CHIEF COMPLAINT: Duodenal and Ampullary Adenoma

PRESENT ILLNESS: Mr. [**Known lastname **] is a 67-year-old
man who comes from a family with a deep history of both
colorectal cancer and polyposis as well as duodenal
adenomatous disease, some family members of which have
undergone duodenectomy.  He has recently presented with
endoscopic evidence of a progressive duodenal and ampullary
adenoma, which is extending up into the inferior bile duct.
It cannot be removed endoscopically and has adenomatous
disease has been biopsy proven.  There has been no pancreatic
or biliary ductal or duodenal obstruction.  In light of this,
he is referred for consideration of elective
pancreatoduodenectomy,

MEDICAL HISTORY: His medical history is again significant for a likely diagnosis
of familial adenomatous polyposis, hypertension, coronary artery
disease, chronic obstructive pulmonary disease (COPD), arthritis
and peripheral vascular disease.

MEDICATION ON ADMISSION: metoprolol 50mg SR', omeprazole 20mg EC', lisinopril 10mg',
vytorin 10/40mg'
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On examination today he appeared in no distress, he was alert
and
oriented x 3.  His vital signs were stable.  He is afebrile.  On
exam HEENT pupils are equal, round and reactive to light,
extraocular muscles were intact.  The mucus membranes were
moist.
Neck was supple.  There was no jugular venous distention (JVD).
His chest was clear to auscultation, bilaterally.  Heart was
regular rate and rhythm.  The abdomen is soft, nontender and
nondistended with normoactive bowel sounds.  The extremities
have
no cyanosis, erythema or edema.  Neurologically, cranial nerves
II-XII were grossly intact, no focal deficits.

FAMILY HISTORY: His family history is significant for his maternal grandfather
that was affected with colorectal cancer, mother that was
affected with polyposis, brother that was affected with
colorectal cancer, 2 daughters that are affected with polyposis,
a grandson that is affected with polyposis, a brother that was
lost to colorectal cancer and a son that is also affected with
polyposis.

SOCIAL HISTORY: SOCIAL HISTORY
His social history is significant for positive tobacco.  He
smokes half pack per day, no alcohol and no IV drugs use, and no
intranasal cocaine use.
Chronic pancreatitis,Subendocardial infarction, initial episode of care,Unspecified protein-calorie malnutrition,Cardiac complications, not elsewhere classified,Chronic cholecystitis,Benign neoplasm of duodenum, jejunum, and ileum,Hypoxemia,Peritoneal adhesions (postoperative) (postinfection),Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution
Chronic pancreatitis,Subendo infarct, initial,Protein-cal malnutr NOS,Surg compl-heart,Chronic cholecystitis,Benign neoplasm sm bowel,Hypoxemia,Peritoneal adhesions,CHF NOS,Chr airway obstruct NEC,Abn react-surg proc NEC,Accid in resident instit
Admission Date:  [**2187-7-3**]              Discharge Date:   [**2187-7-20**]

Date of Birth:  [**2120-3-30**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Duodenal and Ampullary Adenoma

Major Surgical or Invasive Procedure:
1. Pancreatoduodenectomy (Whipple procedure).
2. Open cholecystectomy.
3. Extensive lysis of adhesions.


History of Present Illness:
Mr. [**Known lastname **] is a 67-year-old
man who comes from a family with a deep history of both
colorectal cancer and polyposis as well as duodenal
adenomatous disease, some family members of which have
undergone duodenectomy.  He has recently presented with
endoscopic evidence of a progressive duodenal and ampullary
adenoma, which is extending up into the inferior bile duct.
It cannot be removed endoscopically and has adenomatous
disease has been biopsy proven.  There has been no pancreatic
or biliary ductal or duodenal obstruction.  In light of this,
he is referred for consideration of elective
pancreatoduodenectomy,

The patient states that he was originally diagnosed with
familial
adenomatous polyposis back in the [**2138**] to [**2148**] where he
underwent a total abdominal colectomy for polyposis syndrome.
Since then he has done quite well.  He had been following a
gastroenterologist.  However, he had been lost to followup for
approximately 8 years.  He recently sought the care of Dr. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 78664**] at [**Hospital3 17921**] Center for an abdominal pain syndrome
that he has been having.  He states that the pain is sharp in
nature, located in his periumbilical region and worsens with
eating.  He denies any nausea or vomiting associated with this.
He denies any hematemesis or coffee-ground emesis.  He denies
any
bright-red blood per rectum or diarrhea.  He does state that he
has been experiencing the symptomatology for quite some time.
Based on this, he underwent imaging as well as an endoscopy.  I
do not have the results of the imaging but the endoscopy did
show
a 1.5 cm polyp at the ampulla.  Based on this he was referred to
us for further evaluation and management of his ampulla.


