CHIEF COMPLAINT: Obstructive jaundice

PRESENT ILLNESS: Mr. [**Known lastname 63521**] is a 77 year old,  delightful gentleman who has
widespread recurrent renal cell cancer that is metastatic to
multiple locations including the flank, the pancreas and
probably the bone. He recently had the evolution
of obstructive jaundice, only to an obstructive likely tumor
metastasis in the head of his pancreas. He had an endoscopic
biliary stent placed, but developed stent failure and
cholangitis. He now presents for definitive biliary bypass
and confirmation of histopathology at the root of this
obstruction.

MEDICAL HISTORY: PMH: Pancreatic head mass, obstructive jaundice, RCC, CAD,
^chol, HTN
PSH: R nephrectomy [**2127**], CABG [**2146**]

MEDICATION ON ADMISSION: toprol, accupril, lyrica, neurontin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HR 65, BP 128/66
Gen: looks strong, fit, healthy, and well for his age.  He is
very intelligent, alert, and interactive during the examination.
and physical and history.  He wears bilateral hearing aids but
otherwise his head and neck exam is normal.  He
has no scleral icterus.
CV: RRR, no murmurs. Sternal wound well healed.
Pulm: CTA bilat.
Abd: soft, nontender, nondistended.

FAMILY HISTORY: His mother had a gallbladder operation but
otherwise he has no pertinent family history

SOCIAL HISTORY: He stopped smoking
over 40 years ago and he does not drink alcohol.
Secondary malignant neoplasm of other digestive organs and spleen,Secondary malignant neoplasm of bone and bone marrow,Acute cholecystitis,Hemorrhage complicating a procedure,Personal history of malignant neoplasm of kidney,Obstruction of bile duct,Other alteration of consciousness,Other drugs and medicinal substances causing adverse effects in therapeutic use,Acquired absence of kidney,Peritoneal adhesions (postoperative) (postinfection),Aortocoronary bypass status,Personal history of tobacco use,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension
Sec mal neo GI NEC,Secondary malig neo bone,Acute cholecystitis,Hemorrhage complic proc,Hx of kidney malignancy,Obstruction of bile duct,Other alter consciousnes,Adv eff medicinal NEC,Acquired absence kidney,Peritoneal adhesions,Aortocoronary bypass,History of tobacco use,Cor ath unsp vsl ntv/gft,Hypertension NOS
Admission Date:  [**2148-5-30**]              Discharge Date:   [**2148-6-7**]

Date of Birth:  [**2071-4-24**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Obstructive jaundice

Major Surgical or Invasive Procedure:
Cholecystectomy
Open Head of Pancreatic Biopsy
Hepatico-jejunostomy


History of Present Illness:
Mr. [**Known lastname 63521**] is a 77 year old,  delightful gentleman who has
widespread recurrent renal cell cancer that is metastatic to
multiple locations including the flank, the pancreas and
probably the bone. He recently had the evolution
of obstructive jaundice, only to an obstructive likely tumor
metastasis in the head of his pancreas. He had an endoscopic
biliary stent placed, but developed stent failure and
cholangitis. He now presents for definitive biliary bypass
and confirmation of histopathology at the root of this
obstruction.

Past Medical History:
PMH: Pancreatic head mass, obstructive jaundice, RCC, CAD,
^chol, HTN
PSH: R nephrectomy [**2127**], CABG [**2146**]

Social History:
He stopped smoking
over 40 years ago and he does not drink alcohol.


Family History:
His mother had a gallbladder operation but
otherwise he has no pertinent family history

Physical Exam:
HR 65, BP 128/66
Gen: looks strong, fit, healthy, and well for his age.  He is
very intelligent, alert, and interactive during the examination.
and physical and history.  He wears bilateral hearing aids but
otherwise his head and neck exam is normal.  He
has no scleral icterus.
CV: RRR, no murmurs. Sternal wound well healed.
Pulm: CTA bilat.
Abd: soft, nontender, nondistended.

