CHIEF COMPLAINT: 1. Epigastric Pain
2. Chest pain

PRESENT ILLNESS: 87M with significant cardiac history p/w 4 days of epigastric
and chest pain radiating into the back.  Patient presented to ED
Friday evening after no improvement in the pain. He reports
having subject fevers at home, though he never measured his
temperature.  Otherwise he denies nausea, vomiting, shortness of
breath.  He did report some constipation over the past few days
though reports having a bowel movement today.

MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery
bypass graft in [**2144**] and [**2142**]
2. Left ventricular aneurysm.
3. Congestive heart failure with ejection fraction less than
20% from the echocardiogram in [**2160-6-10**]. He had a
biventricular implantable cardioverter-defibrillator placed
in [**2160-6-10**].
4. s/p IMI
5. AAA - repaired in [**2147**]
6. Chronic obstructive pulmonary disease.
7. Hypertension.
8. Hyperlipidemia status post appendectomy in [**2092**].
9. BPH
10. DM2

MEDICATION ON ADMISSION: DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth every other day
GLIPIZIDE -  (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 5 mg
Tablet
- 1 Tablet(s) by mouth in am and 2 tabs in pm
LISINOPRIL - 5 mg Tablet - [**12-13**] Tablet(s) by mouth once a day
LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
POTASSIUM CHLORIDE - 10 mEq Tablet Sustained Release - 1
Tablet(s) by mouth once a day
SITAGLIPTIN [JANUVIA] -  (Prescribed by Other Provider: [**Name Initial (NameIs) **])
-
50 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN [FLOMAX] -  (Dose adjustment - no new Rx) - 0.4 mg
Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day
WARFARIN [COUMADIN] - 2 mg Tablet - take Tablet(s) by mouth as
directed
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth once a day

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: On Admission:
T100.6 HR102 BP148/80 RR24 O299 RA
NAD
PERRL, EOMI b/l, sclera anicteric
Neck supple
CV: RRR, paced
Pulm: CTA b/l
Abd: soft, min TTP in RUQ, non distended, no rebound/gaurding,
neg [**Doctor Last Name 515**] sign
Ext: no edema

FAMILY HISTORY: Significant for father dying of lung cancer and mother dying of
myocardial infarction at age 65.

SOCIAL HISTORY: 1 PPD x 30 years
Malignant neoplasm of duodenum,Calculus of gallbladder and bile duct with acute and chronic cholecystitis, with obstruction,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction,Chronic systolic heart failure,Bacteremia,Cholangitis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Gout, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypotension, unspecified,Personal history of tobacco use,Asbestosis,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled
Malignant neopl duodenum,Gal&bil cal w/ac&ch w ob,Stomach ulcer NOS-obstr,Chr systolic hrt failure,Bacteremia,Cholangitis,Cor ath unsp vsl ntv/gft,Aortocoronary bypass,Gout NOS,Chr airway obstruct NEC,Hypertension NOS,Hyperlipidemia NEC/NOS,BPH w/o urinary obs/LUTS,Hypotension NOS,History of tobacco use,Asbestosis,Atrial fibrillation,Status autm crd dfbrltr,Old myocardial infarct,DMII wo cmp nt st uncntr
Admission Date:  [**2167-4-4**]              Discharge Date:   [**2167-4-15**]


Service: SURGERY

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
1. Epigastric Pain
2. Chest pain


Major Surgical or Invasive Procedure:
[**2167-4-4**]: ERCP
[**2167-4-6**]: ERCP
[**2167-4-8**]: 1. Distal gastrectomy with Billroth II reconstruction
and
partial duodenectomy.
2. Open cholecystectomy.


History of Present Illness:
87M with significant cardiac history p/w 4 days of epigastric
and chest pain radiating into the back.  Patient presented to ED
Friday evening after no improvement in the pain. He reports
having subject fevers at home, though he never measured his
temperature.  Otherwise he denies nausea, vomiting, shortness of
breath.  He did report some constipation over the past few days
though reports having a bowel movement today.


