CHIEF COMPLAINT: Presyncope

PRESENT ILLNESS: Patient is a 64 year old male with h/o pancreatic adenocarcinoma
s/p Whipple [**1-/2159**], a. fib on warfarin, LV systolic dysfunction
with LVEF 25-30%, and Type II DM who p/w pre-syncope.  Per
report, had pre-syncopal episode earlier today.  Walked to care
with wife, eyes rolled in back of head, wife noted perioral
cyanosis.  Patient denies loss of consciousness.  Denies chest
pain/pressure, palpitations, or dyspnea.  No seizure-like
activity.  No consfusion, no bowel/bladder incontinence.  First
pre-syncopal event.  Evaluated at PCP's office by covering
physician, [**Name10 (NameIs) 8706**] to have abnormal ECG, ? new T wave inversions
in v3, v4.  Sent to [**Hospital **] Hospital for eval, received ASA 162
mg en route.  Initial vitals at [**Location (un) **]  98.1  HR 85  RR 16,
114/61  96% RA.  Patient reports that OSH providers were
discussing pacemeker placement.  Patient then requested transfer
to [**Hospital1 18**]
.
In ED VS were 100.1 HR 68 BP 111/66 RR 16  O2 sat 96% on 4
liters.  Blood and urine cxs sent, received 1.5 liters NS, 2
PRBCs.  Guaiac (+) brown stool.  NG lavage (-).  Received
pantoprazole 40 mg IV x 1, vit K 5 mg PO x 1, vanc 1 gram IV,
levoflox 750 mg PO.  Vitals on transfer:  100/60  (83/58)  HR
60-70s.  mid 90s on 3 liters.
.
Upon arrival to the ICU, patient was asymptomatic.  He verified
the aforementioned history.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats.  Reports 14 pound weight
loss, intentionally, with diuresis over past week.  Denies
headache, sinus tenderness, rhinorrhea or congestion.  He does
have chronic dry cough.  No hemoptysis.  Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Black stools have improved, now
more acholic.  No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

MEDICATION ON ADMISSION: Pantoprazole 40 mg Tablet daily
Digoxin 125 mcg Tablet daily
Atorvastatin 40 mg Tablet daily
Aspirin 81 mg Tablet daily
Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS
Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H PRN
Simethicone 80 mg Tablet, QID PRN
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN
Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [**Hospital1 **]
Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
daily
Patient's dry weight is 180 lbs

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:

FAMILY HISTORY: Mother h/o Breast Ca at early age.  Father CAD.  Brother died
from lung Ca, heavy smoker.  Sister has dementia.

SOCIAL HISTORY: Lives in [**Location 13360**] with wife.  Retired IT tech.  Has one son
age 31, one daughter age 35 with special needs.  No current or
past EtOH use, no current or past tobacco use.
Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Malignant neoplasm of pancreas, part unspecified,Unspecified pleural effusion,Other ascites,Acute posthemorrhagic anemia,Syncope and collapse,Atrial fibrillation,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Chronic kidney disease, unspecified
Chr marginal ulcer w hem,Ac on chr syst hrt fail,Malig neo pancreas NOS,Pleural effusion NOS,Ascites NEC,Ac posthemorrhag anemia,Syncope and collapse,Atrial fibrillation,Long-term use anticoagul,DMII wo cmp nt st uncntr,Old myocardial infarct,Crnry athrscl natve vssl,Renal & ureteral dis NOS,Chronic kidney dis NOS
Admission Date:  [**2159-7-18**]              Discharge Date:   [**2159-7-22**]

Date of Birth:  [**2094-9-7**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins

Attending:[**First Name3 (LF) 613**]
Chief Complaint:
Presyncope

Major Surgical or Invasive Procedure:
[**2159-7-20**] [**Month/Day/Year **]
[**2159-7-21**] Paracentesis


