CHIEF COMPLAINT: Ampullary Tumor

PRESENT ILLNESS: The patient is an 88-year-old woman who is pretty rigorous and
robust and generally healthy.  She presented with biliary
obstruction and workup of this revealed an ampullary tumor.
This was biopsy proven to be adenocarcinoma.  She had a stent
placed followed by a indwelling metal stent by Dr. [**Last Name (STitle) **].  The
patient was referred to Dr. [**Last Name (STitle) **] for resection. The details
of the whipple procedure including all the risks and benefits
were discussed with the patient and she agreed to proceed with
the operation. The patient was also seen by the geratology group
and was seen to have elevated blood pressure. It was found that
she was supposedly treated for this by her primary care
physician, [**Name10 (NameIs) **] had not been following this proposed regimen.  A
lot of her super high blood pressure was due to anxiety issues
she vacillated with her visits.  For this reason we elected to
place an epidural catheter to help manage any postoperative
delirium issues with the use of possible opiate  narcotics.

MEDICAL HISTORY: HTN
PSH:
Her surgical history includes nasal procedures in the past.  Her
GI procedures include an ERCP performed on [**11-26**], which
showed ampullary lesion and this was stented.  The pathology
from
that showed adenocarcinoma in the setting of high-grade
dysplasia.

MEDICATION ON ADMISSION: lisinopril (not taking), cod liver oil (not currently taking)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Discharge:
V/S: 96.9 P 70 BP 146/80 RR 20 O2 98%RA
GEN: NAD, AAx3
CV: RRR, no m/g/r
Lungs: CTAB
ABD: Soft, NT/ND. Jtube in place and patent. Wound is clean,
dry, intact.

FAMILY HISTORY: No h/o colon, pancreatic or other GI tumors.

SOCIAL HISTORY: Denies any smoking or EToH. Lives at home with husband.
Malignant neoplasm of ampulla of vater,Subacute delirium,Mechanical complication of colostomy and enterostomy,Paralytic ileus,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage),Chronic cholecystitis,Esophageal reflux,Anemia, unspecified,Other persistent mental disorders due to conditions classified elsewhere
Mal neo ampulla of vater,Subacute delirium,Colosty/enter comp-mech,Paralytic ileus,Hypertension NOS,Dvrtclo colon w/o hmrhg,Chronic cholecystitis,Esophageal reflux,Anemia NOS,Mental disor NEC oth dis
Admission Date:  [**2107-2-2**]              Discharge Date:   [**2107-2-15**]


Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 148**]
Chief Complaint:
Ampullary Tumor

Major Surgical or Invasive Procedure:
1. Pylorus preserving Whipple's resection.
2. Open cholecystectomy.
3. J-tube placement.


History of Present Illness:
The patient is an 88-year-old woman who is pretty rigorous and
robust and generally healthy.  She presented with biliary
obstruction and workup of this revealed an ampullary tumor.
This was biopsy proven to be adenocarcinoma.  She had a stent
placed followed by a indwelling metal stent by Dr. [**Last Name (STitle) **].  The
patient was referred to Dr. [**Last Name (STitle) **] for resection. The details
of the whipple procedure including all the risks and benefits
were discussed with the patient and she agreed to proceed with
the operation. The patient was also seen by the geratology group
and was seen to have elevated blood pressure. It was found that
she was supposedly treated for this by her primary care
physician, [**Name10 (NameIs) **] had not been following this proposed regimen.  A
lot of her super high blood pressure was due to anxiety issues
she vacillated with her visits.  For this reason we elected to
place an epidural catheter to help manage any postoperative
delirium issues with the use of possible opiate  narcotics.


Past Medical History:
HTN
PSH:
Her surgical history includes nasal procedures in the past.  Her
GI procedures include an ERCP performed on [**11-26**], which
showed ampullary lesion and this was stented.  The pathology
from
that showed adenocarcinoma in the setting of high-grade
dysplasia.


Social History:
Denies any smoking or EToH. Lives at home with husband.

Family History:
No h/o colon, pancreatic or other GI tumors.

Physical Exam:
On Discharge:
V/S: 96.9 P 70 BP 146/80 RR 20 O2 98%RA
GEN: NAD, AAx3
CV: RRR, no m/g/r
Lungs: CTAB
ABD: Soft, NT/ND. Jtube in place and patent. Wound is clean,
dry, intact.