Past Medical History:
1. Coronary artery disease status post coronary artery
bypass graft in [**2144**] and [**2142**]
2. Left ventricular aneurysm.
3. Congestive heart failure with ejection fraction less than
20% from the echocardiogram in [**2160-6-10**]. He had a
biventricular implantable cardioverter-defibrillator placed
in [**2160-6-10**].
4. s/p IMI
5. AAA - repaired in [**2147**]
6. Chronic obstructive pulmonary disease.
7. Hypertension.
8. Hyperlipidemia status post appendectomy in [**2092**].
9. BPH
10. DM2


Social History:
1 PPD x 30 years

He grew up in [**Location (un) 3146**], [**State 350**]. He is a veteran of the
Army. He was in the air corps. He is married, has a wife and
three grown children. He is a retired fireman and insurance
salesman. No tobacco use. He did smoke but quit 20 years ago. He
is an ex-smoker for 50 pack per year, he quit in [**2142**]. No
intravenous drug use. Social alcohol use. No drug use.


Family History:
Significant for father dying of lung cancer and mother dying of
myocardial infarction at age 65.


Physical Exam:
On Admission:
T100.6 HR102 BP148/80 RR24 O299 RA
NAD
PERRL, EOMI b/l, sclera anicteric
Neck supple
CV: RRR, paced
Pulm: CTA b/l
Abd: soft, min TTP in RUQ, non distended, no rebound/gaurding,
neg [**Doctor Last Name 515**] sign
Ext: no edema

On Discharge:
VS: T 97.4, HR 83, BP 115/65, RR 18, 94% RA
Gen: NAD
CV: RRR, paced
Lungs: CTAB
Abd: Midline incision with staples, clean/dry and intact. JP
site with suture c/d/i. Soft, tenderness around incision site.
Nondistended
Ext: Warm, no c/c/e


Pertinent Results:
[**2167-4-3**] 08:10PM   WBC-14.8*# RBC-4.67 HGB-13.9* HCT-40.8 MCV-87
MCH-29.8 MCHC-34.2 RDW-13.4
[**2167-4-3**] 08:10PM   NEUTS-95.5* LYMPHS-1.7* MONOS-2.0 EOS-0.5
BASOS-0.4
[**2167-4-3**] 08:10PM   PT-21.7* PTT-29.8 INR(PT)-2.0*
[**2167-4-3**] 08:10PM   GLUCOSE-207* UREA N-26* CREAT-1.4* SODIUM-137
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-20* ANION GAP-20
[**2167-4-3**] 08:10PM   ALT(SGPT)-313* AST(SGOT)-402* ALK PHOS-135*
TOT BILI-2.9*
[**2167-4-3**] 08:10PM   LIPASE-23
[**2167-4-3**] 09:15PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-12* PH-5.0 LEUK-NEG
[**2167-4-3**] 09:15PM URINE  RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0 TRANS EPI-0-2
[**2167-4-8**] 06:58AM BLOOD WBC-10.4 RBC-4.41* Hgb-12.7* Hct-39.5*
MCV-90 MCH-28.9 MCHC-32.2 RDW-14.2 Plt Ct-168
[**2167-4-8**] 06:58AM BLOOD PT-14.9* PTT-29.1 INR(PT)-1.3*
[**2167-4-8**] 06:58AM BLOOD Glucose-121* UreaN-9 Creat-0.9 Na-141
K-3.8 Cl-109* HCO3-23 AnGap-13
[**2167-4-8**] 06:58AM BLOOD ALT-67* AST-62* LD(LDH)-220 AlkPhos-115
TotBili-1.0
[**2167-4-8**] 06:58AM BLOOD Calcium-8.1* Phos-2.6* Mg-2.0

[**2167-4-3**] 8:15 pm BLOOD CULTURE
                      **FINAL REPORT [**2167-4-6**]**
Blood Culture, Routine (Final [**2167-4-6**]):
ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
296-0154H [**2167-4-3**]. Anaerobic Bottle Gram Stain (Final [**2167-4-4**]):
   GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final [**2167-4-4**]):    GRAM NEGATIVE
ROD(S).
SENSITIVITIES: MIC expressed in MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S

