CHIEF COMPLAINT: nausea, abdominal pain, poor appetite

PRESENT ILLNESS: Mr. [**Known lastname 15829**] is a 59 year old male with a history of a
Schatzki's ring and intermittant chronic abdominal pain who
presents with 3 weeks of abdominal discomfort, nausea, and
decreased appetite.  He has had intermittant abdominal pain for
the past 4-5 years for which he stops eating for a day or two
and then it goes away.  Approximately 3 weeks ago, however, he
developed a different kind of abdominal pain that is primarily
epigastric and less intense that his usual bouts of abdominal
pain, but much longer lasting.  He denies any significant
vomiting, but has been eating relatively little due to poor
appetite.  He has also been primarily bed bound during this
period and now feels very weak overall.  He does endorse weight
loss, but is unsure how much he has lost.  He had fevers and
chills during the first 6 days of his illness but denies any
within the last week.  He had a bowel movement yesterday that
was dark black in color.  Urine is also darker and foul
smelling, but no dysuria.

MEDICAL HISTORY: 1. Schatzki's ring, most recent dilation [**1-/2156**]
2. Depression
3. Emphysema
4. Sciatica
5. Chronic back pain
6. History of left foot drop and peripheral neuropathy, resolved
7. Status post lipoma removal from the neck, ~20 years ago
8. History of multiple broken ribs, s/p falls

MEDICATION ON ADMISSION: Prozac 60 mg daily
Ibuprofen and aspirin prn back pain

ALLERGIES: Iodine-Iodine Containing / Wellbutrin

PHYSICAL EXAM: Vitals: T: 98.9 BP: 150/60 P: 96 R: 16 O2: 100% RA
General: Alert, oriented, no acute distress, gaunt
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, no CVAT
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, TTP in the epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, negative
[**Doctor Last Name 515**] sign.
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro:  CNII-XII intact; 5/5 strength in the biceps, triceps,
hip flexors, foot flexors and extensors bilaterally.  Sensation
grossly intact throughout and equivalent bilaterally.

FAMILY HISTORY: Mother - has "gallbladder problems" but still has her
gallbladder in
Father - healthy
Diabetes in some great aunts.  Maternal grandmother died of a MI
in her 50s.  No family history of cancer.  Multiple suicides in
the family.

SOCIAL HISTORY: Former software programer, not currently working, lives alone.
Drinks two 12 oz cans of beer daily, though none in the last few
weeks.  Smokes 1.5 - 2 ppd x 38 years, but no tobacco the last
couple of weeks.
Cholangitis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Hemorrhage complicating a procedure,Malignant neoplasm of head of pancreas,Malignant neoplasm of liver, secondary,Chronic vascular insufficiency of intestine,Other emphysema,Benign neoplasm of colon,Anemia, unspecified,Stricture and stenosis of esophagus,Internal hemorrhoids without mention of complication,Sciatica,Other chronic pain,Diverticulosis of colon (without mention of hemorrhage),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Essential thrombocythemia
Cholangitis,Acute kidney failure NOS,Hyposmolality,Hemorrhage complic proc,Mal neo pancreas head,Second malig neo liver,Chr vasc insuff intest,Emphysema NEC,Benign neoplasm lg bowel,Anemia NOS,Esophageal stricture,Int hemorrhoid w/o compl,Sciatica,Chronic pain NEC,Dvrtclo colon w/o hmrhg,Abn react-procedure NEC,Essntial thrombocythemia
Admission Date:  [**2158-12-5**]              Discharge Date:   [**2158-12-12**]

Date of Birth:  [**2099-7-1**]             Sex:   M

Service: MEDICINE

Allergies:
Iodine-Iodine Containing / Wellbutrin

Attending:[**First Name3 (LF) 2009**]
Chief Complaint:
nausea, abdominal pain, poor appetite

Major Surgical or Invasive Procedure:
[**First Name3 (LF) **]
MRCP
EGD
Colonoscopy


