CHIEF COMPLAINT: hematemesis

PRESENT ILLNESS: This is a  59 year-old female with a history of advanced
pancreatic cancer who presents with hematemesis. Pt vomited 1
cup of bright red blood this am after eating breakfast. She was
profoundly weak and called EMS who had to break into her
appartment. VS on arrival 80/46, 100, R 20. She has chronic RUQ
and epigastric abd pain which has worsened over the last week.
No F/C/NS.
.
She originally presented to [**Hospital1 1474**] Hosptial where VS were
97/46 and P 99, where HCT of 26.1. Labs from [**Hospital1 **] on
[**2171-2-26**] showed HCT 39, tbili 1.1, cr 0.7.  She received 2 units
of RBC and 2000cc IVF. She was transfered to [**Hospital1 18**] for further
evaluation.
.
In the ED VS showed T98, HR 93, BP 114/62, 20, 99%3L. She
received famotidine 40mg IV. HCT was 27.7 after the 2 units
received in transient. She was seen by GI. NG lavage was refused
by the patient. VS prior to transfer 91, 134/70, 18, 100% RA. Pt
noted to be guiac positive with brown stool.
.
Upon arrival to the floor she remained hemodynamic stable. She
had a 1 L BM of BRBPR with clots.
.
Of note [**2171-1-31**] she had a similar episode of hematemesis with
HCT drop to 22 for which she was admitted to the OSH ICU.
Endoscopy showed bleeding ucleration at the site of the tumor
growth over the duodenel stent. She was given 4 units of RBC
with spontaneous resolution of the bleed. However 1 week after
being d/ced on protonix she developed a whole body rash.
.
Her cancer was discovered after a CT obtained at the time of an
appendectomy showed diffuse hepatobiliary dilatation in [**3-21**]. IN
[**Month (only) **] she had an EUS which showed a 2-cm mass in the pancreas
involving the portal vein. FNA was positive for malignant cells.

MEDICAL HISTORY: anemia
duodenal ulcer at tumor site (present with hematemesis [**1-18**])
hyperlipidemia
HTN
DM2, currently not on treatment
obesity
appendectomy
pancreatic cancer

MEDICATION ON ADMISSION: atenolol 25mg PO daily
Reglan 10mg PO TID
ranitidine 300mg PO BID
oxycodone prn
xeloda capecitabine
Xelox on [**2-22**]

ALLERGIES: Omeprazole / Prochlorperazine

PHYSICAL EXAM: GEN: Alert, no acute distress
HEENT: EOMI, PERRL, sclera icteric, MMM, OP Clear
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mild RUQ tenderness without rebound or gaurding, ND,
+BS, no HSM, no masses
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.
SKIN: mild jaundice. No cyanosis, or gross dermatitis. No
ecchymoses.

FAMILY HISTORY: Father died at 65 from a CVA. Mother died at 70 from liver
disease; she also had DM and HTN. The has had two sisters with
breast cancer, one of whom has died.

SOCIAL HISTORY: The patient works in tech support for State Stree Bank. She is a
lifelong non-smoker and does not drink alcohol. She lives
independently at home.
.
Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Obstruction of bile duct,Malignant neoplasm of head of pancreas,Secondary malignant neoplasm of small intestine including duodenum,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Do not resuscitate status,Anemia, unspecified
Chr duoden ulcer w hem,Obstruction of bile duct,Mal neo pancreas head,Sec malig neo sm bowel,Hyperlipidemia NEC/NOS,Hypertension NOS,DMII wo cmp nt st uncntr,Obesity NOS,Do not resusctate status,Anemia NOS
Admission Date:  [**2171-3-8**]              Discharge Date:   [**2171-3-10**]

Date of Birth:  [**2111-12-5**]             Sex:   F

Service: MEDICINE

Allergies:
Omeprazole / Prochlorperazine

Attending:[**Last Name (NamePattern4) 290**]
Chief Complaint:
hematemesis

Major Surgical or Invasive Procedure:
None.


