CHIEF COMPLAINT: palpitations

PRESENT ILLNESS: Mr. [**Known lastname **] is a 57 year old male with a past medical history
significant for cholangiocarcinoma (unresectable and s/p chemo
w/ gemcitabine and cisplatin), hypertension, and recent GIB
(ischemic v. infectious colitis) who presents with SVT to 180s
from clinic.
.
The patient was in his usual state of health, with chronic
abdominal pain, and was seen today in clinic by Dr. [**Last Name (STitle) **] for
a third round of chemotherapy. While sitting in the chair in the
waiting room, he felt his heart beat "fast." There he was found
to have SVT to 180s and was sent to the ED. His BP at the time
was 102/60. He denies any chest pain, cough, shortness of
breath, lightheadedness, nausea, or vomiting. At baseline, he
ambulates independently and without dyspnea on exertion. Of
note, he also denies noticing any lower extremity edema, fevers,
chills, diarrhea, constipation, melena or BRBPR. He endorses
~30lb weight loss over the course of 3 months.
.
In the ED, initial VS were: HR in 170s. Vagal maneuver was
attempted and failed. He was given adenosine 6mg and converted
to sinus tachycardia. He remained persistantly tachycardic to
120s and so a CTA was done that showed bilateral subsegmental
PEs. His labs were notable for negative CE, leukocytosis of
12.4, hgb/hct 9.9/29.9. On exam he was guaiac neg. Heme/onc was
consulted and recommended heparin gtt without bolus. VS on
transfer were: 109, 124/96, 25, 100% on 2L.
.
Notably, he was recently hospitalized ([**Date range (1) 84012**]) for BRBPR s/p
colonoscopy significant for segmental colitis with biopsies
suggestive of ischemic vs infectious colitis. On that admission,
he developed a fever 2 days and CT scan showed likely colitis;
he was treated with Cipro, Flagyl, and Asacol (which was
discontinued recently by Dr. [**Last Name (STitle) 9916**]. He did not receive any
blood products at that time, and his hct on discharge was 27.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness. Denied nausea, vomiting,
diarrhea, constipation. No recent change in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: #. Cholangiocarcinoma:
- [**9-/2187**] presented with abdominal pain and jaundice.
Percutaneous transhepatic cholangiography was performed on [**10-24**]
w/ malignant cells on brushing.
- He was taken to operating [**10/2187**], found to have
extensive common hepatic involvement and extension into the
liver duodenum as well as head of the pancreas and was
unresectable.
- He is s/p bilateral metallic biliary stent placement on
[**2187-11-22**] (removed on [**11-22**]).
- Started palliative chemotherapy with gemcitobine and cisplatin
(Cycle 1 [**2187-12-19**], cycle ends [**2188-1-8**])
#. Hypertension
#. GI Bleed: s/p sigmoidoscopy [**1-4**] w/ ulcerated friable colon
biopsy c/w ischemic type colitis.

MEDICATION ON ADMISSION: Docusate Sodium 100 [**Hospital1 **]
Hydromorphone 2 mg q4hr prn
MSIR 15 mg Q12
Prochlorperazine Maleate 10 mg every 4-6 hours prn
Lorazepam 1 mg every 6-8 hours prn
ZOFRAN ODT 8 mg Tablet, Rapid Dissolve every 6-8 hours as needed
for nausea.
Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: [**12-15**] once a
day.
Sennosides 8.6 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: BP 133/88 HR 104 RR 20 O2 100 2L O2
General: Alert, oriented, laying in bed, conversant and
following commands, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Surgical scar appreciated along RUQ, abdomen mildly
tense and tender to palpation at mid-epigastric area, no
guarding/rebound tenderness and normal bowel sounds
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, neg pain on dorsiflexion
Skin: No jaundice
Neuro: A&Ox3, tongue midline, PERRL, EOMI, [**4-16**] SCM/trap, neg
babinski, gait deferred

FAMILY HISTORY: No history of GI cancer.