Past Medical History:
His medical history is again significant for a likely diagnosis
of familial adenomatous polyposis, hypertension, coronary artery
disease, chronic obstructive pulmonary disease (COPD), arthritis
and peripheral vascular disease.

PAST SURGICAL HISTORY
His past surgical history is significant for coronary artery
bypass graft (CABG) and carotid endarterectomy.


Social History:
SOCIAL HISTORY
His social history is significant for positive tobacco.  He
smokes half pack per day, no alcohol and no IV drugs use, and no
intranasal cocaine use.


Family History:
His family history is significant for his maternal grandfather
that was affected with colorectal cancer, mother that was
affected with polyposis, brother that was affected with
colorectal cancer, 2 daughters that are affected with polyposis,
a grandson that is affected with polyposis, a brother that was
lost to colorectal cancer and a son that is also affected with
polyposis.


Physical Exam:
On examination today he appeared in no distress, he was alert
and
oriented x 3.  His vital signs were stable.  He is afebrile.  On
exam HEENT pupils are equal, round and reactive to light,
extraocular muscles were intact.  The mucus membranes were
moist.
Neck was supple.  There was no jugular venous distention (JVD).
His chest was clear to auscultation, bilaterally.  Heart was
regular rate and rhythm.  The abdomen is soft, nontender and
nondistended with normoactive bowel sounds.  The extremities
have
no cyanosis, erythema or edema.  Neurologically, cranial nerves
II-XII were grossly intact, no focal deficits.


Pertinent Results:
[**2187-7-3**] 04:10PM BLOOD WBC-10.5 RBC-4.07* Hgb-12.8* Hct-37.2*
MCV-91 MCH-31.5 MCHC-34.5 RDW-13.9 Plt Ct-155
[**2187-7-7**] 05:50AM BLOOD WBC-10.8 RBC-4.04* Hgb-13.1* Hct-36.1*
MCV-89 MCH-32.6* MCHC-36.4* RDW-14.2 Plt Ct-208
[**2187-7-8**] 06:30AM BLOOD Glucose-117* UreaN-23* Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-26 AnGap-13
[**2187-7-5**] 02:00AM BLOOD CK-MB-30* MB Indx-1.9 cTropnT-0.18*
[**2187-7-5**] 10:38AM BLOOD CK-MB-31* MB Indx-2.3 cTropnT-0.36*
[**2187-7-5**] 04:25PM BLOOD CK-MB-24* MB Indx-1.9 cTropnT-0.40*
[**2187-7-6**] 01:24AM BLOOD CK-MB-11* cTropnT-0.23*
[**2187-7-8**] 06:30AM BLOOD Calcium-8.1* Phos-3.0 Mg-2.1
.
Cardiology Report ECG Study Date of [**2187-7-4**]  11:57:18 PM
Read by: [**Last Name (LF) 2889**],[**First Name3 (LF) 2890**] K.
  Intervals Axes
Rate PR QRS QT/QTc P QRS T
94 158 94 [**Telephone/Fax (2) 78665**]3
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-7-5**] 7:37
PM
FINDINGS: In comparison with study of [**7-4**], there is little
change.
Persistent blunting of the left costophrenic angle consistent
with pleural
fluid and atelectatic changes. Similar, though less marked
changes are seen
on the right. The pulmonary vessels appear somewhat less
prominent, possibly
reflecting some improvement in pulmonary venous pressure status.
Catheters
remain in place.
IMPRESSION: Little change except for possibly some improvement
in pulmonary vascular status.
.
[**Known lastname **], [**Known firstname **]       [**Hospital1 18**] [**Numeric Identifier 78666**]Portable TTE
(Complete) Conclusions
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 40-50 %) secondary to hypokinesis of the
inferior and posterior walls. There is no ventricular septal
defect. The right ventricular cavity is dilated with borderline
normal free wall function. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. There is
no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
.

