CHIEF COMPLAINT: Nausea/vomiting/jaundice; mass causing duodenal and biliary
obstruction

PRESENT ILLNESS: Chief Complaint:  nausea, vomiting, jaundice

MEDICAL HISTORY: None documented

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
General: AAOx3, NAD, grossly jaundiced
HEENT: Sclera severely icteric, MM relatively dry, oropharynx
clear, [**Name (NI) 3899**], PERRL
CV: RRR, + S1/S2, 2/6 systolic murmur best heard at RUSB, no
rubs or gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: No cancer in the family. Father died of heart disease at age of
88. Mother died of diabetes.

SOCIAL HISTORY: Lives with family. No alcohol or tobacco use.
[**Doctor First Name **]-Scientist since [**2105**].
Acquired hypertrophic pyloric stenosis,Obstruction of bile duct,Acute kidney failure, unspecified,Acquired coagulation factor deficiency,Secondary malignant neoplasm of small intestine including duodenum,Hypotension, unspecified,Hypovolemia,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Other malignant neoplasm without specification of site,Persistent vomiting,Loss of weight,Other alteration of consciousness,Unspecified disease of pancreas
Acq pyloric stenosis,Obstruction of bile duct,Acute kidney failure NOS,Acq coagul factor defic,Sec malig neo sm bowel,Hypotension NOS,Hypovolemia,Cholelith w cholecys NEC,Malignant neoplasm NOS,Persistent vomiting,Abnormal loss of weight,Other alter consciousnes,Pancreatic disease NOS
Admission Date:  [**2143-8-13**]              Discharge Date:   [**2143-9-4**]

Date of Birth:  [**2072-3-4**]             Sex:   F

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2836**]
Chief Complaint:
Nausea/vomiting/jaundice; mass causing duodenal and biliary
obstruction


Major Surgical or Invasive Procedure:
Percutaneous transhepatic cholangiography/biliary decompression
([**2143-8-16**])

Exploratory laparotomy with biopsy of periduodenal nodule,
cholecystectomy, Roux-en-Y, choledochojejunostomy and
gastrojejunostomy ([**2143-8-23**])


History of Present Illness:
Chief Complaint:  nausea, vomiting, jaundice

Reason for MICU transfer:  hypotension after nausea

71F [**Doctor First Name **] Scientist who presented with a 2 month history of
abdominal pain, nausea and vomiting.  The patient and her family
reported that she had not been able to eat well and had lost
15-20 lbs.  Her family first noted that she became jaundiced 1
month prior.  She denied fevers, chills, diarrhea and
constipation. Her last formed bowel movement had been 2 days
prior.  She denied BRBPR. She denied pain radiating to her back.

The patient resides in [**Location (un) 10123**], NY and came to Massachussetts for
medical care at the [**Doctor First Name **] Scientist "Benevolant Association"
a non-medical care  facility.  It was there that she fell due to
weakness and hit her head.  She had no loss of consciousness and
minor facial abrasions. She decided on
[**8-13**] to pursue further medical care and arranged transport to
the [**Hospital1 18**] ED.

Past Medical History:
None documented

Social History:
Lives with family. No alcohol or tobacco use.
[**Doctor First Name **]-Scientist since [**2105**].


Family History:
No cancer in the family. Father died of heart disease at age of
88. Mother died of diabetes.


Physical Exam:
Admission Exam:
General: AAOx3, NAD, grossly jaundiced
HEENT: Sclera severely icteric, MM relatively dry, oropharynx
clear, [**Name (NI) 3899**], PERRL
CV: RRR, + S1/S2, 2/6 systolic murmur best heard at RUSB, no
rubs or gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. +1
edema b/l
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.

