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and pain was well controlled.  Staples were removed,
and steri-strips placed. The patient was discharged home with
VNA services. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.

Medications on Admission:
Protonix 40mg PO daily

Discharge Medications:
1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
Disp:*120 Tablet(s)* Refills:*0*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*4*
3. Hydromorphone 2 mg Tablet Sig: 1-3 Tablets PO Q3-4 HOURS: PRN
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*1*
5. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*0*
6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*0*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for constipation: Over-the-counter.


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 1474**] VNA

Discharge Diagnosis:
1. Pancreatic cancer.
2. Obstructive jaundice.
3. Postoperative hemorrhage.


Discharge Condition:
Good


Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency  Department for any of the following:

*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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 experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours.  Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.

Please resume all regular home medications , unless specifically
advised not to take a particular medication.  Also, please take
any new medications as prescribed.

Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids.  Avoid lifting
weights greater than [**4-8**] lbs until you follow-up with your
surgeon.

Avoid driving or operating heavy machinery while taking pain
medications.

Incision Care:

*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water.  Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips 7-10 days after surgery.

Followup Instructions:
Please call ([**Telephone/Fax (1) 35953**] to arrange a follow-up appointment
with Dr. [**Last Name (STitle) **] (PCP) in [**1-2**] weeks.
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2187-9-14**] 8:45. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**].



Completed by:[**2187-8-30**]
{'Malignant neoplasm of head of pancreas,Hemorrhage complicating a procedure,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Acidosis,Obstruction of bile duct,Precipitous drop in hematocrit,Pure hypercholesterolemia,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Gout, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Obesity, unspecified,Esophageal reflux,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic cholecystitis'}


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: Jaundice.

PRESENT ILLNESS: This very nice 59-year-old woman recently became jaundiced.  A
workup ensued and found her to have biliary obstruction on
account of a mass in the head of her pancreas.  This mass was
ultimately visualized by CAT scan and seemed to be a resectable
lesion.  It was finally analyzed by endoscopic ultrasound and a
biopsy of this proved adenocarcinoma. The patient has been
informed of the diagnosis. She was admitted for planned Whipple
surgery.

MEDICAL HISTORY: Her medical history is significant for hypercholesterolemia,
sleep apnea, asthma, overactive bladder, arthritis, gout, HTN,
borderline hypothyroidism, obesity, and mild GERD.

MEDICATION ON ADMISSION: Protonix 40mg PO daily

ALLERGIES: Grass Pollen-Bermuda, Standard / [**Doctor Last Name **] / Dust & Pollen Filter
Mask

PHYSICAL EXAM: On Admission:
AVSS/afebrile
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B).
COR: RRR
ABD: Protuberant. Soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.
.
At Discharge:
VS: 98.8 PO, 88, 144/88, 20, 94% RA
GEN: Well appearing in NAD.
HEENT: Sclerae anicteric. O-P clear.
NECK: Supple.
LUNGS: CTA(B).
COR: RRR
ABD: Subcostal and umbilical incisions with steri-strips OTA
c/d/i. Appropriately tender to palpation along incision,
otherwsie soft/NT/ND.
EXTREM: No c/c/e.
NEURO: A+Ox3. Non-focal/grossly intact.

FAMILY HISTORY: Non-contributory.

SOCIAL HISTORY: Occassion alcohol. No tobacco or illicits. 

### Response:
{'Malignant neoplasm of head of pancreas,Hemorrhage complicating a procedure,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Acidosis,Obstruction of bile duct,Precipitous drop in hematocrit,Pure hypercholesterolemia,Asthma, unspecified type, unspecified,Unspecified essential hypertension,Gout, unspecified,Obstructive sleep apnea (adult)(pediatric),Unspecified acquired hypothyroidism,Obesity, unspecified,Esophageal reflux,Surgical operation with anastomosis, bypass, or graft, with natural or artificial tissues used as implant causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic cholecystitis'}