History of Present Illness:
Mr. [**Known lastname 15829**] is a 59 year old male with a history of a
Schatzki's ring and intermittant chronic abdominal pain who
presents with 3 weeks of abdominal discomfort, nausea, and
decreased appetite.  He has had intermittant abdominal pain for
the past 4-5 years for which he stops eating for a day or two
and then it goes away.  Approximately 3 weeks ago, however, he
developed a different kind of abdominal pain that is primarily
epigastric and less intense that his usual bouts of abdominal
pain, but much longer lasting.  He denies any significant
vomiting, but has been eating relatively little due to poor
appetite.  He has also been primarily bed bound during this
period and now feels very weak overall.  He does endorse weight
loss, but is unsure how much he has lost.  He had fevers and
chills during the first 6 days of his illness but denies any
within the last week.  He had a bowel movement yesterday that
was dark black in color.  Urine is also darker and foul
smelling, but no dysuria.

In the ED, initial VS were: pain 4, T 97, HR 104, BP 107/64, R
16 100% RA.  Labs were notable for elevated LFTs and a WBC count
of 21.3K.  RUQ Ultrasound demonstrated dilated biliary tree with
an ill-defined pancreatic head mass.  Surgery and [**Known lastname **] teams
were consulted.  Patient was given 2L NS, ciprofloxacin 400 mg
IV, flagyl 500 mg IV for ?cholangitis, oxycodone 5 mg PO, and
zofran 4 mg IV.  Vitals on transfer were HR 86, BP 110/60, R 16,
96% RA.

Review of systems:
(+) Per HPI, + lightheadedness, +DOE (new), + chronic LBP and
sciatica, + hx of intermittant numbness in extremities (not
currently)
(-) Denies night sweats. Denies headache, sinus tenderness,
rhinorrhea or congestion. Denied cough. Denied chest pain or
tightness, palpitations. Denied diarrhea. No dysuria. Denied
myalgias.



Past Medical History:
1. Schatzki's ring, most recent dilation [**1-/2156**]
2. Depression
3. Emphysema
4. Sciatica
5. Chronic back pain
6. History of left foot drop and peripheral neuropathy, resolved
7. Status post lipoma removal from the neck, ~20 years ago
8. History of multiple broken ribs, s/p falls


Social History:
Former software programer, not currently working, lives alone.
Drinks two 12 oz cans of beer daily, though none in the last few
weeks.  Smokes 1.5 - 2 ppd x 38 years, but no tobacco the last
couple of weeks.

Family History:
Mother - has "gallbladder problems" but still has her
gallbladder in
Father - healthy
Diabetes in some great aunts.  Maternal grandmother died of a MI
in her 50s.  No family history of cancer.  Multiple suicides in
the family.


Physical Exam:
Vitals: T: 98.9 BP: 150/60 P: 96 R: 16 O2: 100% RA
General: Alert, oriented, no acute distress, gaunt
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, no CVAT
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, TTP in the epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, negative
[**Doctor Last Name 515**] sign.
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro:  CNII-XII intact; 5/5 strength in the biceps, triceps,
hip flexors, foot flexors and extensors bilaterally.  Sensation
grossly intact throughout and equivalent bilaterally.