[**2167-4-9**] 6:20 am MRSA SCREEN      Source: Nasal swab.
**FINAL REPORT [**2167-4-11**]**
MRSA SCREEN (Final [**2167-4-11**]):    No MRSA isolated

[**2167-4-3**] EKG:
Ventricular paced rhythm. Compared to the previous tracing of
[**2164-5-6**] there is no change.
[**2167-4-3**] CHEST XRAY:
IMPRESSION: Chronic interstitial lung disease, most pronounced
at the lung
bases, similar to prior. No acute cardiopulmonary abnormality
otherwise
visualized.
[**2167-4-3**] ABD CT:
IMPRESSION: 1. Obstructive choledocholithiasis at the distal CBD
resulting in severe intrahepatic and extrahepatic biliary ductal
dilatation. Recommend ERCP to further assess.
2. No pulmonary embolism or acute aortic pathology. Mild
infrarenal aortic
ectasia.
3. Calcified pleural plaques with pulmonary fibrosis with lower
lobe
predominance, compatible with asbestosis. Multiple pulmonary
nodules, grossly similar or slightly larger in appearance, for
which a nonurgent dedicated CT chest is recommended for further
evaluation.
4. Significant aortic calcification, but major intra-abdominal
arteries are patent.
5. Large right exophytic renal cyst.

[**2167-4-4**] ERCP:
Impression: 1. A moderate amount of semi solid food residue was
noted in the stomach.
2. A stricture was seen in the pylorus. The scope did not
traverse the lesion.
3. A 12mm balloon was introduced for dilation and the diameter
was progressively increased to 15 mm successfully.
4. The duodenoscope was then successfully passed into the
duodenum.
5. A mass was found at the duodenal bulb. Due to duodenal
deformity, we were unable to position the scope in front of the
ampulla to attempt biliary cannulation. Large capacity forceps
biopsies were performed for histology at the mass in the
duodenal bulb.
6. Mass in the duodenal bulb
7. Otherwise normal ercp to third part of the duodenum

[**2167-4-5**] EKG:
Normal sinus rhythm, rate 81, with ventricular synchronous
pacing. Occasional ventricular premature beat. Compared to the
previous tracing of [**2167-4-3**] sinus tachycardia has given way to
normal sinus rhythm and ventricular ectopy is new.

[**2167-4-6**]: ERCP:
Impression: Small ulcer noted at the pylorus, which was stenotic
but improved after dilation 2 days ago.
Mass in the duodenal bulb as seen previously - biopsies pending
A single diverticulum with large opening was found at the major
papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome after a guidewire was placed.
Contrast medium was injected resulting in complete
opacification.
A moderate diffuse dilation was seen at the biliary tree with
the CBD measuring 18 mm.
Three round stones ranging in size from 8 mm to 12 mm that were
causing partial obstruction were seen at the lower third of the
common bile duct.
There was post-obstructive dilation.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
4 large stones and biliary sludge were extracted successfully
using a 15 mm balloon.
The bile duct was clear at the end of the procedure
Otherwise normal ercp to third part of the duodenum

[**2167-4-7**] CARDIAC PERFUSION PERSANTINE:
INTERPRETATION:
The image quality is adequate.
Left ventricular cavity size is normal, with EDV of 114 mL.
Rest and stress perfusion images reveal a severe fixed inferior
wall defect.
Gated images reveal mild global hypokinesis.
The calculated left ventricular ejection fraction is 47%.
IMPRESSION: Severe fixed inferior wall defect. Mild global
hypokinesis.

