CHIEF COMPLAINT: Newly-diagnosed adenocarcinoma of the proximal stomach.

PRESENT ILLNESS: The patient was initially referred to Dr. [**Last Name (STitle) 468**], who has asked
me to see him as I am now doing much of the gastric cancer
surgery at our institution.  The patient is a previously healthy
76 year-old Indian gentleman who reports an at
least 6 month history of upper abdominal discomfort and loss of
appetite.  He recently moved here from [**Location (un) 18296**], [**State 2690**] where he
was noted to be anemic several months ago.  He was advised to
undergo a colonoscopy, but that was deferred as he was moving to
the
[**Location (un) 86**] area.  At the urging of his son, he presented to you and
you performed initially a colonoscopy, which was reportedly
normal. You then did an upper endoscopy on [**9-14**] and
there
was apparently a large, irregular, ulcerating lesion in the
upper
stomach, which upon biopsy was consistent with a moderately to
poorly differentiated invasive adenocarcinoma.  The patient
denies abdominal pain or any increase in the girth of his
abdomen.  He does admit to a 5-pound weight loss over the last
several months.  He has had no nausea or vomiting and tolerates
food without difficulty.  In addition, he denies any black tarry
stools or frank blood in his bowel movements.  He has been
relatively fatigued and this has been attributed to his anemia.
He has not received a blood transfusion and is currently taking
iron supplements.
A Diagnostic laparoscopy was done on [**2197-10-2**], with
biopsies of anterior wall of the stomach and left lateral
segment of the liver, and peritoneal washings for cytology. The
staging was negative for any
other evidence of intraperitoneal disease.

MEDICAL HISTORY: HTN, hyperlipidemia, AdenoCA stomach, h/o TB (treated)

MEDICATION ON ADMISSION: Iron, laxative

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: blood pressure 124/58, pulse 65.  In general,
this is a thin appearing Indian gentleman who is a pleasant.
Sclerae are anicteric.  Neck and supraclavicular fossae are
supple without lymphadenopathy.  Lungs are clear to auscultation
bilaterally.  Heart is regular rate and rhythm.  Abdomen is soft
and nondistended without palpable mass or evidence of ascites.
Extremities show no edema.

FAMILY HISTORY: unremarkable for history of cancers.

SOCIAL HISTORY: The patient has never smoked and only
occasionally drinks alcohol.  He is a retired office worker and
lives in [**Location 70026**], [**State 350**].
Malignant neoplasm of pyloric antrum,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Unspecified essential hypertension
Mal neo pyloric antrum,Chr blood loss anemia,Hyperlipidemia NEC/NOS,Hypertension NOS
Admission Date:  [**2197-10-16**]              Discharge Date:   [**2197-10-24**]

Date of Birth:  [**2121-1-2**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5547**]
Chief Complaint:
Newly-diagnosed adenocarcinoma of the proximal stomach.

Major Surgical or Invasive Procedure:
Total Gastrectomy with Roux-en-Y esophagojejunostomy, Regional
Lymphadenectomy, Jejunostomy Tube Placement, EGD


History of Present Illness:
The patient was initially referred to Dr. [**Last Name (STitle) 468**], who has asked
me to see him as I am now doing much of the gastric cancer
surgery at our institution.  The patient is a previously healthy
76 year-old Indian gentleman who reports an at
least 6 month history of upper abdominal discomfort and loss of
appetite.  He recently moved here from [**Location (un) 18296**], [**State 2690**] where he
was noted to be anemic several months ago.  He was advised to
undergo a colonoscopy, but that was deferred as he was moving to
the
[**Location (un) 86**] area.  At the urging of his son, he presented to you and
you performed initially a colonoscopy, which was reportedly
normal. You then did an upper endoscopy on [**9-14**] and
there
was apparently a large, irregular, ulcerating lesion in the
upper
stomach, which upon biopsy was consistent with a moderately to
poorly differentiated invasive adenocarcinoma.  The patient
denies abdominal pain or any increase in the girth of his
abdomen.  He does admit to a 5-pound weight loss over the last
several months.  He has had no nausea or vomiting and tolerates
food without difficulty.  In addition, he denies any black tarry
stools or frank blood in his bowel movements.  He has been
relatively fatigued and this has been attributed to his anemia.
He has not received a blood transfusion and is currently taking
iron supplements.
A Diagnostic laparoscopy was done on [**2197-10-2**], with
biopsies of anterior wall of the stomach and left lateral
segment of the liver, and peritoneal washings for cytology. The
staging was negative for any
other evidence of intraperitoneal disease.