Pertinent Results:
                  WBC    Hgb   Hct    MCV MCH    RDW Plt Ct
[**2152-12-11**]:15AM    10.2   11.3* 33.9*  96  32.0   17.1* 828*
[**2154-12-11**]:48AM    13.6*  10.7* 32.2*  94  31.2   17.2* 775*
[**2156-12-9**]:40PM                 30.6*
[**2160-12-9**]:09PM                 30.1*
[**2153-12-10**]:18AM    9.5    9.8*  29.7*#  91  29.9  17.1* 730*
[**2156-12-8**]:36PM                 23.5*
[**2155-12-9**]:32PM    9.0    8.3*  23.7*   94  32.9* 15.8* 660*
[**2159-12-9**]:30AM    9.4    7.8*  24.6*   99* 31.1  15.5 934*
[**2154-12-9**]:55AM    10.4   7.1*  21.0*#  97  32.8* 15.3 842*
[**2154-12-8**]:40AM    11.9*  9.4*  29.3*   98  31.4  15.2 853*
[**2156-12-6**]:05AM    16.5*  9.2*  27.9*   97  31.8  15.1 808*
[**2156-12-5**]:25AM    21.8*  10.4* 31.7*   97  31.7  15.2 889*
[**2151-12-5**]:00PM    21.3*# 12.4* 36.9*   97  32.3* 15.3 911*#
.
  DIFFERENTIAL        Neuts  Lymphs Monos Eos Baso
[**2158-12-12**] 04:15AM    71.8*   22.6  4.0  1.3  0.4
[**2158-12-7**] 07:05AM    85.1*   9.6*  4.8  0.2  0.1
[**2158-12-5**] 02:00PM    84*     2 6*  7 0  0 0  0 1*
.
RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy
Polychr
[**2158-12-5**] 02:00PM    NORMAL NORMAL NORMAL 1+ NORMAL NORMAL

BASIC COAGULATION       PT   PTT     INR(PT)
[**2158-12-12**] 04:15AM    12.4  25.1     1.0
[**2158-12-9**] 02:18PM    13.6* 28.7     1.2*
[**2158-12-5**] 09:00PM    14.5* 31.1     1.3*
.
Chemistry
RENAL & GLUCOSE   Glu  BUN   Crt  Na    K   Cl   HCO3 AnGap
[**2152-12-11**]:15AM    132* 13    0.6  134  4.6   99  28   12
[**2154-12-11**]:48AM    123*  9    0.6  133  4.8   98  27   13
[**2153-12-10**]:18AM    105  10    0.4* 132* 4.3  100  26   10
[**2154-12-9**]:55AM    134* 16    0.4* 131* 4.7   97  27   12
[**2154-12-8**]:40AM    138* 12    0.5  132* 4.2   96  31    9
[**2156-12-6**]:05AM    111* 13    0.4* 131* 4.2   95* 26   14
[**2156-12-5**]:25AM    99    8    0.5  129* 4.1   94* 26   13
[**2158-12-5**]:00PM    114*  9    0.5  126* 4.1   90* 27   13
[**2151-12-5**]:00PM    113* 11    0.5  127* 5.1   86* 28   18
.
                 ALT   AST  LD(LDH) AlkPhos TotBili DirBili
IndBili
[**2154-12-9**]:55AM    45*   31          545*                    0.4

[**2154-12-8**]:40AM    54*   25          760*                    0.5

[**2156-12-6**]:05AM    74*   31          919*                    0.7

[**2156-12-5**]:25AM    115*  79*  [**Telephone/Fax (1) 15830**]*                    1.6*

[**2151-12-5**]:00PM    165* 130*        1677*     1.7*   0.7*    1.0
.
                      Lipase
[**2158-12-5**] 02:00PM    105*
                             Calcium Phos Mg  Iron
[**2158-12-12**] 04:15AM          9.0    2.9  2.4
[**2158-12-11**] 06:48AM          8.9    3.4  2.1
[**2158-12-10**] 05:18AM          8.4    3.7  1.6
[**2158-12-9**] 06:55AM          8.1*   3.3  1.7
[**2158-12-8**] 06:40AM          8.5    2.8  1.8
[**2158-12-7**] 07:05AM          8.3*   2.9  2.0   41*
[**2158-12-6**] 07:25AM          8.7    3.4  1.8
[**2158-12-5**] 02:00PM          9.3    3.8  2.0
.
HEMATOLOGIC     calTIBC VitB12      Folate Hapto Ferritn TRF
[**2156-12-6**]:05AM    138* GREATER TH     12.9 399*   833*   106*
.
IMMUNOLOGY CEA
[**2158-12-7**] 07:05AM    3.3
.
Blood Gas
                    Lactate
[**2158-12-9**] 02:47PM    1.5
 .
  Test                          Result              Reference
Range/Units
CA [**67**]-9                       12                  <37 U/mL