[**2167-4-8**]             Pathology Examination
Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 109061**],[**Known firstname **]       [**2079-8-8**]    87 Male      [**Numeric Identifier 109062**] [**Numeric Identifier 109063**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by:   DR. [**Last Name (STitle) **]. ROBENS/cofc
SPECIMEN SUBMITTED: gallbladder, stomach/duodenum.
Procedure date     Tissue received     Report Date    Diagnosed
by
[**2167-4-8**] [**2167-4-8**] [**2167-4-11**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/dsj??????
Previous biopsies:    [**Numeric Identifier 109064**]  G I BIOPSY (1 JAR).
  [**-7/2209**]  G.I. BIOPSIES (2 JARS)
  [**-2/2991**]  GI BIOPSY.
  [**Numeric Identifier 109065**]  (Not on file)
DIAGNOSIS:
I.  Gallbladder (A-C):
Acute and chronic focally necrotizing cholecystitis with
ulceration and transmural inflammation.
One lymph node, no malignancy identified.
II.  Stomach/Duodenum (D-Q):  Adenocarcinoma arising in the
background of an adenoma, see synoptic report.
Small intestine: Polypectomy; Segmental Resection; Whipple
procedure (Pancreaticoduodenectomy, partial or complete, with or
without partial Gastrectomy Synopsis
MACROSCOPIC
Specimen Type:  Segmental resection.
Tumor Site:  Duodenum.
Tumor configuration:  Exophytic (polypoid).
Tumor Size
Greatest dimension:  3.2 cm.  Additional dimensions:  3.0 cm x
2.8 cm.
Other organs Received:    Attached portion of stomach;
gallbladder
MICROSCOPIC
Histologic Type:  Mucinous adenocarcinoma (greater than 50%
mucinous).
Histologic Grade:  G1:  Well differentiated.
EXTENT OF INVASION
Primary Tumor:  pT2:  Tumor invades muscularis propria.
Regional Lymph Nodes:  pN0:  No regional lymph node metastasis.
Lymph Nodes
    Number examined:  1.
    Number involved:  0.
Distant metastasis:  pMX:  Cannot be assessed.
Margins
    Proximal margin:
        Uninvolved by invasive carcinoma.
    Distal margin:
        Uninvolved by invasive carcinoma.
    Circumferential/radial (mesenteric or retroperitoneal)
margin:
        Uninvolved by invasive carcinoma.
    Bile duct margin:   Not applicable
    Pancreatic margin:   Not applicable
    Distance of carcinoma from closest margin:  13 mm.
Specified margin:  Circumferential/radial.
Venous (Large vessel) invasion:  Present.
Perineural invasion:  Absent.
Additional Pathologic Findings:  Adenoma(s).

[**2167-4-14**] IRN 1.5










Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment of severe epigastric and chest pain.
Patient was admitted into MICU for observation. On [**2167-4-4**]
patient underwent ERCP which revealed a mass in the duodenal
bulb, biopsy was taken. On [**2167-4-6**] patient underwent repeat
ERCP with extraction of the 4 large stones and biliary sludge.
On [**2167-4-8**], the patient underwent distal gastrectomy with
Billroth II reconstruction and partial duodenectomy, and open
cholecystectomy which went well without complication (reader
referred to the Operative Note for details). After surgery
patient was transferred into SICU NPO, on IV fluids and
antibiotics, with a foley catheter, and IT Morphine for pain
control. The patient was hemodynamically stable.

Neuro: The patient received IT Morphine postoperatively with
good effect and adequate pain control. POD # 1 patient was
started on Dilaudid PCA, which was changed to IV Dilaudid. When
tolerating oral intake, the patient was transitioned to oral
pain medications. Patient's pain was well controlled during his
hospital course.

CV: On admission patient complained chest pain, and was
hypotensive with SBP in 80s. Cardiac enzymes were sent and they
were negative, hypotension was treated with IV fluid without
pressors. Cardiology was called to consult and ICD evaluation.
Patient underwent Cardiac Echo and Cardiac stress test. Stress
test revealed LVEF is 47%. Cardiac Echo compared with the prior
report of [**2159-4-19**] showed that left ventricular systolic function
is improved. Cardiology recommended continue Lasix with goal
negative 1000 ml, and start Lopressor 5 mg IV q6h. Patient's
Coumadin was hold for procedure, and was restarted on [**4-13**].
Patient was restarted on all his home cardiac medications on
[**4-14**]. Patient was monitored with telemetry during his hospital
course. The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.