Exam upon discharge:
Vitals:
General: AAOx3, NAD
HEENT:
CV: RRR, +S1/S2, systolic murmur
Resp: CTAB
Abdomen: Right subcostal incision open to air with steri strips
and c/d/i.
Ext: no cyanosis/clubbing/edema, warm, well-perfused
bilaterally, 2+ distal pulses bilaterally


Pertinent Results:
Admission Labs:
[**2143-8-13**] 09:35AM BLOOD WBC-16.4* RBC-4.99 Hgb-15.2 Hct-43.9
MCV-88 MCH-30.4 MCHC-34.6 RDW-17.7* Plt Ct-424
[**2143-8-13**] 09:35AM BLOOD Neuts-85.6* Lymphs-9.1* Monos-4.9 Eos-0.1
Baso-0.2
[**2143-8-13**] 09:35AM BLOOD PT-16.5* PTT-33.0 INR(PT)-1.6*
[**2143-8-13**] 09:35AM BLOOD Glucose-126* UreaN-52* Creat-1.6* Na-126*
K-2.0* Cl-69* HCO3-39* AnGap-20
[**2143-8-13**] 09:35AM BLOOD ALT-128* AST-174* AlkPhos-530*
TotBili-42.4* DirBili-28.8* IndBili-13.6
[**2143-8-13**] 09:35AM BLOOD Lipase-48
[**2143-8-13**] 09:35AM BLOOD Albumin-3.4* Calcium-9.7 Phos-2.7 Mg-3.3*
[**2143-8-13**] 09:48AM BLOOD Lactate-2.7*
[**2143-8-13**] 02:55PM URINE Color-DkAmb Appear-Hazy Sp [**Last Name (un) **]-1.014
[**2143-8-13**] 02:55PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-LG Urobiln-NEG pH-6.0 Leuks-NEG
[**2143-8-13**] 02:55PM URINE RBC-<1 WBC-3 Bacteri-FEW Yeast-NONE Epi-0
[**2143-8-13**] 02:55PM URINE CastHy-5*
[**2143-8-13**] 02:55PM URINE Mucous-RARE

CT Head w/o contrast [**8-13**]:  There is no evidence of hemorrhage,
edema, mass, mass effect, or infarction.  The ventricles and
sulci are normal in size and configuration for the patient's
age.  The basal cisterns are patent.  There is preservation of
[**Doctor Last Name 352**]-white matter differentiation.  Atherosclerotic
calcifications are noted in the internal carotid arteries.  No
fracture is identified.  The visualized paranasal sinuses,
mastoid air cells, and middle ear cavities are clear.  The soft
tissues are unremarkable. IMPRESSION:  No acute intracranial
abnormality.

CT C-spine w/o contrast [**8-13**]: 1.  No fracture or malalignment.
2.  Multilevel degenerative changes with multilevel neural
foraminal narrowing due to facet arthrosis. 3.  Multiple nodules
in the thyroid gland.  If clinically indicated, recommend
further evaluation with a thyroid ultrasound.

RUQ U/S [**8-13**]: 1.  Severely dilated intra- and extra-hepatic
biliary ducts without definite associated mass.  Recommend MRCP
for further evaluation if there are no contraindications to MRI.
 Alternatively, a multiphasic CT of the abdomen should be
performed.
2.  Distended gallbladder with cholelithiasis and sludge, but no
other
findings to suggest evidence of acute cholecystitis.

CXR [**8-13**]: no intrathoracic process.

CT Abdomen/Pelvis [**8-14**]: There is a mass lesion involving the
ampullary region which results in severe dilatation of the intra
and extrahepatic biliary tree as well as mild main pancreatic
ductal dilatation. Differential considerations include a
cholangiocarcinoma versus a pancreatic neoplasm.  There is no
evidence of distant metastases.  Trace ascites is seen.
Incidental hepatic and renal hypodensities, likely cysts as
described above. Incidental pancreatic cystic lesions, most
compatible with IPMN.

EGD [**8-14**]: The duodenal bulb was dilated. There was a complete
obstruction in the duodenal bulb preventing an ERCP from being
performed.

PERCUTANEOUS TRANSHEPATIC CHOLANGIOGRAPHY [**8-16**]: 1. Marked intra
and extrahepatic biliary dilatation to the level of the distal
CBD.
2.Successful placement of an 8 French percutaneous transhepatic
biliary drain throught the obstruction which has been left on
free drainage.

OPERATIVE PATHOLOGY:
(Periduodenal nodule): Metastatic well differentiated
adenocarcinoma present in fibroadipose tissue.

