CHIEF COMPLAINT: Jaundice and hematemesis.

PRESENT ILLNESS: This is an 89-year-old woman
resident of [**Location 109829**] with a history of chronic obstructive
pulmonary disease, congestive heart failure, and
hypertension, admitted from [**Hospital3 **] due to
several episodes of hematemesis at nursing facility.  Per
[**Hospital3 **] records she has had nausea and vomiting
over the past two weeks with jaundice noticed the day of
admission.  By Ms. [**Known lastname 109830**] report she denies fevers,
chills, diarrhea, melena, or hematemesis prior to this recent
episode.  She cannot quantify how many times she has vomited,
but denies abdominal pain, or history of ulcer disease.

MEDICAL HISTORY: 1. Chronic obstructive pulmonary
disease.  2. Congestive heart failure.  Echocardiogram showed
normal biventricular function, moderate MR, moderate to
severe TR, and pulmonary hypertension.  3. Hypertension.  4.
Deep venous thrombosis of left popliteal, right popliteal,
and STV in [**2119-4-3**].  5. VRE in [**2114-4-3**].  6.
Clostridium difficile in [**2119-6-3**].  7. Left hemispheric
stroke with residual right hemiplegia, upper extremities
greater than lower extremities.  8. Peripheral vascular
disease status post femoral-popliteal bypass on the left
side.

MEDICATION ON ADMISSION: Tylenol 650 once daily; Norvasc
2.5 once daily; aspirin 325 once daily; Os-Cal 500 once
daily; Colace 100 b.i.d.; Estraderm patch q. three days;
beclomethasone; AeroBid 4 twice a day; Axid; [**Doctor First Name **] 60 mg
once daily; Zestril 5 mg once daily; Citrucel; M.V.I.; and
Detrol.

ALLERGIES: Penicillin, Keflex, Captopril, erythromycin, and
shellfish.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: 
Malignant neoplasm of head of pancreas,Malignant neoplasm of liver, secondary,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Primary pulmonary hypertension,Mitral valve disorders,Diseases of tricuspid valve,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side
Mal neo pancreas head,Second malig neo liver,CHF NOS,Chr airway obstruct NEC,Prim pulm hypertension,Mitral valve disorder,Tricuspid valve disease,Late ef-hemplga side NOS
Admission Date:  [**2122-3-31**]       Discharge Date:  [**2122-4-3**]


Service:

CHIEF COMPLAINT:  Jaundice and hematemesis.

HISTORY OF PRESENT ILLNESS:  This is an 89-year-old woman
resident of [**Location 109829**] with a history of chronic obstructive
pulmonary disease, congestive heart failure, and
hypertension, admitted from [**Hospital3 **] due to
several episodes of hematemesis at nursing facility.  Per
[**Hospital3 **] records she has had nausea and vomiting
over the past two weeks with jaundice noticed the day of
admission.  By Ms. [**Known lastname 109830**] report she denies fevers,
chills, diarrhea, melena, or hematemesis prior to this recent
episode.  She cannot quantify how many times she has vomited,
but denies abdominal pain, or history of ulcer disease.

Per chart she is alert and oriented x 3, independent, with
100% activities of daily living.  Her last admission to [**Hospital1 1444**] was in [**2119**].

In the Emergency Department Ms. [**Known lastname **] was noted to be very
jaundiced.  Bilirubin was 8 (6.9 direct), white blood cell
count 25, alkaline phosphatase over 1,000.

Right upper quadrant ultrasound showed common bile duct 13
mm, distended gallbladder, no choledocholithiasis, no
obstructing mass.  In the Emergency Department the patient
had hematemesis of about 1-2 liters of coffee ground emesis,
cleared with 750 cc of nasogastric lavage.

The patient was hemodynamically stable.  Blood pressure was
about 170 systolic, heart rate in the 80s, with an hematocrit
of 34.2, which dropped to 31.  She was treated with normal
saline boluses, and Protonix intravenously.  Endoscopic
retrograde cholangiopancreatography fellow was called and
scoped in the AM.  The patient is DNR/DNI.

PAST MEDICAL HISTORY:  1. Chronic obstructive pulmonary
disease.  2. Congestive heart failure.  Echocardiogram showed
normal biventricular function, moderate MR, moderate to
severe TR, and pulmonary hypertension.  3. Hypertension.  4.
Deep venous thrombosis of left popliteal, right popliteal,
and STV in [**2119-4-3**].  5. VRE in [**2114-4-3**].  6.
Clostridium difficile in [**2119-6-3**].  7. Left hemispheric
stroke with residual right hemiplegia, upper extremities
greater than lower extremities.  8. Peripheral vascular
disease status post femoral-popliteal bypass on the left
side.

