CHIEF COMPLAINT: Transferred from OSH with hypotension and elevated troponin.

PRESENT ILLNESS: Ms. [**Known lastname **] is an 80 year old female with h/o type II DM, HTN,
hyperlipidemia, and recent diagnosis of pancreatic cancer
([**6-/2198**]) awaiting Whipple procedure, who presented to [**Hospital1 3325**] on the day of admission after a mechanical fall.  EMS
VS en route to [**Hospital3 3583**] were BP 142/74,  HR 90, RR 20,
100% 2L.
.
Per patient, she was sitting on the toilet having a BM when she
slipped off the toilet seat onto the floor.  Says that she did
not experience any lightheadedness, dizziness, palps, or chest
pain prior to the episode.  There was no LOC.  She recalls the
entire event.  A friend found her on the floor and helped her
onto her feet and called an ambulance.
.
At OSH ([**Hospital3 3583**]) her vital signs were 97.4, HR 68, RR
20, BP 78/56, 99% 2L.  Subsequently she was noted to be
hypotensive to SBP 60s, she was given 1.5 liters IVF with SBP to
80s and started on dopamine gtt.  She was noted to have STE in
leads I and aVL and also a troponin I of 3.67 with flat CKs.
She was started on a heparin gtt with bolus.  A head CT at OSH
showed no evidence of intracranial hemorrhage.
.
At baseline, patient says she lives independently and is able to
carry out ADLs and most IADLs.  She denies exertional angina
although to be fair, does not regularly walk up stairs or
long-distances.  ROS positive for one loose bowel movement on
morning of admission, no blood and no mucous.  No abdominal
cramping or pain.  She denies fevers, chills, N/V, or decreased
PO intake in days leading up to admission.  She denies dysuria,
cough or URI symptoms.  ROS positive for malaise during the last
several months and weight loss of twenty pounds which is
attributed to her recent diagnosis of pancreatic cancer
([**Date range (1) 9184**]) made by ERCP at [**Hospital1 18**].
.
Of note, patient was recently treated for UTI with 7-day course
of ciprofloxacin.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
#. TYPE II DM x35 years without end-organ damage
#. HYPERTENSION
#. HYPERLIPIDEMIA
#. SVT: Noted to be in an unspecified SVT when she presented
with painless jaundice at [**Hospital3 3583**] on [**6-26**].  Found to have
a troponin leak thought to be rate related.  She was seen by
cardiology at [**Hospital1 46**], and BB recommended.
#. PANCREATIC MASS WITH OBSTRUCTIVE JAUNDICE: Presented with sxs
of malaise and jaundice to [**Hospital3 **] on [**6-26**], transferred
to [**Hospital1 18**] for further work up.  Work up during [**Hospital1 18**] admission
([**Date range (1) 18128**]) included following:
* [**2198-6-28**] - ERCP: attempted but failed to cannulate the CBD,
cannulated the pancreatic duct and placed a proximal stent. No
distal pancreatic duct obstruction (ductal width not specified)
* [**2198-6-29**] - repeat ERCP: CBD cannulated - very tight 3cm distal
CBD stricture, brushing cyology suspicious for carcinoma. Stent
placed.
* CTA pancreas [**2198-6-29**] - 1.6 x 1.9 pancreatic head mass
consistent
with adenocarcinoma of uncinate process without CT evidence
vascular invasion or significant adenopathy