THIS TEST WAS PERFORMED USING THE SIEMENS ([**Doctor Last Name **])
CHEMILUMINESCENT METHOD.
.
Studies:
[**2158-12-5**] PA & LAT CXR - IMPRESSION:
1. No free air under the diaphragms.
2. Emphysema.
3. No acute cardiopulmonary abnormality.
.
[**2158-12-5**] RUQ ultrasound - IMPRESSION:
1. Intra- and extra-hepatic biliary dilatation to the level of
the pancreatic head where a heterogeneous ill-defined mass is
identified, suspicious for pancreatic neoplasm.
2. 1.6-cm indeterminate liver lesion.
3. Gallbladder sludge, without secondary signs of cholecystitis.

.
[**2158-12-6**] [**Month/Day/Year **] - Impression: A Biliary stricture was found in the
lower third of the bile duct. There was severe post-obstructive
dilation of the bile duct. A sphincterotomy was performed. The
stricture was brushed for cytology. A biliary stent was placed.
(sphincterotomy, cytology, stent placement)
Otherwise normal [**Month/Day/Year **] to third part of the duodenum
 .
[**2158-12-6**] MRCP - IMPRESSION:
FINDINGS:
There is a 5.4 x 3.8 cm complex cystic mass in the head and neck
of the
pancreas, the pancreatic duct is dilated upstream as well as
downstream. The inferior aspect of the head of pancreas is the
only pancreatic tissue that has normal high signal intensity on
pre-contrast T1-weighted sequences, the remaining pancreatic
parenchyma has decreased signal intensity and is isointense to
spleen. The downstream pancreatic duct demonstrates mild
increased signal intensity on T1-weighted sequences, which is
hypointense compared to the signal intensity of bile in the
gallbladder on T2 weighted images. The appearances are
suggestive of mucin within the downstream pancreatic duct. The
overall appearances of the pancreatic mass are most consistent
with an invasive adenocarcinoma arising from an IPMN.

There are several enlarged upper abdominal lymph nodes, some of
which
demonstrate cystic change versus necrosis (image 66, series
200). The
superior mesenteric vein, splenic vein and portal vein are
occluded at their confluence (image 64, series 200). The
intrahepatic course of portal vein remains patent. Collateral
venous flow from the spleen is noted through an enlarged
gastroepiploic vein. The hepatic artery is encased with abnormal
soft tissue consistent with direct involvement with the tumor
versus lymphadenopathy (image 16, series 5). There are multiple
upper abdominal venous collaterals including dilated
gastroepiploic vein.

The intra- and extra-hepatic bile ducts are dilated and the
suprapancreatic common bile duct measures 14 mm (image 3, series
7). A common bile duct stent is seen in situ and the
intrapancreatic CBD as it traverses through the pancreatic head
mass tapers down. There is enhancement of the intrahepatic bile
ducts as well as the wall of the CBD highly suggestive of
cholangitis. However, this could also be related to recent
instrumentation. The gallbladder is distended and there is
mucosal hyperenhancing with an area of interruption of the
mucosal lining of the gallbladder mucosal, which is worrisome
for gangrenous cholecystitis (image 80, series 200). There is
mild hyperemia of the liver parenchyma around the gallbladder
fossa.

There are several liver lesions which demonstrate mild
high-signal intensity on T2-weighted sequences, low-signal
intensity on pre-contrast T1-weighted sequences with enhancement
on the dynamic series. The largest of these is a 2.9 x 2.6 cm
segment 7 lesion (image 9, series 5). One of the lesions in
segment VIII demonstrates a subtle halo of low-signal intensity
on the dynamic series (image 27, series 200). Overall
appearances of these liver lesions are highly worrisome for
metastatic disease. A less likely possibility would be hepatic
abscesses.