MEDICATIONS ON ADMISSION:  Tylenol 650 once daily; Norvasc
2.5 once daily; aspirin 325 once daily; Os-Cal 500 once
daily; Colace 100 b.i.d.; Estraderm patch q. three days;
beclomethasone; AeroBid 4 twice a day; Axid; [**Doctor First Name **] 60 mg
once daily; Zestril 5 mg once daily; Citrucel; M.V.I.; and
Detrol.

ALLERGIES:  Penicillin, Keflex, Captopril, erythromycin, and
shellfish.

PHYSICAL EXAMINATION:  On admission her temperature was
100.3, pulse 89, blood pressure 188/45, respiratory rate 20,
97% on room air.  In general she was a thin, elderly lady
lying in bed in no acute distress.  Head, eyes, ears, nose
and throat - normocephalic, atraumatic, extraocular movements
intact, sclerae icteric, pupils small, 2 mm, surgical,
oropharynx dry.  Chest had rales at the right base.  Heart
was regular rate and rhythm with a 2/6 systolic ejection
murmur at the right upper sternal border.  The abdomen was
soft with bowel sounds, healed mid lower abdominal scar,
nontender, no hepatosplenomegaly noted.  Extremities had 1+
bilateral edema.  The right lower extremity was in an
Aircast.  Rectal examination showed guaiac-positive stools,
brown.  Neurologic examination showed her to be alert and
oriented x 3, moving all four extremities.

Ultrasound showed dilatation of intrahepatic and common bile
duct 13 mm, distended gallbladder, no pericholecystic fluid,
positive dilated bile duct, no choledocholithiasis, no
obstructing mass, normal kidneys.  There was a 2-cm simple
cyst in the right kidney.

LABORATORY STUDIES:  On admission her white count was 25.7,
hematocrit 34.2, platelets 506, sodium 130, potassium 4,
chloride 91, bicarbonate 27, BUN 18, creatinine 0.8, glucose
115, ALT 316, AST 369, alkaline phosphatase 1097, bilirubin
8.7 with direct of 6, amylase 79, lipase 98, INR 1.3, and
partial thromboplastin time 28.

HOSPITAL COURSE:  This is a [**Age over 90 **]-year-old female resident of
[**Hospital3 **] admitted with at least four days of
intermittent nausea, vomiting, and jaundice x 1 day with
coffee ground emesis.

1. Gastrointestinal:  The patient underwent endoscopic
retrograde cholangiopancreatography which had demonstrated
stenosed and ulcerated distal esophagus and a duodenal mass
suggestive of cancer, which was biopsied.  There was moderate
common bile duct dilatation and successful plastic stent
placement in the common bile duct.  The patient subsequently
underwent CT of the abdomen for further staging, which
demonstrated three hypodense lesions in the liver (the
biggest at 13 mm) and an atrophic pancreas.  A hypodense mass
of 20 mm was noted in the head of the pancreas which abuts
the superior mesenteric vein but does not compress it.  The
patient was also noted to have pleural effusion bilaterally
and a hiatal hernia.  No other nodes or significant
lymphadenopathy was noted on CT of the chest and pelvis.

Ulcerations in the esophagus were treated with Protonix
b.i.d.  The patient was able to tolerate food very well after
her procedure and no further hematemesis was noted.  The
patient's hematocrit remained stable and on the day of
discharge was noted to be 34.3 down from 38 on the day of
admission.  The patient's white count also decreased and the
patient will continue a course of levofloxacin for seven days
after endoscopic retrograde cholangiopancreatography as
prophylaxis.

Liver chemistries were noted to taper down and on discharge,
ALT was 201, AST 179, alkaline phosphatase peaked at 1,402,
but dropped down to 1,084, and total bilirubin was down to
3.1.

2. Oncology:  Biopsies from the periduodenal mass are still
pending but likely a metastatic adenocarcinoma to the liver.
We contact[**Name (NI) **] and spoke with the oncology fellow who will
attempt to arrange follow up for the patient in clinic with
Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].  Until biopsy results have returned, the
patient should not and will not start chemotherapy at this
point and will not be followed in the hospital for this.

3. Infectious disease:  The patient was noted to have
low-grade fevers status post procedure and will continue
antibiotics for six to seven more days.  White blood cell
count was noted to be decreasing from 19 on admission to 16.2
on the day of discharge.

4. Cardiovascular:  The patient has a history of hypertension
and congestive heart failure.  Zestril had been held on
admission but was restarted and the patient responded well,
however was noted to have blood pressures ranging 140s to
170s systolic, and probably should be followed up in the next
week or two for a possible increase of Zestril.