Pulmonary: Post op patient developed respiratory distress and
was required CPAP. Patient's respiratory status improved
spontaneously after sedation was weaned off. The patient
remained stable from a pulmonary standpoint; vital signs were
routinely monitored. Good pulmonary toilet, early ambulation and
incentive spirrometry were encouraged throughout
hospitalization.

GI/GU/FEN: Post-operatively, the patient was made NPO with IV
fluids. Patient was started on sips of clears on [**4-12**]. Diet was
advanced when appropriate, which was well tolerated. Currently
patient tolerates regular Diabetic/Consistent Carbohydrate diet.
Patient's intake and output were closely monitored, and IV fluid
was adjusted when necessary, and finally d/cd. Electrolytes were
routinely followed, and repleted when necessary.

ID: On admission, patient's WBC was 21.2. Blood cultures grew
E-coli, patient was started on IV Flagyl and Cipro on [**4-4**].
Patient's WBC is treading down (14.0 on [**4-10**]), he is afebrile.
He will continue on PO Flagyl/Cipro x 4 days after discharge.

Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly. FS was within
normal limits, patient was started on his home meds.

Hematology: The patient's complete blood count was examined
routinely; no transfusions were required. Prior surgery,
patient's Coumadin was on hold, patient received prophylactic
Enoxaparin 30 gm SC BID. Coumadin was restarted on [**4-13**]. INR on
[**4-15**] was 1.5, patient will continue to receive Lovenox until
his INR will 2.0 or higher.

Prophylaxis: The patient received subcutaneous Enoxaparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.

At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating with assistance, voiding without assistance,
and pain was well controlled. The patient received discharge
teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.


Medications on Admission:
DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth every other day
GLIPIZIDE -  (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 5 mg
Tablet
- 1 Tablet(s) by mouth in am and 2 tabs in pm
LISINOPRIL - 5 mg Tablet - [**12-13**] Tablet(s) by mouth once a day
LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
POTASSIUM CHLORIDE - 10 mEq Tablet Sustained Release - 1
Tablet(s) by mouth once a day
SITAGLIPTIN [JANUVIA] -  (Prescribed by Other Provider: [**Name Initial (NameIs) **])
-
50 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN [FLOMAX] -  (Dose adjustment - no new Rx) - 0.4 mg
Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day
WARFARIN [COUMADIN] - 2 mg Tablet - take Tablet(s) by mouth as
directed
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth once a day


Discharge Medications:
1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 4 days. Tablet(s)
2. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day
for 4 days.
3. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day.
6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
8. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1)  Subcutaneous
[**Hospital1 **] (2 times a day): continue until INR 2.0 or greater.
9. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
11. Sitagliptin 50 mg Tablet Sig: One (1) Tablet PO once a day.

12. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One
(1) Tablet Sustained Release PO once a day.
13. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1)
Capsule, Sust. Release 24 hr PO HS (at bedtime).
14. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
PM.
15. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
16. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once
a day.
17. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed for SOB.
18. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q4H (every 4 hours) as
needed for SOB.
19. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
20. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO every
twelve (12) hours for 3 weeks.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 9475**] Care Center - [**Location (un) 3146**]

Discharge Diagnosis:
1. Duodenal tumor
2. Hypotension
3. E-coli bacteremia



Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge 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 [**4-20**] 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.
* Your suture will be removed on [**4-22**]


Followup Instructions:
Please call [**Telephone/Fax (1) 1144**] to arrange a follow up appointment with
Dr. [**Last Name (STitle) **] (PCP) in [**12-13**] weeks after discharge to check your INR
and Coumadin adjustment.
.
Provider:  [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2167-6-25**]
2:30
.
Provider: [**Name10 (NameIs) 1918**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 62**]
Date/Time:[**2167-6-25**] 3:20
.
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2167-5-1**] 9:30. [**Hospital Ward Name 23**] 3, [**Hospital Ward Name **]