History of Present Illness:
This is a  59 year-old female with a history of advanced
pancreatic cancer who presents with hematemesis. Pt vomited 1
cup of bright red blood this am after eating breakfast. She was
profoundly weak and called EMS who had to break into her
appartment. VS on arrival 80/46, 100, R 20. She has chronic RUQ
and epigastric abd pain which has worsened over the last week.
No F/C/NS.
.
She originally presented to [**Hospital1 1474**] Hosptial where VS were
97/46 and P 99, where HCT of 26.1. Labs from [**Hospital1 **] on
[**2171-2-26**] showed HCT 39, tbili 1.1, cr 0.7.  She received 2 units
of RBC and 2000cc IVF. She was transfered to [**Hospital1 18**] for further
evaluation.
.
In the ED VS showed T98, HR 93, BP 114/62, 20, 99%3L. She
received famotidine 40mg IV. HCT was 27.7 after the 2 units
received in transient. She was seen by GI. NG lavage was refused
by the patient. VS prior to transfer 91, 134/70, 18, 100% RA. Pt
noted to be guiac positive with brown stool.
.
Upon arrival to the floor she remained hemodynamic stable. She
had a 1 L BM of BRBPR with clots.
.
Of note [**2171-1-31**] she had a similar episode of hematemesis with
HCT drop to 22 for which she was admitted to the OSH ICU.
Endoscopy showed bleeding ucleration at the site of the tumor
growth over the duodenel stent. She was given 4 units of RBC
with spontaneous resolution of the bleed. However 1 week after
being d/ced on protonix she developed a whole body rash.
.
Her cancer was discovered after a CT obtained at the time of an
appendectomy showed diffuse hepatobiliary dilatation in [**3-21**]. IN
[**Month (only) **] she had an EUS which showed a 2-cm mass in the pancreas
involving the portal vein. FNA was positive for malignant cells.

GIven encasement of the gastric duodenal artery she was felt not
to be a surgical candidate. She underwent 3 cycles of
gemcitabine but had ongoing enlargement of the pancreatic mass.
A doudenal stent was placed in 5/[**2170**]. This was followed with
stereotactic body radiotherapy, 2400 cGy in 3 fractions,
completed [**2170-10-12**]. She had 1st cycle of XELOX
(capecitabine plus oxaliplatin) on [**2-22**] for progressive disease
with tumor overgrowth of teh doudenal stent.

ROS: The patient denies any fevers, chills. + 12 lb weight loss.
+ nausea, vomiting, abdominal pain. No diarrhea, constipation,
chest pain, shortness of breath, lower extremity edema, cough,
urinary frequency, urgency, dysuria, , focal weakness, vision
changes, headache, rash or skin changes.


Past Medical History:
anemia
duodenal ulcer at tumor site (present with hematemesis [**1-18**])
hyperlipidemia
HTN
DM2, currently not on treatment
obesity
appendectomy
pancreatic cancer

Social History:
The patient works in tech support for State Stree Bank. She is a
lifelong non-smoker and does not drink alcohol. She lives
independently at home.
.


Family History:
Father died at 65 from a CVA. Mother died at 70 from liver
disease; she also had DM and HTN. The has had two sisters with
breast cancer, one of whom has died.

Physical Exam:
GEN: Alert, no acute distress
HEENT: EOMI, PERRL, sclera icteric, MMM, OP Clear
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mild RUQ tenderness without rebound or gaurding, ND,
+BS, no HSM, no masses
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.
SKIN: mild jaundice. No cyanosis, or gross dermatitis. No
ecchymoses.


Pertinent Results:
[**2171-3-8**] 06:30PM   WBC-11.3*# RBC-3.23*# HGB-9.2*# HCT-27.7*#
MCV-86 MCH-28.5 MCHC-33.2 RDW-17.6*
[**2171-3-8**] 06:30PM   NEUTS-82.4* BANDS-0 LYMPHS-14.1* MONOS-3.1
EOS-0.1 BASOS-0.3
[**2171-3-8**] 06:30PM   PLT SMR-NORMAL PLT COUNT-326#
[**2171-3-8**] 06:30PM   HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL
POIKILOCY-OCCASIONAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-NORMAL
[**2171-3-8**] 06:30PM   GLUCOSE-138* UREA N-32* CREAT-0.8 SODIUM-137
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2171-3-8**] 06:30PM   CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-2.2
[**2171-3-8**] 06:30PM   ALT(SGPT)-71* AST(SGOT)-67* ALK PHOS-377* TOT
BILI-8.5*
[**2171-3-8**] 06:30PM   LIPASE-14
.
INDICATION: 59-year-old female with pancreatic cancer, new
abdominal pain and
upper GI bleeding.