Discharge Labs:

[**2143-9-1**] 04:15AM BLOOD WBC-10.5 RBC-3.01* Hgb-9.3* Hct-29.1*
MCV-97 MCH-31.0 MCHC-32.1 RDW-15.9* Plt Ct-246
[**2143-9-1**] 04:15AM BLOOD Plt Ct-246
[**2143-9-1**] 04:15AM BLOOD Glucose-107* UreaN-13 Creat-0.7 Na-137
K-3.7 Cl-106 HCO3-25 AnGap-10
[**2143-9-1**] 04:15AM BLOOD ALT-71* AST-77* AlkPhos-245* TotBili-7.0*
DirBili-4.7* IndBili-2.3
[**2143-9-1**] 04:15AM BLOOD Calcium-7.3* Phos-3.4 Mg-2.1
[**2143-8-30**] 04:20AM BLOOD Triglyc-278*

Brief Hospital Course:
At the time of her admission on [**2143-8-13**] the patient was
hypotensive and had an elevated WBC to 16 with a left shift.
She was therefore transferred to the ICU for further management.
 She was started on zosyn and given Vitamin K and FFP to reverse
her coagulopathy. Due to her hypotension, CT scan was initially
post-poned.  Upon stabilization of the patient's blood pressure,
it was decided to proceed with ERCP on [**8-14**].  ERCP was
unsuccessful due to an obstructing duodenal mass.  An NG tube
was placed, and three liters of gastric contents were removed
from her stomach.

At this time, the Hepatobiliary Surgical team was consulted for
evaluation. Upon review of CT Abdomen/Pelvis, it was determined
that the patient had a potentially operable lesion. The patient
was scheduled for an upcoming surgical procedure on [**8-23**]. For
immediate biliary decompression and relief of the associated
symptoms and abnormal laboratory values, on [**8-16**], the patient
underwent percutaneous transhepatic cholangiography with
decompression and drain placement. In the days thereafter, the
patient was noted to have significant improvement in her TBili
laboratory values, and some improvement her jaundiced
appearance. Additionally, on [**8-15**], the patient had a PICC line
placed, and TPN was started. The patient was repleted with
intravenous fluids to replace the losses from both her abdominal
drain as well as her NG tube. The patient had notable
improvement in laboratory values and clinical appearance in this
manner, over the following days, leading up to her scheduled
operation on [**8-23**].

On [**8-23**], the patient underwent an exploratory laparotomy with
biopsy of periduodenal nodule, cholecystectomy, Roux-en-Y,
choledochojejunostomy and gastrojejunostomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO with an NG tube, on IV fluids,
on a single-day-course of IV zosyn, with a foley catheter, and
her PTBD in place, and an epidural for pain control.  The
patient was hemodynamically stable.

On POD#1 ([**8-24**]), she continued to have the epidural for pain
control. She therefore continued to have a foley catheter. She
required aggressive IV fluid hydration post-operatively, which
she responded well to, as gauged by her urine output and vitals,
which remained hemodynamically stable and normal throughout. Her
TPN was held on this day, and she remained NPO with her NGT n
place.

On POD#2 ([**8-25**]), her pain remained well-controlled with the
epidural. Due to a hematocrit of 23, she was transfused 2 units
of Packed Red Blood Cells on this day. Through follow-up of
post-transfusion hematocrit, it was determined that she had
responded well to this step. She worked on ambulating with
Physical Therapy on this day. Her NG tube and foley catheter
were maintained, and she remained NPO. TPN was restarted on this
day.

On POD#3 ([**8-26**]), she continued to have good pain control with the
epidural. Her foley catheter was therefore also maintained. Her
NGT was clamped on this day, and residuals were checked every
four hours. She consequently also remained NPO. She ambulated
twice with Physical Therapy.

On POD#4 ([**8-27**]), she continued to have good pain control with the
epidural. Her foley catheter was also maintained. Her NGT was
removed, and she was permitted to have sips of liquids, which
she tolerated well. She ambulated with Physical Therapy.

On POD#5 ([**8-28**]), the patient's epidural was removed, and she was
transitioned to oral pain medications, which she tolerated well.
Diet was advanced to clears, in addition to having TPN, which
she also tolerated well. She continued to ambulate multiple
times per day. The foley catheter was removed, and she voided
successfully.