The spleen, adrenal glands and kidneys appear unremarkable.
There is no free fluid in the abdomen. There is no abnormal
marrow signal.

Multiplanar 2D and 3D reformations and subtraction images
provided multiple perspectives for the dynamic series.

IMPRESSION:
1. Unresectable large complex pancreatic head/neck mass most
consistent with pancreatic adenocarcinoma arising from an IPMN.
Alternatively, the fluid filled collections could be pseudocysts
in the setting of pancreatitis due to an obstructing
adenocarcinoma. There is extensive venous and arterial
involvement as described above.
2. Multiple liver lesions with appearance worrisome for
metastatic disease.  A less likely possibility is multiple liver
abscesses.
3. Upper abdominal lymphadenopathy.
4. Enhancement of the intra- and extra-hepatic bile ducts,
possibly
indicating cholangitis.
5. Distended gallbladder with hyperenhancing mucosa and foci of
interruption of the mucosal lining worrisome for gangrenous
cholecystitis. Clinical correlation is recommended.
.
EGD:
Normal mucosa in the whole stomach
No acitve bleeding or stigmata of recent bleeding was noted from
the sphincteortomy site. The apex of the sphincterotomy was
emperically cauterized [20 j X 4 pulses]. Not clear if this is
the site of GI bleeding.
Otherwise normal EGD to second part of the duodenum
.
Colonoscopy:
Diverticulosis of the whole colon
Polyp in the sigmoid colon (polypectomy)
Grade 3 internal hemorrhoids
Preparation was fair. Therefore, any underlying small lesions
may have not been visible.
No source of bleeding identified. Terminal ileum was intubated
with no bleeding.
Otherwise normal colonoscopy to terminal ileum
.
Cytology:
Common bile duct brushing:

  ATYPICAL.

  A few groups of atypical glandular epithelial cells in
  crowded groups, non-specific, in a background of reactive
  glandular epithelial cells, bile pigment and bacteria.
.
Blood and urine cultures were negative

Brief Hospital Course:
Mr. [**Known lastname 15829**] is is a 59 year old male who presented with
dehydration, nausea, abdominal pain, and poor appetite who was
found to have a pancreatic head mass and cholangitis.
.
#  Cholangitis - The patient's WBC count was elevated on
presentation.  He spike a fever shortly after arrival on the
floor.  He was treated with ciprofloxacin and flagyl and had an
[**Known lastname **] the morning after admission with sphincterotomy, stent
placement, and brushings for cytology.  The following day, his
WBC count was lower, he was afebrile, pain free, and his diet
was advanced. He was discharged with antibiotics to complete a
14 day course. The ciprofloxacin needed to be switched to
levofloxacin because CVS Careplus did not have ciprofloxacin.
.
#  Pancreatic head mass - Initially seen on abdominal ultrasound
and concerning for malignancy.  As the patient was unable to get
CT scan due to iodinated contrast  allergy, surgery recommended
an MRCP for further evaluation. MRCP showed an
unresectable large complex pancreatic head and neck mass and
multiple liver lesions with appearance worrisome for metastatic
disease or less likely possibility is multiple liver abscesses.
Hematology oncology was consulted and their recommendations were
to await the cytology and CA19-9 an abnormality in either of
which would be diagnostic of pancreatic cancer. Surgery was
consulted and they determined that the mass was unresectable.
His CA [**67**]-9 was normal. He needs an EUS for diagnosis which is
scheduled with Dr. [**Last Name (STitle) 15831**]. He also has an appointment with Dr.
[**Last Name (STitle) **] in oncology.
.
#  Thombosis:
Per heme-once, thrombi in mesenteric veins do not embolize into
the lungs, and  they do not reccommend anticoagulating for this.