History of Present Illness:
Patient is a 64 year old male with h/o pancreatic adenocarcinoma
s/p Whipple [**1-/2159**], a. fib on warfarin, LV systolic dysfunction
with LVEF 25-30%, and Type II DM who p/w pre-syncope.  Per
report, had pre-syncopal episode earlier today.  Walked to care
with wife, eyes rolled in back of head, wife noted perioral
cyanosis.  Patient denies loss of consciousness.  Denies chest
pain/pressure, palpitations, or dyspnea.  No seizure-like
activity.  No consfusion, no bowel/bladder incontinence.  First
pre-syncopal event.  Evaluated at PCP's office by covering
physician, [**Name10 (NameIs) 8706**] to have abnormal ECG, ? new T wave inversions
in v3, v4.  Sent to [**Hospital **] Hospital for eval, received ASA 162
mg en route.  Initial vitals at [**Location (un) **]  98.1  HR 85  RR 16,
114/61  96% RA.  Patient reports that OSH providers were
discussing pacemeker placement.  Patient then requested transfer
to [**Hospital1 18**]
.
In ED VS were 100.1 HR 68 BP 111/66 RR 16  O2 sat 96% on 4
liters.  Blood and urine cxs sent, received 1.5 liters NS, 2
PRBCs.  Guaiac (+) brown stool.  NG lavage (-).  Received
pantoprazole 40 mg IV x 1, vit K 5 mg PO x 1, vanc 1 gram IV,
levoflox 750 mg PO.  Vitals on transfer:  100/60  (83/58)  HR
60-70s.  mid 90s on 3 liters.
.
Upon arrival to the ICU, patient was asymptomatic.  He verified
the aforementioned history.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats.  Reports 14 pound weight
loss, intentionally, with diuresis over past week.  Denies
headache, sinus tenderness, rhinorrhea or congestion.  He does
have chronic dry cough.  No hemoptysis.  Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Black stools have improved, now
more acholic.  No dysuria. Denied arthralgias or myalgias.


Past Medical History:
Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

Social History:
Lives in [**Location 13360**] with wife.  Retired IT tech.  Has one son
age 31, one daughter age 35 with special needs.  No current or
past EtOH use, no current or past tobacco use.


Family History:
Mother h/o Breast Ca at early age.  Father CAD.  Brother died
from lung Ca, heavy smoker.  Sister has dementia.


Physical Exam:
On admission:

VS:  113/58  HR 81  RR  16  96% RA
GA: AOx3, NAD.  pleasant.  marked pallor.  chronically
ill-appearing.
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard.
[**1-27**] holosystolic murmur at apex
Pulm: decreased BS at right base, otherwise CTA
Abd: soft, NT, +BS. no g/rt. neg HSM. neg [**Doctor Last Name 515**] sign.  (+)
ascites, not tense.
Extremities: wwp, trace LE edema. DPs, PTs 2+.
Skin:  chronic venous stasis changes
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL (biceps, achilles, patellar).  gait deferred