COMPARISON: [**2171-1-15**].

TECHNIQUE: Helical MDCT images were acquired from the lung bases
through the
greater trochanters with intravenous and oral Gastrografin
contrast. 5-mm
axial, coronal, and sagittal multiplanar reformats were
generated.

FINDINGS: Mild atelectasis is noted at the lung bases. There are
no pleural
effusions. The heart is normal in size, with trace pericardial
effusion.
Note is made of a small sliding hiatal hernia.

ABDOMEN: A hypo-enhancing mass in the head of the pancreas has
increased in
size to 3.2 cm TV x 2.4 cm AP x 2 cm SI, previously 3 cm TV x
2.2 cm TV x 1.7
cm SI. Fiducial seed is noted at the inferior aspect of this
mass. There is
extensive local infiltration, with heterogeneous soft tissue
density extending
inferolaterally and obscuring fat planes along the C-sweep of
the duodenum.
There is complete encasement of the proximal portal vein,
approximately 270
degrees of involvement at the portosplenic confluence, and 180
degree abutment
of the proximal superior mesenteric vein. However, there is no
evidence of
thrombosis; the main, left, and right portal and hepatic veins,
splenic vein,
and superior mesenteric vein all remain patent. The distal
pancreas is
atrophic, without significant ductal dilation to suggest
obstruction.

There is new massive intrahepatic and common biliary ductal
dilation,
measuring up to 17 mm. The liver enhances homogeneously, without
focal
lesions identified on this single phase examination. A 4-mm
calcified stone
is noted in a partially distended gallbladder, which
demonstrates minimal wall
edema and trace pericholecystic fluid. The spleen is normal in
size.

The adrenals are normal. The kidneys enhance and excrete
contrast promptly
and symmetrically, without masses or hydronephrosis. Bilateral
renal cysts
and hypodensities are present, measuring up to 2.5 cm in the
left interpole.

The stomach is partially collapsed. A metal stent is noted in
the second
portion of the duodenum, with persistent irregular soft tissue
ingrowth within
the stent walls. However, enteric contrast traverses this
region, and there
is no evidence of transition point to suggest obstruction.
Enteric contrast
has progressed to the level of mid ileal loops in the pelvis. A
4 x 2 cm
ovoid filling defect in a pelvic ileal loop (3:52 and 300B:38),
was not
visualized on prior examination, and likely represents ingested
contents.
There are no extraluminal contrast, fluid, or air collections to
suggest
perforation. No focal fat stranding or abnormal enhancement to
indicate acute
inflammation. There is no pneumatosis or mesenteric/portal
venous gas to
reflect ischemia.

PELVIS: The appendix is surgically absent. A moderate amount of
retained
fecal material is noted throughout the colon and rectum. The
bladder is
normal. Bilateral ureteral jets are visualized. The uterus and
adnexa are
unremarkable.

Mesenteric and retroperitoneal lymph nodes are not
pathologically enlarged.

CXR [**3-9**]
Lung volumes are low, no pneumonia or pulmonary edema. Heart
mildly enlarged.
No appreciable pleural effusion. Tip of the infusion port ends
in the low
SVC.

No suspicious lytic or sclerotic osseous lesions are identified.
Moderate
multilevel degenerative changes are present in the thoracolumbar
spine.

IMPRESSION:
1. Interval increase in size of pancreatic head mass, with new
massive
intrahepatic and common biliary ductal dilation indicating
obstruction.
Significant vascular encasement, without evidence of venous
thrombosis.
2. Duodenal stent, with evidence of soft tissue ingrowth, but no
bowel
obstruction or perforation.


