CHIEF COMPLAINT: Ampullary adenoma

PRESENT ILLNESS: Mr. [**Known lastname 112231**] is a 61M who was evaluated to have a pancreatic
ductal dilatation and a bulging ampullary mass that showed
low-grade dysplasia on biopsy.  This was after he developed a
vague abdominal pain and a weight loss over the past  several
months.  He had no prior abdominal surgical history,
but he has relatively new diagnoses of coronary artery disease
that was being evaluated and chronic obstructive pulmonary
disease from 50 years of smoking cigarettes.  He also drinks a
considerable amount.
He had mild jaundice, back pain, abdominal pain and weight loss,
but no steatorrhea.  He is not diabetic.  He does not have any
chest pains, palpitations.  He is on aspirin and which was be
held preoperatively.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
- [**7-/2168**] Cardiac cath - no CAD, mild LV dysfunction without MR
LVEF 45%, non-ischemic cardiomyopathy
- [**1-/2168**] Stress MIBI with abnormal gated scintigraphy. EKG 2mm
ST
depression. Occasional PVCs. Perfusion abnormaloty with mild
anterior wall LV and apex with reversibility. Mild global
hypokinesis.
- Hypertension
- Hyperlipidemia
- 50 pack year h/o tobacco abuse
- h/o impair fasting glucose
- COPD
- h/o ampullary adenoma with pancreatic ductation dilation
- recent 25lb unintentional weight loss since [**2168-2-24**]

MEDICATION ON ADMISSION: ASA 81 mg daily
Atenolol 50 mg daily
Nitrostat - PRN; has never used
Nicotine patch 21 mg daily

ALLERGIES: Thiazides / ACE inhibitors / Terazosin

PHYSICAL EXAM: Upon Discharge:
Vitals: 98.2, 56, 136/70, 12, 96% RA
Gen: AAo X 3, NAD
CV: Sinus bradycardia
Resp: CTAB, diminished bases b/l
Abd: Bilateral subcostal incision with staples and open to air,
moderate erythema around staples line with minimal swelling.
Right lateral portion open with moist-to-dry dressing and
moderate serosanguinous drainage. Old JP site with occlusive
dressing and c/d/i.
Ext: Warm, no c/c/e

FAMILY HISTORY: Uncle premature CAD and death in 50s
Mother alive, no known heart disease
Father died from ETOHism and ?CAD
Brother died from AIDS
Sister unknown health status, estranged

SOCIAL HISTORY: ETOH: [**2-26**] rums/d for 30+ years. Pt does not endorse problem with
[**Name (NI) 31483**]
Tobacco: quit 12 days ago smoked 1.5 ppd for 40+ yrs
Illicits: prior marijuana, denies cocaine, no IVDU
Living: In townshend with wife
Working: [**Name (NI) **] worker driving the [**Name (NI) 68444**] bus
Benign neoplasm of liver and biliary passages,Obstruction of bile duct,Other primary cardiomyopathies,Acidosis,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Alcohol withdrawal,Chronic pancreatitis,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Loss of weight,Other alteration of consciousness,Other and unspecified alcohol dependence, continuous
Ben neo liver/bile ducts,Obstruction of bile duct,Prim cardiomyopathy NEC,Acidosis,Cholelith w cholecys NEC,Alcohol withdrawal,Chronic pancreatitis,Chr airway obstruct NEC,Crnry athrscl natve vssl,Hypertension NOS,Hyperlipidemia NEC/NOS,Tobacco use disorder,Abnormal loss of weight,Other alter consciousnes,Alcoh dep NEC/NOS-contin
Admission Date:  [**2168-8-31**]              Discharge Date:   [**2168-9-8**]

Date of Birth:  [**2107-1-6**]             Sex:   M

Service: SURGERY

Allergies:
Thiazides / ACE inhibitors / Terazosin

Attending:[**First Name3 (LF) 473**]
Chief Complaint:
Ampullary adenoma


Major Surgical or Invasive Procedure:
[**2168-8-31**]:
1. Transduodenal ampullary resection.
2. Reimplantation of common bile duct and pancreatic duct.
3. Open cholecystectomy with common bile duct exploration.