Pertinent Results:
OSH LABS:
Hct 23.8, crea 1.8, MB 2.6, TropI 0.07.  INR 1.6, albumin 2.8.
.
ADMISSION LABS:
[**2159-7-18**] 09:53PM   LACTATE-2.8*
[**2159-7-18**] 08:15PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008
[**2159-7-18**] 08:15PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
[**2159-7-18**] 07:00PM   GLUCOSE-178* UREA N-45* CREAT-1.7* SODIUM-140
POTASSIUM-5.3* CHLORIDE-103 TOTAL CO2-26 ANION GAP-16
[**2159-7-18**] 07:00PM   ALT(SGPT)-15 AST(SGOT)-16 LD(LDH)-191 ALK
PHOS-98 TOT BILI-0.6
[**2159-7-18**] 07:00PM   cTropnT-0.11*
[**2159-7-18**] 07:00PM   ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-4.1#
MAGNESIUM-1.6 IRON-15*
[**2159-7-18**] 07:00PM   calTIBC-307 HAPTOGLOB-140 FERRITIN-75 TRF-236
[**2159-7-18**] 07:00PM   WBC-6.3 RBC-2.51* HGB-7.9* HCT-24.3* MCV-97
MCH-31.4 MCHC-32.4 RDW-16.4*
[**2159-7-18**] 07:00PM   NEUTS-78.9* LYMPHS-15.2* MONOS-5.1 EOS-0.4
BASOS-0.4
[**2159-7-18**] 07:00PM   PLT COUNT-261
[**2159-7-18**] 07:00PM   PT-17.9* PTT-31.9 INR(PT)-1.6*
[**2159-7-18**] 07:00PM   RET AUT-3.5*
.
Micro:
.
[**2159-7-18**] URINE CX: NG
.
[**2159-7-18**] BLOOD CX: NG
.
H.pylori and CMV studies pending
.
Peritoneal fluid studies pending
.
IMAGING:
.
[**2159-7-18**] CTA CHEST:
1. Generalized stranding of the subcutaneous and mediastinal fat
may be
secondary to hypoalbuminaemia or right heart failure.
2. No pulmonary embolism.
3. Moderately severe bilateral nonhemorrhagic pleural effusions
and
associated compressive atelectasis.
.
Discharge Labs:
[**2159-7-22**] 06:06AM BLOOD WBC-7.9 RBC-2.60* Hgb-8.1* Hct-24.4*
MCV-94 MCH-31.3 MCHC-33.4 RDW-16.1* Plt Ct-230
[**2159-7-21**] 04:26AM BLOOD PT-15.4* PTT-63.0* INR(PT)-1.4*
[**2159-7-22**] 06:06AM BLOOD Glucose-190* UreaN-38* Creat-1.4* Na-137
K-4.7 Cl-101 HCO3-32 AnGap-9
[**2159-7-20**] 06:54AM BLOOD proBNP-[**Numeric Identifier 20158**]*
[**2159-7-22**] 06:06AM BLOOD Calcium-8.2* Phos-2.4* Mg-3.1*
[**2159-7-21**] 01:52PM ASCITES WBC-125* RBC-2550* Polys-10* Lymphs-24*
Monos-66*
[**2159-7-21**] 01:52PM ASCITES TotPro-3.0 LD(LDH)-95 Amylase-9
Albumin-1.8 Triglyc-36
.


Brief Hospital Course:
64 year old with h/o pancreatic adenocarcinoma s/p Whipple
[**1-/2159**], a. fib on warfarin, LV systolic dysfunction with LVEF
25-30%, and Type II DM who p/w syncope and concern for GI
hemorrhage.
.
# Pre-syncope: Patient describes a self limiting episode of
lightheadedness with reported periorbital cyanosis. Initial
differential included venous thromboembolism, orthostasis,
autonomic dysfunction, anemia, hypoxia, and myocardial ischemia.
 History is not consistent with seizure activity as no focal
deficits, no involuntary movements, no loss of consciousness, no
loss of bowel or bladder function. Given modified [**Doctor Last Name 3012**] criteria
score of 4, patient underwent CTA chest which showed no evidence
of pulmonary embolism but did reveal large bilateral non
hemorrhagic effusions.  He was monitored on telemetry overnight
without events. Cardiac enzymes were mildly elevated (peak Trop
0.11) though medical record reveals recent troponins that were
as high as 0.21. EKG was without ischemic changes.  Patient
hematocrit was 24.8 on presentation which was slightly below
recent baseline of 27. He was transfused 1 Unit of PRBCs. GI
performed [**Doctor Last Name **], which showed an ulcer at the anastomosis.
Biopsies were performed and were sent for H.pylori and CMV. The
patient had no further episodes of bleeding. Coumadin was held
and patient was encouraged to make a PCP appointment to discuss
restarting this medication. Protonix was started at 40 mg [**Hospital1 **].
The patient may need a repeat [**Hospital1 **] as an outpatient to be sure
the ulcer is healing and also because the entire stomach was not
visualized on [**Hospital1 **].
.
# Iron deficiency anemia: Patient presents with hematocrit of
24.8 with recent hematocrits near 27. Patient had guaiac
positive brown stool at the outside hospital. NG lavage was
negative for blood. He was transfused 1 unit pRBC and given 2 L
IV NS. He was admitted to the MICU for monitoring where he
remained hemodynamically stable overnight. He denied recent
nausea, vomiting, or bloody stool.  He does admit to a history
of intermittent black stools since his Whipple surgery in [**1-31**].
GI team was consulted who recommended [**Date Range **], with findings as
above.
.
#Pleural effusions/ascites: Paracentesis was performed and
showed SAAG of 1.3, most likely secondary to CHF. Gram stain and
culture were sent and were pending at the time of discharge.
Cytology was also pending. The patient's diuretics were changed
to Lasix 20 mg qd and spironolactone 25 mg qd. The patient will
also require optimization of his heart failure medications.
.
# Pancreatic adenocarcinoma: Stage IIB on diagnosis.  S/p
Whipple with adjuvant chemotherapy and radiation.  Patient with
ascites and large pleural effusions. Paracentesis was performed,
and cytology was still pending at the time of discharge.
Unfortunately, there was not enough fluid for cell block. The
patient was instructed to schedule an outpatient appointment
with his primary oncologist, Dr. [**First Name (STitle) 3443**].
.
# Chronic atrial fibrillation: Coumadin was held given GI bleed
and procedure. The patient was instructed to make an appointment
with his PCP to discuss restarting this medication as well as
Flomax and Digoxin.
.
# Type II DM: Continued basal/bolus insulin.
.
The patient was on pneumoboots for prophylaxis. The patient
remained full code during this admission.