Completed by:[**2167-4-15**]
{'Malignant neoplasm of duodenum,Calculus of gallbladder and bile duct with acute and chronic cholecystitis, with obstruction,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction,Chronic systolic heart failure,Bacteremia,Cholangitis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Gout, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypotension, unspecified,Personal history of tobacco use,Asbestosis,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}


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: 1. Epigastric Pain
2. Chest pain

PRESENT ILLNESS: 87M with significant cardiac history p/w 4 days of epigastric
and chest pain radiating into the back.  Patient presented to ED
Friday evening after no improvement in the pain. He reports
having subject fevers at home, though he never measured his
temperature.  Otherwise he denies nausea, vomiting, shortness of
breath.  He did report some constipation over the past few days
though reports having a bowel movement today.

MEDICAL HISTORY: 1. Coronary artery disease status post coronary artery
bypass graft in [**2144**] and [**2142**]
2. Left ventricular aneurysm.
3. Congestive heart failure with ejection fraction less than
20% from the echocardiogram in [**2160-6-10**]. He had a
biventricular implantable cardioverter-defibrillator placed
in [**2160-6-10**].
4. s/p IMI
5. AAA - repaired in [**2147**]
6. Chronic obstructive pulmonary disease.
7. Hypertension.
8. Hyperlipidemia status post appendectomy in [**2092**].
9. BPH
10. DM2

MEDICATION ON ADMISSION: DIGOXIN - 125 mcg Tablet - 1 Tablet(s) by mouth once a day
FUROSEMIDE -  (Dose adjustment - no new Rx) - 20 mg Tablet - 1
Tablet(s) by mouth every other day
GLIPIZIDE -  (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 5 mg
Tablet
- 1 Tablet(s) by mouth in am and 2 tabs in pm
LISINOPRIL - 5 mg Tablet - [**12-13**] Tablet(s) by mouth once a day
LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day
METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - 1
Tablet(s) by mouth once a day
OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s)
by mouth once a day
POTASSIUM CHLORIDE - 10 mEq Tablet Sustained Release - 1
Tablet(s) by mouth once a day
SITAGLIPTIN [JANUVIA] -  (Prescribed by Other Provider: [**Name Initial (NameIs) **])
-
50 mg Tablet - 1 Tablet(s) by mouth once a day
TAMSULOSIN [FLOMAX] -  (Dose adjustment - no new Rx) - 0.4 mg
Capsule, Sust. Release 24 hr - 1 Capsule(s) by mouth once a day
WARFARIN [COUMADIN] - 2 mg Tablet - take Tablet(s) by mouth as
directed
ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by
mouth once a day
CYANOCOBALAMIN [VITAMIN B-12] - 1,000 mcg Tablet - 1 Tablet(s)
by
mouth once a day

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: On Admission:
T100.6 HR102 BP148/80 RR24 O299 RA
NAD
PERRL, EOMI b/l, sclera anicteric
Neck supple
CV: RRR, paced
Pulm: CTA b/l
Abd: soft, min TTP in RUQ, non distended, no rebound/gaurding,
neg [**Doctor Last Name 515**] sign
Ext: no edema

FAMILY HISTORY: Significant for father dying of lung cancer and mother dying of
myocardial infarction at age 65.

SOCIAL HISTORY: 1 PPD x 30 years 

### Response:
{'Malignant neoplasm of duodenum,Calculus of gallbladder and bile duct with acute and chronic cholecystitis, with obstruction,Gastric ulcer, unspecified as acute or chronic, without mention of hemorrhage or perforation, with obstruction,Chronic systolic heart failure,Bacteremia,Cholangitis,Coronary atherosclerosis of unspecified type of vessel, native or graft,Aortocoronary bypass status,Gout, unspecified,Chronic airway obstruction, not elsewhere classified,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Hypotension, unspecified,Personal history of tobacco use,Asbestosis,Atrial fibrillation,Automatic implantable cardiac defibrillator in situ,Old myocardial infarction,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled'}