Past Medical History:
HTN, hyperlipidemia, AdenoCA stomach, h/o TB (treated)

Social History:
 The patient has never smoked and only
occasionally drinks alcohol.  He is a retired office worker and
lives in [**Location 70026**], [**State 350**].


Family History:
unremarkable for history of cancers.


Physical Exam:
blood pressure 124/58, pulse 65.  In general,
this is a thin appearing Indian gentleman who is a pleasant.
Sclerae are anicteric.  Neck and supraclavicular fossae are
supple without lymphadenopathy.  Lungs are clear to auscultation
bilaterally.  Heart is regular rate and rhythm.  Abdomen is soft
and nondistended without palpable mass or evidence of ascites.
Extremities show no edema.


Pertinent Results:
[**2197-10-16**] 01:25PM BLOOD WBC-7.7 RBC-2.78* Hgb-8.5* Hct-25.4*
MCV-91 MCH-30.7 MCHC-33.7 RDW-17.0* Plt Ct-337
[**2197-10-18**] 05:17AM BLOOD WBC-10.5 RBC-3.14* Hgb-9.5* Hct-27.5*
MCV-88 MCH-30.1 MCHC-34.3 RDW-17.7* Plt Ct-267
[**2197-10-16**] 01:25PM BLOOD Glucose-133* UreaN-12 Creat-0.8 Na-139
K-3.7 Cl-110* HCO3-24 AnGap-9
[**2197-10-18**] 05:17AM BLOOD Glucose-95 UreaN-19 Creat-0.8 Na-134
K-3.7 Cl-102 HCO3-26 AnGap-10
[**2197-10-18**] 05:17AM BLOOD Calcium-7.5* Phos-1.9* Mg-1.9

Pathology Examination

Name Birthdate    Age     Sex Pathology #     [**Hospital1 18**] [**Known lastname 70027**],[**Known firstname 70028**]       [**2121-1-2**]    76 Male
[**-4/4702**] [**Numeric Identifier 70029**]
Report to:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]
Gross Description by:   DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/cofc



SPECIMEN SUBMITTED: TOTAL GASTRECTOMY, JEJUNUM, AND ESOPHAGUS
DONUT.

Procedure date     Tissue received     Report Date    Diagnosed
by
[**2197-10-16**] [**2197-10-16**] [**2197-10-18**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/vf
Previous biopsies:    [**-4/4652**]  Consult slides referred to Dr.
[**Last Name (STitle) **]. [**Doctor Last Name **].
  [**-4/4517**]  LIVER BX & STOMACH BX.

DIAGNOSIS:

  I.  Stomach, total gastrectomy (A-Z):

1.  Adenocarcinoma of the mid-portion, see synoptic report.

2.  Chronic inactive antral gastritis and duodenitis.

3.  Peritoneal fibrous adhesions with small fragment of skeletal
muscle.

4.  There is esophageal mucosa at the proximal and duodenal
mucosa at the distal  margin.

 II.  Jejunum donut (AA):

Small intestinal fragment, no malignancy identified.

III.  Esophagus donut (A,B):

Esophageal fragment, no malignancy identified.



Stomach: Resection Synopsis


MACROSCOPIC

Specimen Type:  Total gastrectomy.

Tumor Site:  Upper antrum.

Tumor configuration:  Ulcerating.

Tumor Size
    Greatest dimension:  5.8 cm.  Additional dimensions:  4.5 cm
x 2.0 cm.

MICROSCOPIC

Histologic Type:  Adenocarcinoma, intestinal type.
Histologic Grade:  Moderately differentiated.

Primary Tumor:  pT2b:  Tumor invades subserosa.

Regional Lymph Nodes:  pN0:  No regional lymph node metastasis.

Lymph Nodes
    Number examined:  14.
    Number involved:  0.

Distant metastasis:  pMX:  Cannot be assessed.

Margins
    Proximal margin:  Uninvolved by invasive carcinoma.
    Distal margin:  Uninvolved by invasive carcinoma.
    Omental (radial) margins
        Lesser omental margin:  Uninvolved by invasive
carcinoma.
        Greater omental margin:  Uninvolved by invasive
carcinoma.
    Distance from closest margin:  14 mm.
    Specified margin:  Lesser omentum.