MEDICATION ON ADMISSION: HCTZ 25 daily
Avapro 300 qam
Atenolol 25 daily
Novolog 70/30 20 units [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
VS: T 100.6, BP 96/57 (manual 110/70-->no pulsus), HR 81, RR,
100% 2L
Gen: Elderly female in NAD, respiratory or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CV: RRR, distant S1/S2.  No obvious m/r/g.
CHEST: Mild kyphosis.  No focal changes in breath sounds.  No
wheezes.  No crackles.
[**Last Name (un) **]: Obese, soft, NTND.  No [**Doctor Last Name 515**] sign on right or left
side.  Normal to slightly hyperactive bowel sounds.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Dopplerable triphasic DP pulses bilaterally
.
.
On Discharge:
VS: Tm 99.1, BP 104/60, HR 98, RR 20, O2 Sat 99% on RA.  Exam
otherwise not notably changed and benign.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Lives in [**Location 3320**], is widowed with 3 children who live near by.
Retired and lives independently.
Hypovolemia,Malignant neoplasm of head of pancreas,Systolic heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Other ill-defined heart diseases,Old myocardial infarction,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Diarrhea,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia
Hypovolemia,Mal neo pancreas head,Systolic hrt failure NOS,Crnry athrscl natve vssl,Ill-defined hrt dis NEC,Old myocardial infarct,DMII oth nt st uncntrld,Diarrhea,Hypertension NOS,Cardiac dysrhythmias NEC,Hyperlipidemia NEC/NOS
Admission Date:  [**2198-7-30**]              Discharge Date:   [**2198-8-2**]

Date of Birth:  [**2117-8-7**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1145**]
Chief Complaint:
Transferred from OSH with hypotension and elevated troponin.

Major Surgical or Invasive Procedure:
None

History of Present Illness:
Ms. [**Known lastname **] is an 80 year old female with h/o type II DM, HTN,
hyperlipidemia, and recent diagnosis of pancreatic cancer
([**6-/2198**]) awaiting Whipple procedure, who presented to [**Hospital1 3325**] on the day of admission after a mechanical fall.  EMS
VS en route to [**Hospital3 3583**] were BP 142/74,  HR 90, RR 20,
100% 2L.
.
Per patient, she was sitting on the toilet having a BM when she
slipped off the toilet seat onto the floor.  Says that she did
not experience any lightheadedness, dizziness, palps, or chest
pain prior to the episode.  There was no LOC.  She recalls the
entire event.  A friend found her on the floor and helped her
onto her feet and called an ambulance.
.
At OSH ([**Hospital3 3583**]) her vital signs were 97.4, HR 68, RR
20, BP 78/56, 99% 2L.  Subsequently she was noted to be
hypotensive to SBP 60s, she was given 1.5 liters IVF with SBP to
80s and started on dopamine gtt.  She was noted to have STE in
leads I and aVL and also a troponin I of 3.67 with flat CKs.
She was started on a heparin gtt with bolus.  A head CT at OSH
showed no evidence of intracranial hemorrhage.
.
At baseline, patient says she lives independently and is able to
carry out ADLs and most IADLs.  She denies exertional angina
although to be fair, does not regularly walk up stairs or
long-distances.  ROS positive for one loose bowel movement on
morning of admission, no blood and no mucous.  No abdominal
cramping or pain.  She denies fevers, chills, N/V, or decreased
PO intake in days leading up to admission.  She denies dysuria,
cough or URI symptoms.  ROS positive for malaise during the last
several months and weight loss of twenty pounds which is
attributed to her recent diagnosis of pancreatic cancer
([**Date range (1) 9184**]) made by ERCP at [**Hospital1 18**].
.
Of note, patient was recently treated for UTI with 7-day course
of ciprofloxacin.

Past Medical History:
PAST MEDICAL HISTORY:
#. TYPE II DM x35 years without end-organ damage
#. HYPERTENSION
#. HYPERLIPIDEMIA
#. SVT: Noted to be in an unspecified SVT when she presented
with painless jaundice at [**Hospital3 3583**] on [**6-26**].  Found to have
a troponin leak thought to be rate related.  She was seen by
cardiology at [**Hospital1 46**], and BB recommended.
#. PANCREATIC MASS WITH OBSTRUCTIVE JAUNDICE: Presented with sxs
of malaise and jaundice to [**Hospital3 **] on [**6-26**], transferred
to [**Hospital1 18**] for further work up.  Work up during [**Hospital1 18**] admission
([**Date range (1) 18128**]) included following:
* [**2198-6-28**] - ERCP: attempted but failed to cannulate the CBD,
cannulated the pancreatic duct and placed a proximal stent. No
distal pancreatic duct obstruction (ductal width not specified)
* [**2198-6-29**] - repeat ERCP: CBD cannulated - very tight 3cm distal
CBD stricture, brushing cyology suspicious for carcinoma. Stent
placed.
* CTA pancreas [**2198-6-29**] - 1.6 x 1.9 pancreatic head mass
consistent
with adenocarcinoma of uncinate process without CT evidence
vascular invasion or significant adenopathy

Social History:
Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Lives in [**Location 3320**], is widowed with 3 children who live near by.
Retired and lives independently.