History of Present Illness:
Mr. [**Known lastname 112231**] is a 61M who was evaluated to have a pancreatic
ductal dilatation and a bulging ampullary mass that showed
low-grade dysplasia on biopsy.  This was after he developed a
vague abdominal pain and a weight loss over the past  several
months.  He had no prior abdominal surgical history,
but he has relatively new diagnoses of coronary artery disease
that was being evaluated and chronic obstructive pulmonary
disease from 50 years of smoking cigarettes.  He also drinks a
considerable amount.
He had mild jaundice, back pain, abdominal pain and weight loss,
but no steatorrhea.  He is not diabetic.  He does not have any
chest pains, palpitations.  He is on aspirin and which was be
held preoperatively.

Past Medical History:
PAST MEDICAL HISTORY:
- [**7-/2168**] Cardiac cath - no CAD, mild LV dysfunction without MR
LVEF 45%, non-ischemic cardiomyopathy
- [**1-/2168**] Stress MIBI with abnormal gated scintigraphy. EKG 2mm
ST
depression. Occasional PVCs. Perfusion abnormaloty with mild
anterior wall LV and apex with reversibility. Mild global
hypokinesis.
- Hypertension
- Hyperlipidemia
- 50 pack year h/o tobacco abuse
- h/o impair fasting glucose
- COPD
- h/o ampullary adenoma with pancreatic ductation dilation
- recent 25lb unintentional weight loss since [**2168-2-24**]

PAST SURGICAL HISTORY:
- EGD/ERCP
- Right breast nodule excision
- [**8-/2168**] transduodenal ampullary resection
- [**8-/2168**] open cholecystectomy with common bile duct exploration

Social History:
ETOH: [**2-26**] rums/d for 30+ years. Pt does not endorse problem with
[**Name (NI) 31483**]
Tobacco: quit 12 days ago smoked 1.5 ppd for 40+ yrs
Illicits: prior marijuana, denies cocaine, no IVDU
Living: In townshend with wife
Working: [**Name (NI) **] worker driving the [**Name (NI) 68444**] bus

Family History:
Uncle premature CAD and death in 50s
Mother alive, no known heart disease
Father died from ETOHism and ?CAD
Brother died from AIDS
Sister unknown health status, estranged

Physical Exam:
Upon Discharge:
Vitals: 98.2, 56, 136/70, 12, 96% RA
Gen: AAo X 3, NAD
CV: Sinus bradycardia
Resp: CTAB, diminished bases b/l
Abd: Bilateral subcostal incision with staples and open to air,
moderate erythema around staples line with minimal swelling.
Right lateral portion open with moist-to-dry dressing and
moderate serosanguinous drainage. Old JP site with occlusive
dressing and c/d/i.
Ext: Warm, no c/c/e

Pertinent Results:
[**2168-9-6**] 03:13AM BLOOD WBC-4.2 RBC-4.19* Hgb-13.8* Hct-42.0
MCV-100* MCH-32.9* MCHC-32.8 RDW-14.0 Plt Ct-210
[**2168-9-1**] 05:40AM BLOOD WBC-9.0 RBC-4.54* Hgb-15.4 Hct-46.7
MCV-103* MCH-33.9* MCHC-32.9 RDW-13.7 Plt Ct-137*
[**2168-9-6**] 03:13AM BLOOD Glucose-124* UreaN-5* Creat-0.6 Na-142
K-3.8 Cl-102 HCO3-33* AnGap-11

Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 112232**],[**Known firstname **]       [**2107-1-6**]    61 Male      [**-1/3519**]
[**Numeric Identifier 112233**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by:   DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/mtd

SPECIMEN SUBMITTED:  Gallbladder, ampulla Vater.
Procedure date     Tissue received     Report Date    Diagnosed
by
[**2168-8-31**] [**2168-8-31**] [**2168-9-2**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 15706**]/dsj??????