Pertinent Results:
[**2107-2-2**] 05:41PM BLOOD WBC-9.9 RBC-3.56* Hgb-11.8* Hct-33.6*
MCV-94 MCH-33.3* MCHC-35.2* RDW-13.4 Plt Ct-206
[**2107-2-14**] 07:15AM BLOOD WBC-11.6* RBC-3.27* Hgb-10.6* Hct-31.8*
MCV-97 MCH-32.6* MCHC-33.5 RDW-14.2 Plt Ct-387
[**2107-2-2**] 05:41PM BLOOD Glucose-167* UreaN-10 Creat-0.6 Na-139
K-3.6 Cl-105 HCO3-24 AnGap-14
[**2107-2-14**] 07:15AM BLOOD Glucose-116* UreaN-7 Creat-0.7 Na-139
K-4.4 Cl-104 HCO3-29 AnGap-10
[**2107-2-14**] 07:15AM BLOOD ALT-9 AST-11 AlkPhos-73 Amylase-25
TotBili-0.3
[**2107-2-8**] 05:33PM ASCITES Amylase-7980
[**2107-2-12**] 10:35AM ASCITES Amylase-[**Numeric Identifier **]

CT A/P - [**2107-2-9**]
IMPRESSION:
1. Several dilated loops of small bowel with air-fluid levels;
however, there is no transition point and contrast passes into
the transverse colon.  Findings are suggestive of an ileus.
2. Expected postoperative appearance status post Whipple.


Brief Hospital Course:
The patient was admitted to the General Surgical Service on
[**2107-2-2**] for treatment of ampullary cancer. On [**2107-2-2**], the
patient underwent pylorus-preserving pancreaticoduodenectomy
(Whipple) and open cholecystectomy, and Jtube placement, which
went well without complication. Please refer to the operative
note for further details. The patient was extubated in the
operating room and was initially sent to the unit for blood
pressure control with a strict goal of SBP 140-160s. This was
managed with IV labetolol prn. On POD1, the patient was
transferred to the floor. She was NPO with NGT, on IV fluids
with a foley catheter and JP drain in place. She was receiving
epidural with good pain control. The patient was hemodynamically
stable. Her CVL was d/c'd on POD1.

Post-operative pain was initially well controlled with epidural,
which was converted to oral pain medication when tolerating
clear liquids. The NG tube was self discontinued on POD 2, and
the epidural/foley catheter were both discontinued on POD#4. The
patient subsequently voided without problem, but [**Name (NI) **] was low, so
foley was replaced on POD5 and bolus was given, which patient
responded to accordingly. Foley was again d/c'd on POD6, and
patient voided without problem for the remainder of her stay.

The patient was started on sips of clears on POD#3, which was
progressively advanced as tolerated to a regular diet. The
patient did not take much by mouth during her stay, so tube
feeds were started to supplement her nutrition.  These feeds
were via the j-tube and were advanced slowly to goal rate. The
patient had a bout of nausea/emesis on POD6 and patient was made
NPO, and tube feeds were held. JP amylase was sent in the
evening of  POD#6 and was elevated to 7980. CT scan on POD7
showed ileus pattern, but no obvious fluid collections, and the
JP drain was in good position. On POD9, trophic tube feeds were
restarted and patient was given sips, which were tolerated well.
Her diet was re-advanced to regular at discharge, and tube feeds
were readvanced to goal. On POD10, JP amylase was rechecked and
was elevated to [**Numeric Identifier 87873**], but patient was eating well with no
complaints. On POD11, patient's J-tube became blocked, and was
unable to be fixed with bedside viokase and guide-wire. The
patient was sent to IR and had her j-tube replaced. The JP
output was decreasing at time of discharge, and JP drain was
left in place. The JP fluid was sent for culture and initially
grew out GNRs, mixed flora, and budding yeast. The patient was
started on cipro, flagyl, and fluconazole. The cipro was
transitioned to keflex, when speciation showed ancef sensitive
EColi.