Family History:
Non-contributory

Physical Exam:
On Admission:
VS: T 100.6, BP 96/57 (manual 110/70-->no pulsus), HR 81, RR,
100% 2L
Gen: Elderly female in NAD, respiratory or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CV: RRR, distant S1/S2.  No obvious m/r/g.
CHEST: Mild kyphosis.  No focal changes in breath sounds.  No
wheezes.  No crackles.
[**Last Name (un) **]: Obese, soft, NTND.  No [**Doctor Last Name 515**] sign on right or left
side.  Normal to slightly hyperactive bowel sounds.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Dopplerable triphasic DP pulses bilaterally
.
.
On Discharge:
VS: Tm 99.1, BP 104/60, HR 98, RR 20, O2 Sat 99% on RA.  Exam
otherwise not notably changed and benign.


Pertinent Results:
<B><U>LABORATORY RESULTS<U><B>
On Admission:
WBC-16.0* RBC-3.20* Hgb-9.7* Hct-29.8* MCV-93 Plt Ct-551*
Glucose-88 UreaN-28* Creat-1.3* Na-141 K-3.9 Cl-111* HCO3-18*
AnGap-16
PT-14.5* PTT-150* INR(PT)-1.3*
ALT-17 AST-31 LD(LDH)-276* CK(CPK)-127 AlkPhos-193* Amylase-48
TotBili-1.3
Lipase-34
Albumin-2.9* Calcium-8.8 Phos-2.7 Mg-2.0
.
On Discharge:
WBC-10.2 RBC-2.71* Hgb-8.4* Hct-26.0* MCV-96 Plt Ct-435
Glucose-135* UreaN-15 Creat-0.8 Na-138 K-4.3 Cl-108 HCO3-17*
AnGap-17
PT-17.1* PTT-53.4* INR(PT)-1.5*
Calcium-8.8 Phos-2.7 Mg-1.6
.
Cardiac Enzymes
----------------
CK: 127- 131- 91
CK-MB-12*-13*-NotDone
MB Indx-9.4*-9.9*
cTropnT-0.50*-0.42*-0.30*
.
Urinalysis:
Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
RBC-<1 WBC-3 Bacteri-NONE Yeast-NONE Epi-2
.
<b><u>IMAGING/RADIOLOGY<B><U>
EKG on [**2198-7-30**]: Normal sinus rhythm with indeterminate axis. Low
QRS voltage throughout, most pronunced in the limb leads.
Anterior myocardial infarction of indeterminate age. ST-T wave
changes are suggestive of ischemia in the anteroapical region.
Compared to the previous tracing of [**2198-7-13**] QRS voltage is lower
throughout. Anterior Q waves are more pronounced and anterior ST
segment changes are new.
(When compared to previous EKG's from OSH from as long a [**8-3**]
mos ago no significant changes)
.
TRANSTHORACIC ECHO ([**2198-7-30**]):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thicknesses and cavity size are normal. There
is moderate regional left ventricular systolic dysfunction with
near akinesis of the distal half of the septum and anterior
walls, distal inferior and lateral walls, and apex. The apex is
aneurysmal with a 2.3cm mural thrombus. The remaining segments
contract normally (LVEF = 30-35 %). The estimated cardiac index
is normal (>=2.5L/min/m2). Right ventricular chamber size is
normal. with focal hypokinesis of the apical free wall. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic regurgitation. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is a trivial/physiologic pericardial
effusion.
IMPRESSION: Extensive regional left ventricular systolic
dysfunction c/w CAD (mid-LAD distribution and extending to
apical right ventricle). Apical left ventricular aneurysm/large
mural thrombus. Mild mitral regurgitation. Mild pulmonary artery
systolic hypertension.
.
VENOUS LOWER EXTREMITY DOPPLERS ([**2198-7-30**]):
No DVT seen in either leg.
.
Persantine Stress Test [**2198-8-1**]:
IMPRESSION: No anginal symptoms or ST segment changes in
response to
dipyridamole infusion. Nuclear report sent separately.
IMPRESSION:
1. Fixed distal anterior and inferior as well as apical defects
along the
distal anterior and inferior walls as well as apex consistent
with known
anterior wall MI with apical aneurysm.
2. Images at the apex are limited but there is likely
paradoxical motion of the known left apical ventricular
aneurysm.