Pertinent Results:
[**2148-6-5**] 05:17AM BLOOD WBC-9.8 RBC-2.69* Hgb-8.7* Hct-26.0*
MCV-97 MCH-32.4* MCHC-33.5 RDW-14.5 Plt Ct-196
[**2148-6-5**] 06:00PM BLOOD Hct-29.0*
[**2148-5-31**] 08:10AM BLOOD WBC-16.8*# RBC-3.07* Hgb-10.2* Hct-30.2*
MCV-99* MCH-33.1* MCHC-33.6 RDW-15.8* Plt Ct-177
[**2148-6-5**] 03:55AM BLOOD Glucose-142* UreaN-11 Creat-0.9 Na-137
K-3.8 Cl-104 HCO3-24 AnGap-13
[**2148-6-5**] 03:55AM BLOOD ALT-38 AST-52* AlkPhos-87 Amylase-58
TotBili-0.6
[**2148-5-31**] 08:10AM BLOOD Lipase-290*
[**2148-6-5**] 03:55AM BLOOD Lipase-105*
[**2148-5-31**] 08:10AM BLOOD ALT-26 AST-38 AlkPhos-107 Amylase-337*
TotBili-0.8
[**2148-6-5**] 03:55AM BLOOD Calcium-7.8* Phos-2.8 Mg-1.9
.
CT HEAD W/O CONTRAST  [**2148-6-4**] 3:27 PM
IMPRESSION: No evidence of an intracranial hemorrhage or mass
effect.
.
CAROTID SERIES COMPLETE  [**2148-6-5**] 2:58 PM
IMPRESSION: Less than 40% stenosis of the proximal internal
carotid arteries bilaterally.
.


Brief Hospital Course:
He was admitted on [**2148-5-30**] for a
hepaticojejunostomy/cholecystectomy for biliary obstruction.

His post-op course was complicated by three unresponsive
episodes, with stable VS,  requiring transfer to the SICU on
[**6-4**]. Pt transferred back to floor on following day and
unresponsive episodes did not reoccur

GI/Abd: He was NPO, with IVF and a NGT. The NGT was removed on
POD 3. He was started back on a diet on POD 4 and this was
slowly advanced. He was tolerating a regular diet at time of
discharge. His incision was C/D/I. The staples were D/C'd prior
to discharge.

Pain: He had good pain control with an epidural - APS was
following along. His epidural remained in place until POD 5. He
was transitioned to PO meds.

Event [**6-4**]: pt found unresponsive, however his vitals were
stable--> stat CT head/CT torso.CT Head [**6-4**]: No evidence of an
intracranial hemorrhage or mass effect

CT Torso:  1.No pulmonary embolism.  2. Multiple pancreatic
masses unchanged.
3.Post-hepaticojejunostomy without fluid surrounding the
hepaticojejunostomy site.

CAROTID ULTRASOUND [**6-5**]: Less than 40% stenosis of the proximal
internal carotid arteries bilaterally.

Neuro consult obtained:
His exam was notable for anisocoria but reactive pupils and
asterixis. The asterixis indicates that there is likely a
metabolic abnormality which may be the etiology of these
episodes. Infectious causes have been ruled out by negative U/A
and chest CT. Seizure is very unlikely, given the closed eyes,
lack of eye/head deviation, absence of motor activity, and
absence of post-ictal state. The episodes are also too long in
duration to suggest seizure. However, if he continues to have
frequent episodes, it may be worthwhile to get an EEG to capture
a spell. Otherwise, EEG could be considered non-urgently.
Vascular issues are also very low probability, given that he is
lying in bed during the events, has a normal blood pressure, and
has no other abnormalities suggesting brainstem localization on
exam (other than anisocoria, but normal EOMs). Medications may
be a cause, especially the Lyrica or Neurontin.  It would be
useful in the setting of these events to hold all sedating
medications (Neurontin and Lyrica), or at least to decrease the
dose.

[**6-5**]: Normal EEG in the waking and drowsy states. There were no
focal abnormalities or epileptiform features.

Neurontin and Lyrica discontinued based on recommendations per
neurology. Patient also felt that Neurontin and Lyrica were not
helping with his shingles and he preferred to discontinue these
medications.  Pt did not have any issues after he stopped
Neurontin and Lyrica.