[**2187-7-12**] 06:10AM BLOOD WBC-10.6 RBC-3.10* Hgb-9.7* Hct-28.3*
MCV-91 MCH-31.3 MCHC-34.3 RDW-13.9 Plt Ct-287
[**2187-7-19**] 04:30AM BLOOD Glucose-88 UreaN-18 Creat-0.6 Na-134
K-4.2 Cl-105 HCO3-21* AnGap-12
[**2187-7-11**] 03:00AM BLOOD CK(CPK)-72
[**2187-7-11**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.14*
[**2187-7-19**] 04:30AM BLOOD Calcium-7.6* Phos-3.1 Mg-1.9
[**2187-7-15**] 05:28AM BLOOD calTIBC-178* Ferritn-918* TRF-137*
[**2187-7-15**] 05:28AM BLOOD Triglyc-173*
.
Radiology Report CHEST (PORTABLE AP) Study Date of [**2187-7-17**] 2:11
PM
IMPRESSION:
1. PICC terminates in the lower SVC.
2. Bibasilar atelectasis.
3. Vague opacity in the right middle lobe may represent
additional
atelectasis or pneumonia.
.
Radiology Report CT ABDOMEN W/CONTRAST Study Date of [**2187-7-10**]
11:04 AM

IMPRESSION:
1. Unremarkable post-operative appearance with no evidence for
abscess.
2. Moderate gastric distension without evidence for obstruction.

.
Radiology Report ABDOMEN (SUPINE & ERECT) Study Date of [**2187-7-12**]
11:35 AM

IMPRESSION: Paucity of bowel gas, nonspecific bowel gas pattern.
NG tube
with side port in esophagus needs further advancement.


Brief Hospital Course:
This is a 67 year old male with ampullary polyp who went to the
OR on [**2187-7-3**] for:
1. Pancreatoduodenectomy (Whipple procedure).
2. Open cholecystectomy.
3. Extensive lysis of adhesions.

He followed the "Whipple" pathway.
Pain: He had an epidural for pain control and was followed by
APS. The epidural, per the pathway, was removed on POD 4. He was
transitioned to a PCA and then oral pain medications once
tolerating a diet.

Post-op Pulmonary Edema: He was Triggered for O2 sat 88 on 2L;
60yr h/o smoking, COPD; CXR showed slightly more vascular
congestion; EKG essentially normal; ABG NL with O2 in 70s; given
nebs, venti mask; and was transferred to the ICU as his cardiac
enzymes were rising. He had a cardiology consult who felt this
was not a MI, but rather a pulmonary overload (demand ischemia)
issue.
[**7-6**] Echo: LVEF 40-50% hypokinesis inf/post walls, trace AR, 1+MR


He was started on ASA and his Lopressor was titrated up.

On [**2187-7-9**], a CXR revealed an area of patchy opacification that
is developed in the right mid to lower zone. Levofloxacin was
started for possible pneumonia.

On POD 7, he complained of chest pain and had some EXG changes.
Again cards was called, but felt that this was a normal variant
and his "chest pain" was likely reflux.

GI/ABD: He was NPO, with a NGT and IVF. The NGT, per the
pathway, was removed on POD 3. His diet was slowly advanced as
she had return of bowel function. He was tolerating clears
liquids by POD 5. On POD 6, a JP Amylase was measured and was
1254 The drain was left in place. A repeat JP Amylase on [**7-17**]
was  [**Numeric Identifier 78667**]. The drain was converted to passive drainage.

For clinical concerns, a CT was obtained to rule out
abscess/leak.
[**7-10**]: CT abd: No evidence for abscess, moderate gastric
distension. He then had emesis on POD 9. A NGT was placed and
put out a large amount of bilious fluid. He was started on TPN.

He also had some redness and bogginess on his right flank near
the drain site. Vancomycin was started and a week was completed.

After 3 days of the NGT, it was removed and again his diet was
advanced. The TPN was weaned down and he was tolerating regular
food and reported +flatus and +BM thru the ostomy prior to
discharge.