Brief Hospital Course:
This is an 80-year old female with h/o type II diabetes
mellitus, hypertension, hyperlipidemia, and recent diagnosis of
pancreatic cancer who presents from OSH s/p mechanical fall with
hypotension and elevated cardiac markers.

# PUMP/HYPOTENSION:  Per OSH records, she had hypotension to SBP
70 and subsequently received a 700 cc bolus of NS with bump in
SBP to 100 at time of transfer.  Upon arrival, she received an
additional 2L of NS by repeated 500 cc boluses and her SBP came
up to 110-120.  Differential diagnosis on admission for her
hypotension included cardiogenic causes (principally acute MI,
pericardial tamponade, or pulmonary embolism) versus
distributive causes (sepsis) versus hypovolemia from decreased
PO intake and recent diarrhea. A TTE on night of admission
showed LVEF 30-35% and regional systolic dysfunction in the
distribution of the mid-LAD.  There was an apical left
ventricular aneurysm and mural thrombus.  There was no
significant pericardial effusion.  LE dopplers were negative for
DVT.  Cardiac enzymes, as below, were down-trending.  She was
started empirically on IV flagyl for C dif colitis.  Her blood
pressure increase in response to fluid boluses suggested that
the main cause for her hypotension was hypovolemia in the
context of generally well compensated systolic heart failure.
This was supported by her bump in creatinine at presentation,
which resolved with IVF.  Ultimately, we were able to obtain
outside EKGs, which showed Q waves suggesting her MI had
occurred greater than six months ago and that her decreased EF
and systolic heart failure had been well compensated to this
point with minimal symptomatology especially given her sedentary
lifestyle.  Initially, she had been started on heparin and then
coumadin for anticoagulation of the LV thrombus, but after
concluding that her LV dysfunction and aneurysm had been present
for several months we discontinued this anticoagulation given
the generally stable nature of long-standing clots and minimal
risk of embolization.  She was also restarted on ACEI and
restarted on a BB when her blood pressure recovered for her
hypovolemia as part of a good CHF regimen.  She never had signs
of fluid overload or decompensated heart failure while in the
hospital.

# CAD/ISCHEMIA:  At time of presentation, she had no known
history of coronary artery disease.  As above, her
echocardiogram was strongly suggestive of apical ischemia and
showed Q waves suggestive of old MI.  Large wall motion
abnormality and aneurysmal dilation of LV was consistent with
this.  Initially, there was some concern she was having and ACS
but CKs were relatively low and stable and troponin elevations
were not impressive.  Her treating team believed this was most
consistent with demand ischemia in the context of hypotension as
opposed to ACS.  She had previously been on a statin for known
hyperlipidemia but this had been discontinued due her
transaminitis (in the setting of biliary obstruction from
pancreatic CA) in [**2198-6-22**].  We restarted her statin as
her transaminases had since returned to [**Location 213**].  We continued
her outpatient aspirin in the hospital.  A persantine stress
test was performed prior to hospitalization and showed no
reversible ischemia.

# RHYTHM:  She was monitored on telemetry throughout
hospitalization.  She had several bouts of atrial tachycardia
that were managed by up-titrating her beta blocker dose.  She
was asymptomatic and remained hemodynamically stable during
these events.

# DIARRHEA:  Initially, given her previous course of
ciprofloxacin and diarrhea with hypotension on presentation she
was started on IV metronidazole for empiric therapy of C. diff.
Given her abdominal exam remained benign and the quick
resolution of her hypotension we became less concerned for C
diff and/or toxic megacolon.  After one negative C diff toxin
assay we discontinued her IV metronidazole and she remained
afebrile.  Prior to discharge she had a second negative toxin
assay.  Most likely this was simply antibiotic associated
diarrhea vs a viral enteritis.