SOCIAL HISTORY: He works in a restaurant. He moved to the USA 20 years ago. He
is married with 5 kids, the oldest 33 years old. He speaks
minimal English. Wife speaks no English. Children speak English
well. He smoked 1 pack for many years but quit 20 years ago. He
denies alcohol or illicit drug use.
Other specified cardiac dysrhythmias,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Malignant neoplasm of intrahepatic bile ducts
Cardiac dysrhythmias NEC,Pulm embol/infarct NEC,Ac DVT/embl low ext NOS,Mal neo intrahepat ducts
Admission Date:  [**2188-1-16**]              Discharge Date:   [**2188-1-22**]

Date of Birth:  [**2130-9-14**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
palpitations

Major Surgical or Invasive Procedure:
IVC filter

History of Present Illness:
Mr. [**Known lastname **] is a 57 year old male with a past medical history
significant for cholangiocarcinoma (unresectable and s/p chemo
w/ gemcitabine and cisplatin), hypertension, and recent GIB
(ischemic v. infectious colitis) who presents with SVT to 180s
from clinic.
.
The patient was in his usual state of health, with chronic
abdominal pain, and was seen today in clinic by Dr. [**Last Name (STitle) **] for
a third round of chemotherapy. While sitting in the chair in the
waiting room, he felt his heart beat "fast." There he was found
to have SVT to 180s and was sent to the ED. His BP at the time
was 102/60. He denies any chest pain, cough, shortness of
breath, lightheadedness, nausea, or vomiting. At baseline, he
ambulates independently and without dyspnea on exertion. Of
note, he also denies noticing any lower extremity edema, fevers,
chills, diarrhea, constipation, melena or BRBPR. He endorses
~30lb weight loss over the course of 3 months.
.
In the ED, initial VS were: HR in 170s. Vagal maneuver was
attempted and failed. He was given adenosine 6mg and converted
to sinus tachycardia. He remained persistantly tachycardic to
120s and so a CTA was done that showed bilateral subsegmental
PEs. His labs were notable for negative CE, leukocytosis of
12.4, hgb/hct 9.9/29.9. On exam he was guaiac neg. Heme/onc was
consulted and recommended heparin gtt without bolus. VS on
transfer were: 109, 124/96, 25, 100% on 2L.
.
Notably, he was recently hospitalized ([**Date range (1) 84012**]) for BRBPR s/p
colonoscopy significant for segmental colitis with biopsies
suggestive of ischemic vs infectious colitis. On that admission,
he developed a fever 2 days and CT scan showed likely colitis;
he was treated with Cipro, Flagyl, and Asacol (which was
discontinued recently by Dr. [**Last Name (STitle) 9916**]. He did not receive any
blood products at that time, and his hct on discharge was 27.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness. Denied nausea, vomiting,
diarrhea, constipation. No recent change in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias.


Past Medical History:
#. Cholangiocarcinoma:
- [**9-/2187**] presented with abdominal pain and jaundice.
Percutaneous transhepatic cholangiography was performed on [**10-24**]
w/ malignant cells on brushing.
- He was taken to operating [**10/2187**], found to have
extensive common hepatic involvement and extension into the
liver duodenum as well as head of the pancreas and was
unresectable.
- He is s/p bilateral metallic biliary stent placement on
[**2187-11-22**] (removed on [**11-22**]).
- Started palliative chemotherapy with gemcitobine and cisplatin
(Cycle 1 [**2187-12-19**], cycle ends [**2188-1-8**])
#. Hypertension
#. GI Bleed: s/p sigmoidoscopy [**1-4**] w/ ulcerated friable colon
biopsy c/w ischemic type colitis.


Social History:
He works in a restaurant. He moved to the USA 20 years ago. He
is married with 5 kids, the oldest 33 years old. He speaks
minimal English. Wife speaks no English. Children speak English
well. He smoked 1 pack for many years but quit 20 years ago. He
denies alcohol or illicit drug use.


Family History:
No history of GI cancer.

Physical Exam:
Vitals: BP 133/88 HR 104 RR 20 O2 100 2L O2
General: Alert, oriented, laying in bed, conversant and
following commands, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Surgical scar appreciated along RUQ, abdomen mildly
tense and tender to palpation at mid-epigastric area, no
guarding/rebound tenderness and normal bowel sounds
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, neg pain on dorsiflexion
Skin: No jaundice
Neuro: A&Ox3, tongue midline, PERRL, EOMI, [**4-16**] SCM/trap, neg
babinski, gait deferred


Pertinent Results:
CTA
1. Bilateral segmental and subsegmental pulmonary embolism
without evidence of right heart strain.
2. Nodular mural atheroma in the descending thoracic aorta with
configuration worrisome for future embolization.
3. Hypoenhancing infiltrative hepatic mass extending into the
porta hepatis and left hepatic lobe compatible with known
cholangiocarcinoma. Associated biliary obstruction again noted.
4. Increasing ascites with persistent multiple nodular
peritoneal implants.
5. Persistent pancreatic ductal dilation.