His abdomen was soft, nondistended and the incision with staples
was C/D/I. The staples were removed prior to discharge and steri
strips placed. There were no signs of infection.


Medications on Admission:
metoprolol 50mg SR', omeprazole 20mg EC', lisinopril 10mg',
vytorin 10/40mg'
.


Discharge Medications:
1. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed.
3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
5. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
Disp:*120 Tablet(s)* Refills:*2*
6. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*
7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed.
Disp:*45 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 269**] Home Health & Hospice

Discharge Diagnosis:
duodenal and ampullary adenoma
Post-op Pulmonary Edema; hypoxemia; Demand Ischemia
Post-op Delayed Gastric Emptying
Malnutrition


Discharge Condition:
Good


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in 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.
* Your skin, or the whites of your eyes become yellow.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or
back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
* Take all new meds as ordered.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
* Continue to increase activity daily
* Monitor your incision for signs of infection.
* You may shower and wash, no tub baths or swimming.
* Continue with drain care. Empty and record daily output.
Change dressing/appliance as needed.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] on [**2187-8-13**] at 10:15. Call
[**Telephone/Fax (1) 2835**] with questions or concerns.



Completed by:[**2187-7-20**]
{'Chronic pancreatitis,Subendocardial infarction, initial episode of care,Unspecified protein-calorie malnutrition,Cardiac complications, not elsewhere classified,Chronic cholecystitis,Benign neoplasm of duodenum, jejunum, and ileum,Hypoxemia,Peritoneal adhesions (postoperative) (postinfection),Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution'}


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: Duodenal and Ampullary Adenoma

PRESENT ILLNESS: Mr. [**Known lastname **] is a 67-year-old
man who comes from a family with a deep history of both
colorectal cancer and polyposis as well as duodenal
adenomatous disease, some family members of which have
undergone duodenectomy.  He has recently presented with
endoscopic evidence of a progressive duodenal and ampullary
adenoma, which is extending up into the inferior bile duct.
It cannot be removed endoscopically and has adenomatous
disease has been biopsy proven.  There has been no pancreatic
or biliary ductal or duodenal obstruction.  In light of this,
he is referred for consideration of elective
pancreatoduodenectomy,

MEDICAL HISTORY: His medical history is again significant for a likely diagnosis
of familial adenomatous polyposis, hypertension, coronary artery
disease, chronic obstructive pulmonary disease (COPD), arthritis
and peripheral vascular disease.

MEDICATION ON ADMISSION: metoprolol 50mg SR', omeprazole 20mg EC', lisinopril 10mg',
vytorin 10/40mg'
.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On examination today he appeared in no distress, he was alert
and
oriented x 3.  His vital signs were stable.  He is afebrile.  On
exam HEENT pupils are equal, round and reactive to light,
extraocular muscles were intact.  The mucus membranes were
moist.
Neck was supple.  There was no jugular venous distention (JVD).
His chest was clear to auscultation, bilaterally.  Heart was
regular rate and rhythm.  The abdomen is soft, nontender and
nondistended with normoactive bowel sounds.  The extremities
have
no cyanosis, erythema or edema.  Neurologically, cranial nerves
II-XII were grossly intact, no focal deficits.

FAMILY HISTORY: His family history is significant for his maternal grandfather
that was affected with colorectal cancer, mother that was
affected with polyposis, brother that was affected with
colorectal cancer, 2 daughters that are affected with polyposis,
a grandson that is affected with polyposis, a brother that was
lost to colorectal cancer and a son that is also affected with
polyposis.

SOCIAL HISTORY: SOCIAL HISTORY
His social history is significant for positive tobacco.  He
smokes half pack per day, no alcohol and no IV drugs use, and no
intranasal cocaine use. 

### Response:
{'Chronic pancreatitis,Subendocardial infarction, initial episode of care,Unspecified protein-calorie malnutrition,Cardiac complications, not elsewhere classified,Chronic cholecystitis,Benign neoplasm of duodenum, jejunum, and ileum,Hypoxemia,Peritoneal adhesions (postoperative) (postinfection),Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Accidents occurring in residential institution'}