# POSITIVE BLOOD CULTURE:  On admission she had blood cultures
drawn as part of a general hypotension work up.  On hospital day
two one out of two of these cultures turned positive for gram
positive cocci.  Thus, given the etiology of hypotension was
still unclear and we were unsure of the organism, vancomycin was
started empirically.  This was discontinued when the culture was
speciated as coagulase negative staph as this organism in [**11-22**]
blood cultures is likely to represent a contaminant.
.
# HTN:  When her blood pressure permitted, we restarted her
outpatient BB and started her on an ACEI for its
cardioprotective effect.  Hydrochlorthiazide was held and not
restarted so as to give her the most room for increased ACEI and
BB.
.
# DM:  She was initially started on her outpatient insulin
regimen, 70/30, 20 units twice daily.  On HD 1, she was
hypoglycemic to 40s overnight.  We decided to stop her standing
insulin and treat her only with sliding scale.  On discharge,
assuming she would eat better at home we restarted her on a much
smaller dose of 70/30 of 2 units [**Hospital1 **] with instructions to
titrate up with her PCP and following her blood glucose values.

.
Ms. [**Known lastname **] was fed a cardiac/heart healthy and diabetic diet.
She was treated with subcutaneous heparin for DVT prophylaxis
(when she wasn't on IV heparin).  She was full code.

Medications on Admission:
HCTZ 25 daily
Avapro 300 qam
Atenolol 25 daily
Novolog 70/30 20 units [**Hospital1 **]

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
5. Novolog 100 unit/mL Solution Sig: Two (2) units Subcutaneous
twice a day.
6. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: One (1)
Tablet Sustained Release 24 hr PO once a day.
Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Partners

Discharge Diagnosis:
Coronary heart Disease
Hypotension with Troponin Leak
Diabetes type 2
Pancreatic Cancer


Discharge Condition:
Vital signs stable.  Afebrile.


Discharge Instructions:
You were admitted to the hospital because your blood pressure
was low and some of the enzymes in your blood were elevated
indicating that you may have suffered a heart attack. With
further testing we do not believe you had an acute blockage in a
vessel in your heart.  Your EKG showed an old heart attack so
your couamdin (warfarin) was discontinued.  Your stress test did
not show any evidence that your heart is not getting enough
blood flow at present.
.
Please weigh yourself every day, let Dr. [**First Name (STitle) 27598**] know if you gain
more than 3 pounds in 1 day of 6 pounds in 3 days.
.
You did not need a lot of insulin in the hospital. We decreased
the Novolog to [**12-23**] to take after discharge. Please continue to
check your fingersticks at home, you may need to increase the
Novolog.

Followup Instructions:
PCP:
[**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone: [**Telephone/Fax (1) 27599**] Date/time: Thursday
[**2198-8-9**] at 3pm.
.
Surgery:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: ([**Telephone/Fax (1) 2363**] Date/Time:
His office will call you with an appt.



Completed by:[**2198-8-3**]
{'Hypovolemia,Malignant neoplasm of head of pancreas,Systolic heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Other ill-defined heart diseases,Old myocardial infarction,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Diarrhea,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia'}


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: Transferred from OSH with hypotension and elevated troponin.