.
#  Hyponatremia - The patient was hyponatremic on presentation
with a serum sodium of 127.  His hyponatremia improved with IV
fluids.
.
#  acute blood loss anemia/GI bleeding-
On [**2158-12-9**] patient was noted to have a maroon colored stool.  At
that time his pressure was noted to be systolic 80-90 and a hct
was 21 down from 29 (although a repeat was noted to be 24.6).
He was transferred to the MICU for concern for a
post-sphincterotomy bleed.  He was transfused blood and an
endoscopy was performed that day in the MICU and no source of
bleeding could be found.  The sphincterotomy site was cauterized
prophylactically.  The patient tolerated the procedure without
any complications and was called out to the floor team on [**12-11**].
He also had a colonoscopy which revealed a sigmoid polyp which
was removed but no evidence of bleeding. His hematocrit remained
stable.
.
#  Depression - The patient has a history of chronic, severe
depression.  He was continued on prozac.  Social work also saw
the patient to facilitate finding services to help him in the
community. His psychiatrist Dr. [**Last Name (STitle) **] C [**Last Name (STitle) **] was contact[**Name (NI) **] and he
had an appointment with him on the day of discharge. He denied
suicidal ideation.
.
# concern for gangrenous cholecystitis on MRCP
- felt to be low prob as had no abdominal pain after stenting
.
# Code status was discussed and he wished to be full code but
expressed hesitation about life prolonged life support if it
became necessary and there was low probability for recovery. In
his word, "For now, please resusitate me."

Medications on Admission:
Prozac 60 mg daily
Ibuprofen and aspirin prn back pain


Discharge Medications:
1. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY
(Daily).
2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 6 days: 6 more days plus dose for tonight.
Disp:*19 Tablet(s)* Refills:*0*
3. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day
for 6 days.
Disp:*6 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary Diagnoses:
1. Cholangitis
2. Pancreatic head mass, likely malignant
3. Multiple liver masses, likely metastases
4. Gastrointestinal bleed

Secondary Diagnosis:
Major Depression


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


Discharge Instructions:
Dear Mr. [**Last Name (Titles) **],
You were admitted to the hospital for evaluation of nausea and
abdominal pain.  You were found to have cholangitis (an
infection of the bile tract).  You had a procedure called [**Last Name (Titles) **]
and they placed a stent to help keep this open.  You will need a
repeat [**Last Name (Titles) **] in about 2 months.  This appointment has been made
for you.  You will also need to continue taking antibiotics for
six more days.

You were also found to have masses in your pancrease and liver
that are concerning for cancer. You have an appointment with an
oncologist (cancer doctor) this week. You will also be scheduled
for an endoscopic ultrasound to evaluate the lesions in your
liver.

You also developed a bleed in your gastrointestinal tract. This
may have been related to the procedure you had and is a
complication of this procedure. The endoscopist did not find any
source of bleeding but they cauterized the area around the stent
to prevent further bleeding. They also did a colonoscopy and
removed a polyp but did not see any sign of bleeding.

The following additions have been made to your medications:
Take the antibiotics levofloxacin and metronidazole (flagyl) for
six more days to completely treat the bile infection. One of
your antibiotics (ciprofloxacin) is being switched to a nearly
equivalent medicine that is available at the pharmacy. It is
called levofloxacin. We will give you your second dose of
ciprofloxacin here and then start the levofloxacin, which is
once a day tomorrow morning.

Followup Instructions:
Tuesday [**12-12**] at 4pm with Dr. [**Last Name (STitle) **].

Dr.[**Name (NI) 15832**] office will call you and schedule you for an
endoscopic ultrasound soon.