ECHO
The left atrium is normal in size. There is a 2x2 cm echodensity
posterior to the left atrium (cine loop 52), probably in the
posterior mediastinum. It is outside the heart and anatomically
could be associated with the esophagus or the surrounding
structures. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is borderline pulmonary artery systolic hypertension. Very
small pericardial effusion. There is an anterior space which
most likely represents a fat pad. There are no echocardiographic
signs of tamponade. No right atrial or right ventricular
diastolic collapse is seen.

IMPRESSION: Very small pericardial effusion without signs of
tamponade. Normal global and regional biventricular systolic
function. No pulmonary hypertension or clinically-significant
valvular disease seen. Probable extracardiac posterior
mediastinal mass.

Compared with the prior study (images reviewed) of [**2187-12-20**],
cardiac findings are similar. The extracardiac mass was not
appreciated on the prior study. Findings discussed with Dr. [**Last Name (STitle) **]
at 1650 hours on the day of the study.

Ultrasound LE:
Occlusive DVT in one of the two right posterior tibial veins. R
[**Doctor Last Name **] V patent.  No other thrombus noted.

ADMISSION LABS:

[**2188-1-16**] 02:25PM BLOOD WBC-12.4*# RBC-3.25* Hgb-9.9* Hct-29.9*
MCV-92 MCH-30.5 MCHC-33.1 RDW-16.5* Plt Ct-510*
[**2188-1-16**] 02:25PM BLOOD Neuts-79.1* Lymphs-14.9* Monos-5.0
Eos-0.4 Baso-0.6
[**2188-1-16**] 02:25PM BLOOD PT-12.5 PTT-21.7* INR(PT)-1.1
[**2188-1-16**] 02:25PM BLOOD Glucose-115* UreaN-10 Creat-0.7 Na-135
K-3.5 Cl-101 HCO3-28 AnGap-10
[**2188-1-16**] 02:25PM BLOOD CK(CPK)-50
[**2188-1-17**] 05:56AM BLOOD ALT-19 AST-32 LD(LDH)-219 AlkPhos-117
TotBili-0.6
[**2188-1-16**] 02:25PM BLOOD Calcium-8.9 Phos-3.0 Mg-2.3

DISCHARGE LABS:
[**2188-1-22**] 07:15AM BLOOD WBC-9.3 RBC-2.88* Hgb-9.3* Hct-27.1*
MCV-94 MCH-32.2* MCHC-34.2 RDW-16.6* Plt Ct-282
[**2188-1-20**] 06:45AM BLOOD Neuts-69.8 Lymphs-22.8 Monos-5.6 Eos-1.3
Baso-0.4
[**2188-1-21**] 06:10AM BLOOD PT-12.0 PTT-21.4* INR(PT)-1.0
[**2188-1-22**] 07:15AM BLOOD Glucose-92 UreaN-7 Creat-0.5 Na-136 K-3.7
Cl-106 HCO3-22 AnGap-12
[**2188-1-21**] 06:10AM BLOOD ALT-17 AST-23 AlkPhos-111 TotBili-0.8
[**2188-1-22**] 07:15AM BLOOD Albumin-3.7 Calcium-8.5 Phos-3.5 Mg-2.2