DIAGNOSIS:
1.  Gallbladder, cholecystectomy (A-B): Chronic cholecystitis
and cholelithiasis.
2.  Ampulla of Vater, resection (C-F):
A.  Adenoma (low-grade dysplasia) involving duodenum with
minimal involvement of the ampullary duct; no invasive carcinoma
seen.
B.  Cauterized margins free of dysplasia.
Clinical:   Ampullary adenoma.


Brief Hospital Course:
The patient was admitted to the General Surgical Service for
evaluation and treatment.  On [**2168-8-31**], the patient underwent
transduodenal ampullary resection, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor NPO, on IV fluids, with a foley
catheter, with CIWA protocol in place for alcohol withdrawal,
and an epidural for pain control.  The patient was
hemodynamically stable.
On POD#1 ([**9-1**]): The epidural was continued for pain control, and
the foley catheter was maintained. IVF were continued, and the
patient remained NPO. Due to an episode of questionable chest
pain, an ECG, CXR, and cardiac enzymes were obtained, all of
which were negative. In the evening, his pain control was split
between an epidural and a PCA.
On POD#2 ([**9-2**]): He was continued on IVF, and due to an episode
of brief mom[**Name (NI) 12823**] unresponsiveness responding well to
supplementary oxygen, cardiac enzymes and CXR were repeated,
which were once again unremarkable. On this day his epidural was
discontinued, but foley catheter was maintained for strict input
and output monitoring.
On POD#3 ([**9-3**]): Due to some concern for erythema around his
incision, he was placed on IV antibiotics (cefazolin). IVF were
continued, and his PCA was maintained for pain control. Due to
severe agitation and signs of withdrawal in the evening, he was
transferred to the SICU for further care.
On POD#4 ([**9-4**]): He continued to display symptoms of withdrawal,
for which the CIWA protocol was employed. His foley catheter was
maintained, and IVF were continued.
On POD#5 ([**9-5**]): He had some continued, but improved symptoms of
withdrawal and agitation. His foley catheter was maintained, and
he was continued on IVF. He remained NPO for diet. His pain was
controlled with intermittent IV dilaudid.
On POD#6 ([**9-6**]): Patient was transferred on the floor from ICU
in stable condition. His diet was increased to clears and was
well tolerated. Small amount of erythema was noticed around
incision without any drainage.
On POD#7 ([**9-7**]): Diet increased to full liquids. Patient
ambulate independently. He was started on IV Cefazolin
empirically s/t redness around his wound was increased and small
fluid collection was palpable on right lateral site of incision.
JP drain was removed.
On POD#8 ([**9-8**]): Patient remained afebrile. Diet advanced to
regular and well tolerated. Right lateral aspect of incision was
open and moist-to-dry dressing was started, patient will
continue to have moist-to-dry dressing at home with VNA. The
patient was discharged home in stable condition.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization. Electrolytes were routinely
followed, and repleted when necessary. The patient's white blood
count and fever curves were closely watched for signs of
infection. Wound care was performed regularly and thoroughly.
The patient's blood sugar was monitored throughout his stay;
insulin dosing was adjusted accordingly. The patient received
subcutaneous heparin 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, 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:
ASA 81 mg daily
Atenolol 50 mg daily
Nitrostat - PRN; has never used
Nicotine patch 21 mg daily

Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Nitroglycerin SL 0.3 mg SL PRN chest pain
5. Nicotine Patch 14 mg TD DAILY
6. Cephalexin 500 mg PO Q6H
7. Famotidine 20 mg PO Q12H
8. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain
9. Docusate Sodium 100 mg PO BID


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
1. Ampullary adenoma
2. Chronic cholecystitis and cholelithiasis
3. EtOH withdrawal


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


Discharge Instructions:
You were admitted to the surgery service at [**Hospital1 18**] for surgical
resection of your pancreatic mass. You have done well in the
post operative period and are now safe to return home to
complete your recovery with the following 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 [**6-2**] 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.
*Right lateral part of you wound is open and will be packed with
gauze.
*Please call Dr. [**Last Name (STitle) 468**] office if you notice fever > 101, your
incision become more red or swollen, output will increase or
become odorous.