Medications on Admission:
Pantoprazole 40 mg Tablet daily
Digoxin 125 mcg Tablet daily
Atorvastatin 40 mg Tablet daily
Aspirin 81 mg Tablet daily
Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS
Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H PRN
Simethicone 80 mg Tablet, QID PRN
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN
Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [**Hospital1 **]
Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
daily
Patient's dry weight is 180 lbs


Discharge Medications:
1. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
3. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
4. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
5. Insulin Glargine 100 unit/mL (3 mL) Insulin Pen Sig: One (1)
10 Units Subcutaneous once a day.
6. Humalog 100 unit/mL Cartridge Sig: One (1) 1-12 Units
Subcutaneous four times a day.
7. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
9. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
10. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
UGIB
chronic systolic CHF with new ascites and pleural effusions
.
Secondary:
pancreatic ca s/p Whipple [**2159-1-31**]
DMII
OSA


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


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you at [**Hospital1 827**]. You were admitted for lightheadedness and near
fainting and for your history of dark stools. No certain cause
for your lightheadedness was determined, however, we did rule
out many causes such as a blood clot in your lungs. The GI
doctors performed [**Name5 (PTitle) **] [**Name5 (PTitle) **], which showed a non-bleeding ulcer at a
site where your Whipple procedure closed your small bowel.
Biopsies of this ulcer are still pending to see if there are
bacteria or viruses responsible for your ulcer.
.
You also had a drainage procedure performed of the fluid in your
abdomen. Tests on this fluid were also still pending at the time
of your discharge and will need follow-up by your PCP, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **]
[**Last Name (NamePattern1) 9346**] and your oncologist, Dr. [**First Name (STitle) 3443**].
.
We made the following changes to your medications:
We held Flomax, coumadin and Digoxin while you were in the
hospital. You should speak with your PCP and about when and if
it is safe for you to restart these medications.

We CHANGED your home medication omeprazole 20 mg once per day to
protonix 40 mg twice per day.
We CHANGED your diuretic dosing to lasix 20mg daily and
spironolactone 25mg daily.

You should call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9346**] to schedule a
hospital-follow-up appointment in the next 10-14 days.


Followup Instructions:
You should call your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 9346**] at [**Telephone/Fax (1) 24734**] to schedule
a hospital-follow-up appointment in the next 10-14 days.