Brief Hospital Course:
57M with cholangiocarcinoma (unresectable and s/p chemo w/
gemcitabine and cisplatin), hypertension, and recent GIB
(ischemic v. infectious colitis) who presents with SVT to 180s
from clinic and was found to have bilateral subsegmental PEs and
right LE DVT. Initially admitted to the ICU for monitoring and
then transferred to the oncology service.
.
# Pulmonary Embolism / DVT: Patient was started on heparin gtt
for bilateral subsegmental PE noted on CTA and DVT on LENI then
switched to lovenox SQ. She had IVC filter placed today due to
hx of GI bleed and the risk of bleeding with anticoagulation.
She tolerated the procedure well and had no signs of bleeding.
All stools were guaiac negative. Her Hct was stable at 27 on the
day of discharge.
.
#. History of BRBPR / ischemic colitis: Sigmoidoscopy [**12-23**] sig
for biopsies consistent with ischemic colitis though patient was
also treated for possible infectious colitis. He was recently
seen by his outpatient GI doctor, Dr. [**Last Name (STitle) 9916**], who stopped
his Asacol and has sent off stool cx for E. coli and c diff
which were negative. As noted above she was guaiac negative and
HCT stayed stable.
.
.
#. SVT: Likely AVNRT/AVRT with termination by adenosine. In the
[**Hospital Unit Name 153**] had a brief episodes of SVT, but is currently in sinus. Has
had episodes of AVNRT/AVRT in the past controlled by
metoprolol/amiodarone though these have been held since last
admission, given concern for bleed. Metoprolol was restarted on
[**2188-1-18**] at higher dose at 25mg TID and was started on diltiazen
30mg QID (will change to long acting prior to discharge) for
rate control. Pt had short runs, only a few seconds of sinus
tachycardia, asymptomatic. She also had aggressive electrolytes
control. PE management as outlined above.
.
#. Metastatic Cholangiocarcinoma: Preliminary read is concerning
for progression of metastatic disease, increase size of hepatic
mass, and worsening ascites. Prior CT scan notable for sclerotic
lesion in sacrum. Prior head CT w/ multiple subcentimeter low
density regions (likely small vessel disease) and no evidence of
obvious mets. Followed by Dr. [**Last Name (STitle) 84321**] as outpatient and is
currently undergoing palliative chemotherapy. Pt also has
increase in abdominal girth and fluid shift on exam consistant
with ascitis. She had therapeutic tap with 1 L removed. She was
continued on home meds including Megace, pain management with
dilaudid PRN, antiemetics with Compazine/Zofran and ativan prn.

.
# FEN: Regular diet tolerating well, replete electrolytes PRN.
.
# PPx: Pain control with dilaudid prn, bowel regimen, DVT PPx
lovenox
.
# Comm: With patient
# Code: FULL
# Dispo: pending above

Medications on Admission:
Docusate Sodium 100 [**Hospital1 **]
Hydromorphone 2 mg q4hr prn
MSIR 15 mg Q12
Prochlorperazine Maleate 10 mg every 4-6 hours prn
Lorazepam 1 mg every 6-8 hours prn
ZOFRAN ODT 8 mg Tablet, Rapid Dissolve every 6-8 hours as needed
for nausea.
Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: [**12-15**] once a
day.
Sennosides 8.6 mg [**Hospital1 **]


Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea.
3. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for nausea, anxiety.
4. Ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea.
5. Megestrol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day.
Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0*
8. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1)
Capsule, Sustained Release PO DAILY (Daily).
Disp:*30 Capsule, Sustained Release(s)* Refills:*0*
9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO twice a day.
10. Dilaudid 2 mg Tablet Sig: One (1) Tablet PO every 4-6 hours
as needed for pain.
11. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
cholangiocarcinoma
bilateral subsegmental PE
DVT
AVNRT/AVRT


Discharge Condition:
Mental Status:Clear and coherent
Level of Consciousness:Alert and interactive
Activity Status:Ambulatory - Independent


Discharge Instructions:
You were admitted to [**Hospital1 18**] for a fast heart rate and you were
found to have a pulmonary embolism and blood clot in your right
leg. You were initially treated with anticoagulation (blood
thining medication) and medication to decrease your heart rate.
You had a filter placed in your vein to hopefully prevent clots
from moving to your lungs. You did well after your procedure.
You were also very uncomfortable due to fluid in your abdomen.
You had fluid removed from your abdomen and you are feeling
better. You also had episodes of increase heart rate and you
were started on medication to lower your heart rate.

We added the following medications to your regimen:
-Started you on metoprolol XL 75mg once daily
-Diltiazem 120mg orally once daily
-Omeprazole 20mg daily

We have not made any changes to your other medications.

You will need to follow-up tomorrow with oncology as listed belw
and with cardiology for your fast heart rate.

Followup Instructions:
Cardiology: You have an appointment with Dr. [**Last Name (STitle) 84322**] on
[**2188-2-12**] at 11:00 AM on [**Hospital Ward Name 23**] building [**Location (un) 436**], Cardiology
Phone # [**Telephone/Fax (1) 62**]

ONCOLOGY: You have an appointment with Dr. [**Last Name (STitle) **] tomorrow at
1:00PM
On [**Hospital Ward Name 23**] [**Location (un) **]
([**Telephone/Fax (1) 27917**]
{'Other specified cardiac dysrhythmias,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Malignant neoplasm of intrahepatic bile ducts'}