During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale  insulin was
administered when indicated. The patient was started on
lisinopril, and metoprolol XR to assist with blood pressure.
During here hospital stay, her BP ranged from 140-160s systolic,
and occasionally higher to the 180s. She remained completely
asymptomatic from her HTN during her stay.

At the time of discharge on [**2107-2-15**] the patient was doing well,
afebrile with stable vital signs.  The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled.  Staples were removed, and steri-strips
placed. The patient was discharged to rehab. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.


Medications on Admission:
lisinopril (not taking), cod liver oil (not currently taking)

Discharge Medications:
1. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
3. metoprolol succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
5. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours): Stop on [**2107-2-23**].
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. cephalexin 500 mg Capsule Sig: One (1) Capsule PO four times
a day: Stop on [**2107-2-23**].
8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours): stop on [**2107-2-23**].
9. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4
times a day (before meals and at bedtime)).
10. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).


Discharge Disposition:
Extended Care

Facility:
Life Care Center of [**Location 15289**]

Discharge Diagnosis:
Ampullary Cancer


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


Discharge Instructions:
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down 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.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within 8-12 hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
.
General 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 [**6-14**] 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.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
Call the doctor, nurse practitioner, or VNA nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently.  Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
JP Drain Care: To bulb suction. Cleanse insertion site with mild
soap and water or sterile saline, pat dry, and place a drain
sponge daily and PRN. Monitor and record quality and quantity of
output. Empty bulb frequently. Ensure that the JP is secured to
the patient.
Monitor for s/s infection or dislocation.


Followup Instructions:
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:[**Telephone/Fax (1) 1231**]
Date/Time:[**2107-3-4**] 9:45

Please call your Primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] an appointment
in One week to have your blood pressure medications adjusted as
necessary.



Completed by:[**2107-2-15**]
{'Malignant neoplasm of ampulla of vater,Subacute delirium,Mechanical complication of colostomy and enterostomy,Paralytic ileus,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage),Chronic cholecystitis,Esophageal reflux,Anemia, unspecified,Other persistent mental disorders due to conditions classified elsewhere'}


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: Ampullary Tumor

PRESENT ILLNESS: The patient is an 88-year-old woman who is pretty rigorous and
robust and generally healthy.  She presented with biliary
obstruction and workup of this revealed an ampullary tumor.
This was biopsy proven to be adenocarcinoma.  She had a stent
placed followed by a indwelling metal stent by Dr. [**Last Name (STitle) **].  The
patient was referred to Dr. [**Last Name (STitle) **] for resection. The details
of the whipple procedure including all the risks and benefits
were discussed with the patient and she agreed to proceed with
the operation. The patient was also seen by the geratology group
and was seen to have elevated blood pressure. It was found that
she was supposedly treated for this by her primary care
physician, [**Name10 (NameIs) **] had not been following this proposed regimen.  A
lot of her super high blood pressure was due to anxiety issues
she vacillated with her visits.  For this reason we elected to
place an epidural catheter to help manage any postoperative
delirium issues with the use of possible opiate  narcotics.

MEDICAL HISTORY: HTN
PSH:
Her surgical history includes nasal procedures in the past.  Her
GI procedures include an ERCP performed on [**11-26**], which
showed ampullary lesion and this was stented.  The pathology
from
that showed adenocarcinoma in the setting of high-grade
dysplasia.

MEDICATION ON ADMISSION: lisinopril (not taking), cod liver oil (not currently taking)

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Discharge:
V/S: 96.9 P 70 BP 146/80 RR 20 O2 98%RA
GEN: NAD, AAx3
CV: RRR, no m/g/r
Lungs: CTAB
ABD: Soft, NT/ND. Jtube in place and patent. Wound is clean,
dry, intact.

FAMILY HISTORY: No h/o colon, pancreatic or other GI tumors.

SOCIAL HISTORY: Denies any smoking or EToH. Lives at home with husband. 

### Response:
{'Malignant neoplasm of ampulla of vater,Subacute delirium,Mechanical complication of colostomy and enterostomy,Paralytic ileus,Unspecified essential hypertension,Diverticulosis of colon (without mention of hemorrhage),Chronic cholecystitis,Esophageal reflux,Anemia, unspecified,Other persistent mental disorders due to conditions classified elsewhere'}