PRESENT ILLNESS: Ms. [**Known lastname **] is an 80 year old female with h/o type II DM, HTN,
hyperlipidemia, and recent diagnosis of pancreatic cancer
([**6-/2198**]) awaiting Whipple procedure, who presented to [**Hospital1 3325**] on the day of admission after a mechanical fall.  EMS
VS en route to [**Hospital3 3583**] were BP 142/74,  HR 90, RR 20,
100% 2L.
.
Per patient, she was sitting on the toilet having a BM when she
slipped off the toilet seat onto the floor.  Says that she did
not experience any lightheadedness, dizziness, palps, or chest
pain prior to the episode.  There was no LOC.  She recalls the
entire event.  A friend found her on the floor and helped her
onto her feet and called an ambulance.
.
At OSH ([**Hospital3 3583**]) her vital signs were 97.4, HR 68, RR
20, BP 78/56, 99% 2L.  Subsequently she was noted to be
hypotensive to SBP 60s, she was given 1.5 liters IVF with SBP to
80s and started on dopamine gtt.  She was noted to have STE in
leads I and aVL and also a troponin I of 3.67 with flat CKs.
She was started on a heparin gtt with bolus.  A head CT at OSH
showed no evidence of intracranial hemorrhage.
.
At baseline, patient says she lives independently and is able to
carry out ADLs and most IADLs.  She denies exertional angina
although to be fair, does not regularly walk up stairs or
long-distances.  ROS positive for one loose bowel movement on
morning of admission, no blood and no mucous.  No abdominal
cramping or pain.  She denies fevers, chills, N/V, or decreased
PO intake in days leading up to admission.  She denies dysuria,
cough or URI symptoms.  ROS positive for malaise during the last
several months and weight loss of twenty pounds which is
attributed to her recent diagnosis of pancreatic cancer
([**Date range (1) 9184**]) made by ERCP at [**Hospital1 18**].
.
Of note, patient was recently treated for UTI with 7-day course
of ciprofloxacin.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
#. TYPE II DM x35 years without end-organ damage
#. HYPERTENSION
#. HYPERLIPIDEMIA
#. SVT: Noted to be in an unspecified SVT when she presented
with painless jaundice at [**Hospital3 3583**] on [**6-26**].  Found to have
a troponin leak thought to be rate related.  She was seen by
cardiology at [**Hospital1 46**], and BB recommended.
#. PANCREATIC MASS WITH OBSTRUCTIVE JAUNDICE: Presented with sxs
of malaise and jaundice to [**Hospital3 **] on [**6-26**], transferred
to [**Hospital1 18**] for further work up.  Work up during [**Hospital1 18**] admission
([**Date range (1) 18128**]) included following:
* [**2198-6-28**] - ERCP: attempted but failed to cannulate the CBD,
cannulated the pancreatic duct and placed a proximal stent. No
distal pancreatic duct obstruction (ductal width not specified)
* [**2198-6-29**] - repeat ERCP: CBD cannulated - very tight 3cm distal
CBD stricture, brushing cyology suspicious for carcinoma. Stent
placed.
* CTA pancreas [**2198-6-29**] - 1.6 x 1.9 pancreatic head mass
consistent
with adenocarcinoma of uncinate process without CT evidence
vascular invasion or significant adenopathy

MEDICATION ON ADMISSION: HCTZ 25 daily
Avapro 300 qam
Atenolol 25 daily
Novolog 70/30 20 units [**Hospital1 **]

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: On Admission:
VS: T 100.6, BP 96/57 (manual 110/70-->no pulsus), HR 81, RR,
100% 2L
Gen: Elderly female in NAD, respiratory or otherwise. Oriented
x3. Mood, affect appropriate. Pleasant.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with no JVD.
CV: RRR, distant S1/S2.  No obvious m/r/g.
CHEST: Mild kyphosis.  No focal changes in breath sounds.  No
wheezes.  No crackles.
[**Last Name (un) **]: Obese, soft, NTND.  No [**Doctor Last Name 515**] sign on right or left
side.  Normal to slightly hyperactive bowel sounds.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Dopplerable triphasic DP pulses bilaterally
.
.
On Discharge:
VS: Tm 99.1, BP 104/60, HR 98, RR 20, O2 Sat 99% on RA.  Exam
otherwise not notably changed and benign.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Social history is significant for the absence of current tobacco
use. There is no history of alcohol abuse. There is no family
history of premature coronary artery disease or sudden death.
Lives in [**Location 3320**], is widowed with 3 children who live near by.
Retired and lives independently. 

### Response:
{'Hypovolemia,Malignant neoplasm of head of pancreas,Systolic heart failure, unspecified,Coronary atherosclerosis of native coronary artery,Other ill-defined heart diseases,Old myocardial infarction,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Diarrhea,Unspecified essential hypertension,Other specified cardiac dysrhythmias,Other and unspecified hyperlipidemia'}