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: palpitations

PRESENT ILLNESS: Mr. [**Known lastname **] is a 57 year old male with a past medical history
significant for cholangiocarcinoma (unresectable and s/p chemo
w/ gemcitabine and cisplatin), hypertension, and recent GIB
(ischemic v. infectious colitis) who presents with SVT to 180s
from clinic.
.
The patient was in his usual state of health, with chronic
abdominal pain, and was seen today in clinic by Dr. [**Last Name (STitle) **] for
a third round of chemotherapy. While sitting in the chair in the
waiting room, he felt his heart beat "fast." There he was found
to have SVT to 180s and was sent to the ED. His BP at the time
was 102/60. He denies any chest pain, cough, shortness of
breath, lightheadedness, nausea, or vomiting. At baseline, he
ambulates independently and without dyspnea on exertion. Of
note, he also denies noticing any lower extremity edema, fevers,
chills, diarrhea, constipation, melena or BRBPR. He endorses
~30lb weight loss over the course of 3 months.
.
In the ED, initial VS were: HR in 170s. Vagal maneuver was
attempted and failed. He was given adenosine 6mg and converted
to sinus tachycardia. He remained persistantly tachycardic to
120s and so a CTA was done that showed bilateral subsegmental
PEs. His labs were notable for negative CE, leukocytosis of
12.4, hgb/hct 9.9/29.9. On exam he was guaiac neg. Heme/onc was
consulted and recommended heparin gtt without bolus. VS on
transfer were: 109, 124/96, 25, 100% on 2L.
.
Notably, he was recently hospitalized ([**Date range (1) 84012**]) for BRBPR s/p
colonoscopy significant for segmental colitis with biopsies
suggestive of ischemic vs infectious colitis. On that admission,
he developed a fever 2 days and CT scan showed likely colitis;
he was treated with Cipro, Flagyl, and Asacol (which was
discontinued recently by Dr. [**Last Name (STitle) 9916**]. He did not receive any
blood products at that time, and his hct on discharge was 27.
.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough, shortness of
breath. Denied chest pain or tightness. Denied nausea, vomiting,
diarrhea, constipation. No recent change in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: #. Cholangiocarcinoma:
- [**9-/2187**] presented with abdominal pain and jaundice.
Percutaneous transhepatic cholangiography was performed on [**10-24**]
w/ malignant cells on brushing.
- He was taken to operating [**10/2187**], found to have
extensive common hepatic involvement and extension into the
liver duodenum as well as head of the pancreas and was
unresectable.
- He is s/p bilateral metallic biliary stent placement on
[**2187-11-22**] (removed on [**11-22**]).
- Started palliative chemotherapy with gemcitobine and cisplatin
(Cycle 1 [**2187-12-19**], cycle ends [**2188-1-8**])
#. Hypertension
#. GI Bleed: s/p sigmoidoscopy [**1-4**] w/ ulcerated friable colon
biopsy c/w ischemic type colitis.

MEDICATION ON ADMISSION: Docusate Sodium 100 [**Hospital1 **]
Hydromorphone 2 mg q4hr prn
MSIR 15 mg Q12
Prochlorperazine Maleate 10 mg every 4-6 hours prn
Lorazepam 1 mg every 6-8 hours prn
ZOFRAN ODT 8 mg Tablet, Rapid Dissolve every 6-8 hours as needed
for nausea.
Megestrol 400 mg/10 mL (40 mg/mL) Suspension Sig: [**12-15**] once a
day.
Sennosides 8.6 mg [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: BP 133/88 HR 104 RR 20 O2 100 2L O2
General: Alert, oriented, laying in bed, conversant and
following commands, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: Surgical scar appreciated along RUQ, abdomen mildly
tense and tender to palpation at mid-epigastric area, no
guarding/rebound tenderness and normal bowel sounds
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, neg pain on dorsiflexion
Skin: No jaundice
Neuro: A&Ox3, tongue midline, PERRL, EOMI, [**4-16**] SCM/trap, neg
babinski, gait deferred

FAMILY HISTORY: No history of GI cancer.

SOCIAL HISTORY: He works in a restaurant. He moved to the USA 20 years ago. He
is married with 5 kids, the oldest 33 years old. He speaks
minimal English. Wife speaks no English. Children speak English
well. He smoked 1 pack for many years but quit 20 years ago. He
denies alcohol or illicit drug use. 

### Response:
{'Other specified cardiac dysrhythmias,Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of unspecified deep vessels of lower extremity,Malignant neoplasm of intrahepatic bile ducts'}