Oncology:
Provider: [**First Name4 (NamePattern1) 488**] [**Last Name (NamePattern1) 6401**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-12-20**] 10:00
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2158-12-20**] 10:00

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]
Specialty: Internal Medicine-Primary Care
Date/ Time: [**2158-12-22**] 8:10am
Location: [**Street Address(2) 15833**], [**Location (un) 538**]- [**Hospital3 **] JP
Phone number: [**Telephone/Fax (1) 608**]

Your Repeat [**Telephone/Fax (1) **] is scheduled as follows:
Provider: [**Name Initial (NameIs) **] 2 (ST-4) GI ROOMS Date/Time:[**2159-2-1**] 11:00
Provider: [**Name10 (NameIs) 1948**] [**Last Name (NamePattern4) 1949**], MD Phone:[**Telephone/Fax (1) 463**]
Date/Time:[**2159-2-1**] 11:00
{'Cholangitis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Hemorrhage complicating a procedure,Malignant neoplasm of head of pancreas,Malignant neoplasm of liver, secondary,Chronic vascular insufficiency of intestine,Other emphysema,Benign neoplasm of colon,Anemia, unspecified,Stricture and stenosis of esophagus,Internal hemorrhoids without mention of complication,Sciatica,Other chronic pain,Diverticulosis of colon (without mention of hemorrhage),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Essential thrombocythemia'}


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: nausea, abdominal pain, poor appetite

PRESENT ILLNESS: Mr. [**Known lastname 15829**] is a 59 year old male with a history of a
Schatzki's ring and intermittant chronic abdominal pain who
presents with 3 weeks of abdominal discomfort, nausea, and
decreased appetite.  He has had intermittant abdominal pain for
the past 4-5 years for which he stops eating for a day or two
and then it goes away.  Approximately 3 weeks ago, however, he
developed a different kind of abdominal pain that is primarily
epigastric and less intense that his usual bouts of abdominal
pain, but much longer lasting.  He denies any significant
vomiting, but has been eating relatively little due to poor
appetite.  He has also been primarily bed bound during this
period and now feels very weak overall.  He does endorse weight
loss, but is unsure how much he has lost.  He had fevers and
chills during the first 6 days of his illness but denies any
within the last week.  He had a bowel movement yesterday that
was dark black in color.  Urine is also darker and foul
smelling, but no dysuria.

MEDICAL HISTORY: 1. Schatzki's ring, most recent dilation [**1-/2156**]
2. Depression
3. Emphysema
4. Sciatica
5. Chronic back pain
6. History of left foot drop and peripheral neuropathy, resolved
7. Status post lipoma removal from the neck, ~20 years ago
8. History of multiple broken ribs, s/p falls

MEDICATION ON ADMISSION: Prozac 60 mg daily
Ibuprofen and aspirin prn back pain

ALLERGIES: Iodine-Iodine Containing / Wellbutrin

PHYSICAL EXAM: Vitals: T: 98.9 BP: 150/60 P: 96 R: 16 O2: 100% RA
General: Alert, oriented, no acute distress, gaunt
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, no CVAT
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, TTP in the epigastrium, non-distended, bowel
sounds present, no rebound tenderness or guarding, negative
[**Doctor Last Name 515**] sign.
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro:  CNII-XII intact; 5/5 strength in the biceps, triceps,
hip flexors, foot flexors and extensors bilaterally.  Sensation
grossly intact throughout and equivalent bilaterally.

FAMILY HISTORY: Mother - has "gallbladder problems" but still has her
gallbladder in
Father - healthy
Diabetes in some great aunts.  Maternal grandmother died of a MI
in her 50s.  No family history of cancer.  Multiple suicides in
the family.

SOCIAL HISTORY: Former software programer, not currently working, lives alone.
Drinks two 12 oz cans of beer daily, though none in the last few
weeks.  Smokes 1.5 - 2 ppd x 38 years, but no tobacco the last
couple of weeks. 

### Response:
{'Cholangitis,Acute kidney failure, unspecified,Hyposmolality and/or hyponatremia,Hemorrhage complicating a procedure,Malignant neoplasm of head of pancreas,Malignant neoplasm of liver, secondary,Chronic vascular insufficiency of intestine,Other emphysema,Benign neoplasm of colon,Anemia, unspecified,Stricture and stenosis of esophagus,Internal hemorrhoids without mention of complication,Sciatica,Other chronic pain,Diverticulosis of colon (without mention of hemorrhage),Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Essential thrombocythemia'}