Followup Instructions:
Department: SURGICAL SPECIALTIES
When: MONDAY [**2168-9-19**] at 11:45 AM
With: [**First Name8 (NamePattern2) 251**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 2835**]
Building: [**Hospital6 29**] [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
.
Please follow up with Dr. [**Last Name (STitle) 71878**] (PCP) in [**2-26**] weeks after
discharge.
.
Please follow up with your Cardiologist in [**2-26**] weeks after
discharge.



Completed by:[**2168-9-8**]
{'Benign neoplasm of liver and biliary passages,Obstruction of bile duct,Other primary cardiomyopathies,Acidosis,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Alcohol withdrawal,Chronic pancreatitis,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Loss of weight,Other alteration of consciousness,Other and unspecified alcohol dependence, continuous'}


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 adenoma

PRESENT ILLNESS: Mr. [**Known lastname 112231**] is a 61M who was evaluated to have a pancreatic
ductal dilatation and a bulging ampullary mass that showed
low-grade dysplasia on biopsy.  This was after he developed a
vague abdominal pain and a weight loss over the past  several
months.  He had no prior abdominal surgical history,
but he has relatively new diagnoses of coronary artery disease
that was being evaluated and chronic obstructive pulmonary
disease from 50 years of smoking cigarettes.  He also drinks a
considerable amount.
He had mild jaundice, back pain, abdominal pain and weight loss,
but no steatorrhea.  He is not diabetic.  He does not have any
chest pains, palpitations.  He is on aspirin and which was be
held preoperatively.

MEDICAL HISTORY: PAST MEDICAL HISTORY:
- [**7-/2168**] Cardiac cath - no CAD, mild LV dysfunction without MR
LVEF 45%, non-ischemic cardiomyopathy
- [**1-/2168**] Stress MIBI with abnormal gated scintigraphy. EKG 2mm
ST
depression. Occasional PVCs. Perfusion abnormaloty with mild
anterior wall LV and apex with reversibility. Mild global
hypokinesis.
- Hypertension
- Hyperlipidemia
- 50 pack year h/o tobacco abuse
- h/o impair fasting glucose
- COPD
- h/o ampullary adenoma with pancreatic ductation dilation
- recent 25lb unintentional weight loss since [**2168-2-24**]

MEDICATION ON ADMISSION: ASA 81 mg daily
Atenolol 50 mg daily
Nitrostat - PRN; has never used
Nicotine patch 21 mg daily

ALLERGIES: Thiazides / ACE inhibitors / Terazosin

PHYSICAL EXAM: Upon Discharge:
Vitals: 98.2, 56, 136/70, 12, 96% RA
Gen: AAo X 3, NAD
CV: Sinus bradycardia
Resp: CTAB, diminished bases b/l
Abd: Bilateral subcostal incision with staples and open to air,
moderate erythema around staples line with minimal swelling.
Right lateral portion open with moist-to-dry dressing and
moderate serosanguinous drainage. Old JP site with occlusive
dressing and c/d/i.
Ext: Warm, no c/c/e

FAMILY HISTORY: Uncle premature CAD and death in 50s
Mother alive, no known heart disease
Father died from ETOHism and ?CAD
Brother died from AIDS
Sister unknown health status, estranged

SOCIAL HISTORY: ETOH: [**2-26**] rums/d for 30+ years. Pt does not endorse problem with
[**Name (NI) 31483**]
Tobacco: quit 12 days ago smoked 1.5 ppd for 40+ yrs
Illicits: prior marijuana, denies cocaine, no IVDU
Living: In townshend with wife
Working: [**Name (NI) **] worker driving the [**Name (NI) 68444**] bus 

### Response:
{'Benign neoplasm of liver and biliary passages,Obstruction of bile duct,Other primary cardiomyopathies,Acidosis,Calculus of gallbladder with other cholecystitis, without mention of obstruction,Alcohol withdrawal,Chronic pancreatitis,Chronic airway obstruction, not elsewhere classified,Coronary atherosclerosis of native coronary artery,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Loss of weight,Other alteration of consciousness,Other and unspecified alcohol dependence, continuous'}