[**6-7**] POD#7:  Pt doing well clinically tolerating a regular diet,
ambulating and pain well controlled.  Incision C/D/I.  Pt
discharged to home and is to follow up with Dr. [**Last Name (STitle) 468**] and
Neurology in [**3-2**] weeks.

Medications on Admission:
toprol, accupril, lyrica, neurontin

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr
Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily).
3. Quinapril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
5. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours
for 2 weeks.
Disp:*25 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Pancreatic Head Mass
Post-op Unresponsive episodes x 3


Discharge Condition:
Good
A+O x 3
Tolerating diet
Pain controlled


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 vomitting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomitting,
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.
=
=
=
=
=
================================================================
Please resume all regular home medications and take any new meds
as ordered. Do not take your Neurontin or Lyrica. Discuss with
your PCP if there is a need to restart these meds. Discuss your
unresponsive episodes with your PCP before considering
restarting these medications.
.
Continue to ambulate several times per day.
.
It is OK to shower, no tub baths. [**Date Range **] incision dry and keep
clean and dry.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 468**] in [**3-2**] weeks. Call ([**Telephone/Fax (1) 27734**] to schedule an appointment.
Please follow-up with Neurology in [**3-2**] weeks. Call ([**Telephone/Fax (1) 8951**] to schedule an appointment.
Please follow-up with your PCP [**Last Name (NamePattern4) **] 2 weeks re: your medications.
Do not restart Neurontin or Lyrica without talking to your PCP.



Completed by:[**2148-6-7**]
{'Secondary malignant neoplasm of other digestive organs and spleen,Secondary malignant neoplasm of bone and bone marrow,Acute cholecystitis,Hemorrhage complicating a procedure,Personal history of malignant neoplasm of kidney,Obstruction of bile duct,Other alteration of consciousness,Other drugs and medicinal substances causing adverse effects in therapeutic use,Acquired absence of kidney,Peritoneal adhesions (postoperative) (postinfection),Aortocoronary bypass status,Personal history of tobacco use,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension'}


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: Obstructive jaundice

PRESENT ILLNESS: Mr. [**Known lastname 63521**] is a 77 year old,  delightful gentleman who has
widespread recurrent renal cell cancer that is metastatic to
multiple locations including the flank, the pancreas and
probably the bone. He recently had the evolution
of obstructive jaundice, only to an obstructive likely tumor
metastasis in the head of his pancreas. He had an endoscopic
biliary stent placed, but developed stent failure and
cholangitis. He now presents for definitive biliary bypass
and confirmation of histopathology at the root of this
obstruction.

MEDICAL HISTORY: PMH: Pancreatic head mass, obstructive jaundice, RCC, CAD,
^chol, HTN
PSH: R nephrectomy [**2127**], CABG [**2146**]

MEDICATION ON ADMISSION: toprol, accupril, lyrica, neurontin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: HR 65, BP 128/66
Gen: looks strong, fit, healthy, and well for his age.  He is
very intelligent, alert, and interactive during the examination.
and physical and history.  He wears bilateral hearing aids but
otherwise his head and neck exam is normal.  He
has no scleral icterus.
CV: RRR, no murmurs. Sternal wound well healed.
Pulm: CTA bilat.
Abd: soft, nontender, nondistended.

FAMILY HISTORY: His mother had a gallbladder operation but
otherwise he has no pertinent family history

SOCIAL HISTORY: He stopped smoking
over 40 years ago and he does not drink alcohol. 

### Response:
{'Secondary malignant neoplasm of other digestive organs and spleen,Secondary malignant neoplasm of bone and bone marrow,Acute cholecystitis,Hemorrhage complicating a procedure,Personal history of malignant neoplasm of kidney,Obstruction of bile duct,Other alteration of consciousness,Other drugs and medicinal substances causing adverse effects in therapeutic use,Acquired absence of kidney,Peritoneal adhesions (postoperative) (postinfection),Aortocoronary bypass status,Personal history of tobacco use,Coronary atherosclerosis of unspecified type of vessel, native or graft,Unspecified essential hypertension'}