Brief Hospital Course:
This is a 59 year-old female with a history of pancreatic cancer
who presents with hematemesis and hematochezia secondary
ulcerated tumor at the duodenal stent found to have common bile
duct obstruction and gallbladder distension from progression of
pancreatic cancer.
.
# Goals of care. At time of admission code status extensively
discussed with patient. It was explained that without
intervention a major bleed may be fatal without intubation. At
discussions end, patient confirmed DNR/ DNI code status and
ultimately opted to return home with hospice services. At her
request she has agreed to continued antibiotics as well as
palliative transfusions. At time of discharged prescriptions for
antibiotics as well as short term anti-emetics, analgesics
written for. Proper DNI/DNR paper work was filled out.
.
# GI bleed: Likely source: ulcerated tumor at the duodenal stent
site.  NG lavage negative suggesting against gastric cause.
Patient transfused as needed and serial hematocrits monitored.
Patient opted against further invasive intervention to control
the bleed. Hematocrit stable at time of discharge. Desires
palliative transfusions once home.
.
# Common bile duct obstruction, gallbladder distension. Imaging
consistent with intrahepatic, CBD and GB distension likely
secondary to extrahepatic conpression from the pancreatic mass.
Though no fevers to suggest active cholangitis patient covered
with empiric unasyn to prevent cholangitis which was
transitioned to PO ciprofloxacin and flagyl at time of discharge
.
# Pancreatic cancer. Likely causative factor of both bleed and
obstruction. Primary oncologist contact[**Name (NI) **]. [**Name2 (NI) **] to return
home with hospice
.
# Hypertension. Held home atenolol during stay. At discharge
instructed to discontinue medication.
.
# Comm:  [**Name (NI) 1154**], daughter, [**Telephone/Fax (1) 86621**]


Medications on Admission:
atenolol 25mg PO daily
Reglan 10mg PO TID
ranitidine 300mg PO BID
oxycodone prn
xeloda capecitabine
Xelox on [**2-22**]

Discharge Medications:
1. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for shortness of breath or wheezing.
Disp:*4 Tablet(s)* Refills:*0*
2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day.
Disp:*28 Tablet(s)* Refills:*0*
3. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*28 Tablet(s)* Refills:*0*
4. morphine concentrate 20 mg/mL Solution Sig: 5-20 mg PO q1hour
as needed for pain: Please call [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] if pain becomes
severe.
Disp:*1 30cc vial* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Old [**Hospital **] Hospice

Discharge Diagnosis:
Primary Diagnosis: Duodenal ulcer, Biliary tract obstruction
Secondary Diagnosis: Metastatic Pancreatic Cancer


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


Discharge Instructions:
Ms. [**Known lastname **],

It was a pleasure taking care of your during your stay here at
[**Hospital1 18**].

Regarding your episodes of bleeding, it is thought that you have
persistent bleeding from an ulcer in your duodenum.  It is
possible that you may rebleed again.  If so please contact your
hospice providers and they can arrange for you to receive
transfusions as needed.

In addition, your biliary tract was found to be obstructed,
likely secondary to worsening pancreatic cancer.  A percutaneous
cholecystostomy was offered but you opted to forego further
intervention and instead use antibiotics to treat any
potentional infection.

Hospice will follow along with you at home to ensure your
comfort.

Changes to your medications
To treat potential infection:
Start taking Ciprofloxacin 500mg tablets. Please take one tablet
twice daily
Start taking Metronidazole 500mg tablets. Please take one tablet
twice daily
To treat shortness of breath/anxiety
Start taking Ativan 0.5mg PO at night time.
To treat pain;
Start taking Morphine concentrate as needed every hour: 5-20mg
Q1hr sublingual or by mouth for pain control
- this medicine can be swallowed or dropped under the tongue for
pain control.
- If you are having severe pain plase contact [**Name (NI) 2270**] [**Name (NI) 1764**]
guarding increasing dosage.
Stop taking your atenolol
.
Again please do not contact the ICU or [**First Name8 (NamePattern2) 2270**] [**Name (NI) 1764**] if any
questions arise.