                             [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]
{'Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Malignant neoplasm of pancreas, part unspecified,Unspecified pleural effusion,Other ascites,Acute posthemorrhagic anemia,Syncope and collapse,Atrial fibrillation,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Chronic kidney disease, unspecified'}


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: Presyncope

PRESENT ILLNESS: Patient is a 64 year old male with h/o pancreatic adenocarcinoma
s/p Whipple [**1-/2159**], a. fib on warfarin, LV systolic dysfunction
with LVEF 25-30%, and Type II DM who p/w pre-syncope.  Per
report, had pre-syncopal episode earlier today.  Walked to care
with wife, eyes rolled in back of head, wife noted perioral
cyanosis.  Patient denies loss of consciousness.  Denies chest
pain/pressure, palpitations, or dyspnea.  No seizure-like
activity.  No consfusion, no bowel/bladder incontinence.  First
pre-syncopal event.  Evaluated at PCP's office by covering
physician, [**Name10 (NameIs) 8706**] to have abnormal ECG, ? new T wave inversions
in v3, v4.  Sent to [**Hospital **] Hospital for eval, received ASA 162
mg en route.  Initial vitals at [**Location (un) **]  98.1  HR 85  RR 16,
114/61  96% RA.  Patient reports that OSH providers were
discussing pacemeker placement.  Patient then requested transfer
to [**Hospital1 18**]
.
In ED VS were 100.1 HR 68 BP 111/66 RR 16  O2 sat 96% on 4
liters.  Blood and urine cxs sent, received 1.5 liters NS, 2
PRBCs.  Guaiac (+) brown stool.  NG lavage (-).  Received
pantoprazole 40 mg IV x 1, vit K 5 mg PO x 1, vanc 1 gram IV,
levoflox 750 mg PO.  Vitals on transfer:  100/60  (83/58)  HR
60-70s.  mid 90s on 3 liters.
.
Upon arrival to the ICU, patient was asymptomatic.  He verified
the aforementioned history.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats.  Reports 14 pound weight
loss, intentionally, with diuresis over past week.  Denies
headache, sinus tenderness, rhinorrhea or congestion.  He does
have chronic dry cough.  No hemoptysis.  Denied chest pain or
tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. Black stools have improved, now
more acholic.  No dysuria. Denied arthralgias or myalgias.

MEDICAL HISTORY: Past Medical History:
- Type II DM
- CHF with an EF of 30%
- CAD s/p MI
- h/o atrial fibrillation on Coumadin
- Chronic Renal Insufficiency (baseline creatinine 1.3)
- Adenocarcinoma of the pancreas s/p Whipple in [**Month (only) **]/[**2158**] with
positive margins, currently undergoing adjuvant chemotherapy
with gemcitabine (about three cycles in); most recent
chemotherapy (Gemcitabine) was two weeks ago, per patient
.
Past Surgical History:
- sinus surgery
- (L)LE bypass for nonhealing toe ulcer
- ERCP with stent placement
- Whipple procedure as above

MEDICATION ON ADMISSION: Pantoprazole 40 mg Tablet daily
Digoxin 125 mcg Tablet daily
Atorvastatin 40 mg Tablet daily
Aspirin 81 mg Tablet daily
Lipase-Protease-Amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS
Warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily
Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID
Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime)
Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H PRN
Simethicone 80 mg Tablet, QID PRN
Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID PRN
Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID PRN
Furosemide 10 mg/mL Solution Sig: Forty (40) mg Injection [**Hospital1 **]
Insulin Glargine 100 unit/mL Solution Sig: Fifteen (15) units
daily
Patient's dry weight is 180 lbs

ALLERGIES: Penicillins

PHYSICAL EXAM: On admission:

FAMILY HISTORY: Mother h/o Breast Ca at early age.  Father CAD.  Brother died
from lung Ca, heavy smoker.  Sister has dementia.

SOCIAL HISTORY: Lives in [**Location 13360**] with wife.  Retired IT tech.  Has one son
age 31, one daughter age 35 with special needs.  No current or
past EtOH use, no current or past tobacco use. 

### Response:
{'Chronic or unspecified gastrojejunal ulcer with hemorrhage, without mention of obstruction,Acute on chronic systolic heart failure,Malignant neoplasm of pancreas, part unspecified,Unspecified pleural effusion,Other ascites,Acute posthemorrhagic anemia,Syncope and collapse,Atrial fibrillation,Long-term (current) use of anticoagulants,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Old myocardial infarction,Coronary atherosclerosis of native coronary artery,Unspecified disorder of kidney and ureter,Chronic kidney disease, unspecified'}