Code status:  DNR/DNI.

FLUIDS, ELECTROLYTES AND NUTRITION:  The patient was noted to
have hypomagnesemia and was repleted with two to three days
of magnesium oxide; also noted to be hypocalcemic, and will
receive Tums x 3 days with meals.  She was also noted to be
hypophosphatemic and received Neutra-Phos with meals and
responded quite well to this treatment.

DISPOSITION:  The patient will be discharged back to [**Hospital3 1761**] Center.  The patient will follow up with
oncology, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], at a to be determined date.  The
patient should have electrolytes followed and repleted in the
next 1-2 weeks.

DISCHARGE MEDICATIONS:
1. Levofloxacin 500 mg p.o. once daily x [**6-8**] more days.
2. Flovent 2 puffs b.i.d.
3. Albuterol metered dose inhaler two puffs q. 4-6 hours
p.r.n.
4. Protonix 40 mg p.o. b.i.d.
5. Tums 500 mg p.o. t.i.d. x two more days.
6. Neutra-Phos two packets p.o. x 1 at nursing home.
7. Magnesium oxide 400 mg p.o. t.i.d. x 2 more days.
8. Zestril 5 mg p.o. once daily.
9. Colace 100 mg p.o. b.i.d.
10. Milk of Magnesia 30 cc p.o. q. 4 hours p.r.n..
11. Dulcolax 10 mg p.o./p.r. b.i.d. p.r.n.
12. Trazodone 50 mg p.o. q.h.s. p.r.n.
13. Norvasc 2.5 mg p.o. once daily.
14. Os-Cal 500 once daily.
15. Estraderm patch q. 3 days.
16. Citrucel, M.V.I., [**Doctor First Name **] 60 mg b.i.d., AeroBid, and
beclomethasone.

DISCHARGE CONDITION:  Fair.

DISCHARGE DIAGNOSES:
1. Possible adenocarcinoma of pancreas.
2. Esophageal ulcerations.
3. Liver lesions.


                         DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-806



Dictated By:[**Last Name (NamePattern1) 19212**]
MEDQUIST36

D:  [**2122-4-3**]  11:44
T:  [**2122-4-3**]  12:13
JOB#:  [**Job Number 11285**]
{'Malignant neoplasm of head of pancreas,Malignant neoplasm of liver, secondary,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Primary pulmonary hypertension,Mitral valve disorders,Diseases of tricuspid valve,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side'}


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: Jaundice and hematemesis.

PRESENT ILLNESS: This is an 89-year-old woman
resident of [**Location 109829**] with a history of chronic obstructive
pulmonary disease, congestive heart failure, and
hypertension, admitted from [**Hospital3 **] due to
several episodes of hematemesis at nursing facility.  Per
[**Hospital3 **] records she has had nausea and vomiting
over the past two weeks with jaundice noticed the day of
admission.  By Ms. [**Known lastname 109830**] report she denies fevers,
chills, diarrhea, melena, or hematemesis prior to this recent
episode.  She cannot quantify how many times she has vomited,
but denies abdominal pain, or history of ulcer disease.

MEDICAL HISTORY: 1. Chronic obstructive pulmonary
disease.  2. Congestive heart failure.  Echocardiogram showed
normal biventricular function, moderate MR, moderate to
severe TR, and pulmonary hypertension.  3. Hypertension.  4.
Deep venous thrombosis of left popliteal, right popliteal,
and STV in [**2119-4-3**].  5. VRE in [**2114-4-3**].  6.
Clostridium difficile in [**2119-6-3**].  7. Left hemispheric
stroke with residual right hemiplegia, upper extremities
greater than lower extremities.  8. Peripheral vascular
disease status post femoral-popliteal bypass on the left
side.

MEDICATION ON ADMISSION: Tylenol 650 once daily; Norvasc
2.5 once daily; aspirin 325 once daily; Os-Cal 500 once
daily; Colace 100 b.i.d.; Estraderm patch q. three days;
beclomethasone; AeroBid 4 twice a day; Axid; [**Doctor First Name **] 60 mg
once daily; Zestril 5 mg once daily; Citrucel; M.V.I.; and
Detrol.

ALLERGIES: Penicillin, Keflex, Captopril, erythromycin, and
shellfish.

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Malignant neoplasm of head of pancreas,Malignant neoplasm of liver, secondary,Congestive heart failure, unspecified,Chronic airway obstruction, not elsewhere classified,Primary pulmonary hypertension,Mitral valve disorders,Diseases of tricuspid valve,Late effects of cerebrovascular disease, hemiplegia affecting unspecified side'}