Followup Instructions:
You will be coming home with hospice. Please contact the ICU and
[**First Name8 (NamePattern2) 2270**] [**Name (NI) 1764**] if you have any questions or concerns after
discharge.


                             [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

Completed by:[**2171-3-10**]
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Obstruction of bile duct,Malignant neoplasm of head of pancreas,Secondary malignant neoplasm of small intestine including duodenum,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Do not resuscitate status,Anemia, unspecified'}


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: hematemesis

PRESENT ILLNESS: This is a  59 year-old female with a history of advanced
pancreatic cancer who presents with hematemesis. Pt vomited 1
cup of bright red blood this am after eating breakfast. She was
profoundly weak and called EMS who had to break into her
appartment. VS on arrival 80/46, 100, R 20. She has chronic RUQ
and epigastric abd pain which has worsened over the last week.
No F/C/NS.
.
She originally presented to [**Hospital1 1474**] Hosptial where VS were
97/46 and P 99, where HCT of 26.1. Labs from [**Hospital1 **] on
[**2171-2-26**] showed HCT 39, tbili 1.1, cr 0.7.  She received 2 units
of RBC and 2000cc IVF. She was transfered to [**Hospital1 18**] for further
evaluation.
.
In the ED VS showed T98, HR 93, BP 114/62, 20, 99%3L. She
received famotidine 40mg IV. HCT was 27.7 after the 2 units
received in transient. She was seen by GI. NG lavage was refused
by the patient. VS prior to transfer 91, 134/70, 18, 100% RA. Pt
noted to be guiac positive with brown stool.
.
Upon arrival to the floor she remained hemodynamic stable. She
had a 1 L BM of BRBPR with clots.
.
Of note [**2171-1-31**] she had a similar episode of hematemesis with
HCT drop to 22 for which she was admitted to the OSH ICU.
Endoscopy showed bleeding ucleration at the site of the tumor
growth over the duodenel stent. She was given 4 units of RBC
with spontaneous resolution of the bleed. However 1 week after
being d/ced on protonix she developed a whole body rash.
.
Her cancer was discovered after a CT obtained at the time of an
appendectomy showed diffuse hepatobiliary dilatation in [**3-21**]. IN
[**Month (only) **] she had an EUS which showed a 2-cm mass in the pancreas
involving the portal vein. FNA was positive for malignant cells.

MEDICAL HISTORY: anemia
duodenal ulcer at tumor site (present with hematemesis [**1-18**])
hyperlipidemia
HTN
DM2, currently not on treatment
obesity
appendectomy
pancreatic cancer

MEDICATION ON ADMISSION: atenolol 25mg PO daily
Reglan 10mg PO TID
ranitidine 300mg PO BID
oxycodone prn
xeloda capecitabine
Xelox on [**2-22**]

ALLERGIES: Omeprazole / Prochlorperazine

PHYSICAL EXAM: GEN: Alert, no acute distress
HEENT: EOMI, PERRL, sclera icteric, MMM, OP Clear
NECK: No JVD, trachea midline
COR: RRR, no M/G/R, normal S1 S2, radial pulses +2
PULM: Lungs CTAB, no W/R/R
ABD: Soft, mild RUQ tenderness without rebound or gaurding, ND,
+BS, no HSM, no masses
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.
SKIN: mild jaundice. No cyanosis, or gross dermatitis. No
ecchymoses.

FAMILY HISTORY: Father died at 65 from a CVA. Mother died at 70 from liver
disease; she also had DM and HTN. The has had two sisters with
breast cancer, one of whom has died.

SOCIAL HISTORY: The patient works in tech support for State Stree Bank. She is a
lifelong non-smoker and does not drink alcohol. She lives
independently at home.
. 

### Response:
{'Chronic or unspecified duodenal ulcer with hemorrhage, without mention of obstruction,Obstruction of bile duct,Malignant neoplasm of head of pancreas,Secondary malignant neoplasm of small intestine including duodenum,Other and unspecified hyperlipidemia,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Obesity, unspecified,Do not resuscitate status,Anemia, unspecified'}