On POD#6 ([**8-29**]), the patient's PTBD drain was removed. She was
advanced to full liquids, which she tolerated well. She was
continued on TPN. She continued to ambulate multiple times
daily, with physical therapy.

On POD#7 ([**8-30**]), the patient was continued on TPN, and Enlive
supplementation was added to her full liquid diet. Her pain was
well controlled with oral medications. She continued to ambulate
frequently and regularly.

On POD#8 ([**8-31**]), per recommendations by Hematology/Oncology, a
CT Chest was obtained for staging purposes. She was continued on
TPN, but the volume was decreased to half. She continued to have
good pain control, tolerating full liquids, and ambulating
regularly.

On POD#9 ([**9-1**]), she was advanced to a regular diet with Enlive
supplementation, and continued on half-volume TPN. She continued
to ambulate regularly, and have good pain control.

On POD#10 ([**9-2**]), she was maintained on half-volume TPN, regular
diet with Enlive supplementation, ambulating regularly, working
with PT.

During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, 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.

At the time of discharge, 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 without/with
services.***** The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.

Medications on Admission:
None

Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*5
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*1
3. Senna 1 TAB PO BID:PRN constipation
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. Megestrol Acetate 400 mg PO DAILY
RX *megestrol 400 mg/10 mL (40 mg/mL) 1 Suspension(s) by mouth
once a day Disp #*30 Packet Refills:*0
6. Metoclopramide 10 mg PO QIDACHS
RX *metoclopramide HCl 10 mg 1 by mouth QIDACHS Disp #*56 Tablet
Refills:*0
7. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-21**] tablet(s) by mouth every four (4) hours
Disp #*120 Tablet Refills:*0


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 112308**]Health

Discharge Diagnosis:


1. Metastatic well differentiated adenocarcinoma.
2. Chronic cholecystitis and cholelithiasis.


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


Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for surgical
evaluation of your biliary obstruction. You have done well in
the
post operative period and are now safe to return home to
complete your recovery with the following instructions:

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 [**5-30**] lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.

Avoid driving or operating heavy machinery while taking pain
medications.

Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.

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.

Please call your doctor or nurse practitioner if you experience
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.

Followup Instructions:
Please call Dr.[**Name (NI) 5067**] office at ([**Telephone/Fax (1) 8105**] if you have any
questions or concerns.
.
Please follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks after discharge



Completed by:[**2143-9-4**]
{'Acquired hypertrophic pyloric stenosis,Obstruction of bile duct,Acute kidney failure, unspecified,Acquired coagulation factor deficiency,Secondary malignant neoplasm of small intestine including duodenum,Hypotension, unspecified,Hypovolemia,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Other malignant neoplasm without specification of site,Persistent vomiting,Loss of weight,Other alteration of consciousness,Unspecified disease of pancreas'}


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: Nausea/vomiting/jaundice; mass causing duodenal and biliary
obstruction

PRESENT ILLNESS: Chief Complaint:  nausea, vomiting, jaundice

MEDICAL HISTORY: None documented

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Exam:
General: AAOx3, NAD, grossly jaundiced
HEENT: Sclera severely icteric, MM relatively dry, oropharynx
clear, [**Name (NI) 3899**], PERRL
CV: RRR, + S1/S2, 2/6 systolic murmur best heard at RUSB, no
rubs or gallops
Lungs: CTAB, no wheezes, rales, ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: No cancer in the family. Father died of heart disease at age of
88. Mother died of diabetes.

SOCIAL HISTORY: Lives with family. No alcohol or tobacco use.
[**Doctor First Name **]-Scientist since [**2105**]. 

### Response:
{'Acquired hypertrophic pyloric stenosis,Obstruction of bile duct,Acute kidney failure, unspecified,Acquired coagulation factor deficiency,Secondary malignant neoplasm of small intestine including duodenum,Hypotension, unspecified,Hypovolemia,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Other malignant neoplasm without specification of site,Persistent vomiting,Loss of weight,Other alteration of consciousness,Unspecified disease of pancreas'}