Lymphatic (Small Vessel) Invasion:  Absent.

Venous (Large vessel) invasion:  Absent.

Perineural invasion:  Absent.

ESOPHAGUS  [**2197-10-23**] 9:38 AM

ESOPHAGUS

Reason: Please evaluate for anastamotic leak
Contrast: CONRAY

[**Hospital 93**] MEDICAL CONDITION:
76 year old s/p esophagogastrectomy, please do swallow study to
evaluate for anastamotic leak.
REASON FOR THIS EXAMINATION:
Please evaluate for anastamotic leak
INDICATION: 76-year-old man with a history of gastric cancer
status post gastrectomy with Roux-en-Y esophagojejunostomy.
Please evaluate for anastomotic leak.

FINDINGS: Scout view demonstrated no free air under the
diaphragm. A jejunostomy tube overlies the left upper quadrant.
Midline skin staples are still seen. There is a small left-sided
pleural effusion.

Conray followed by thin barium was used in this study. Contrast
flows freely and promptly through the esophagus through the
anastomosis and into the jejunum. There is no evidence of
contrast leak. There is mild thickening of the jejunal folds
near the anastamosis, suggesting mild edema. The loops of small
bowel are not dilated and contrast flows freely into the distal
small bowel.

IMPRESSION: No evidence of anastomotic leak.


Brief Hospital Course:
She was admitted on [**2197-10-16**] for a total gastrectomy and
Roux-en-Y stapled esophagojejunostomy. He tolerated the
procedure well and post-operatively he was stable. He had no
complications during his post-op period.

Abd: He had an incision that was C,D,I. He had a feeding J-tube
to gravity. His abdomen was nondistended and soft. The drain was
removed POD 9. His staples were removed and steri strips applied
on POD 9.
.
GI: He was NPO with a NGT. He was started on J-tube feedings on
POD 2. The NGT was D/C'd POD 3. He remained NPO for 5 days. He
had a swallow study to assess for a anastomotic leak on POD 8.
The study showed no evidence of anastomotic leak. He was started
on clears on after said study and advanced to fulls. He will be
discharge on a full liquid diet and Tube feedings (3/4 strength
Impact) at 90 cc/hr.
.
HEME: He received 1 Unit of PRBC for a HCT of 25 and his HCT
rose to 32.9 post transfusion.
.
ID: He was started on Cefazolin and Flagyl perioperatively.
These were discontinued post-op.
.
Pain: He had an epidural for pain control. POD 0, in the PACU,
he had episodes of apnea and very sleepy, most likely due to
anesthesia. The epidural was turned down. The epidural was D/C'd
on POD 4. He was then well controlled with a PCA and eventually
switched to Roxicet elixir.
.
Renal: POD 3, he required a 250cc bolus for low urine output. He
responded well to the fluids.
.
Pulm: He had faint crackles at the bases. He required oxygen by
nasal cannula for 3 days. His respiratory status improved with
IS, deep breathing, and ambulation.
.
Activity: He was weak and deconditioned. We encouraged
ambulation. He was safe to go home.

Medications on Admission:
Iron, laxative

Discharge Medications:
1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
Disp:*60 Tablet(s)* Refills:*2*
2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for 1 months.
Disp:*50 ML(s)* Refills:*0*
3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO once a day.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **]

Discharge Diagnosis:
Gastric Cancer


Discharge Condition:
Good


Discharge Instructions:
* Increasing pain
* Fever (>101.5 F)
* Inability to eat or persistent vomiting
* Inability to pass gas or stool
* Increasing shortness of breath
* Chest pain

Please resume all of your regular medications and take any new
meds as ordered.
Continue to ambulate several times per day.
You will continue with tubefeedings at 90cc/hr (3/4 strength
Impact)
Flush your J-tube with 30cc water 3x/day.
Full liquid diet.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 1924**] in 1 week. Call ([**Telephone/Fax (1) 55864**]
to schdule an appointment.



Completed by:[**2197-10-24**]

Name:  [**Known lastname 11896**],[**Known firstname 11897**]     Unit No:   [**Numeric Identifier 11898**]

Admission Date:  [**2197-10-16**]              Discharge Date:   [**2197-10-24**]

Date of Birth:  [**2121-1-2**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3130**]
Addendum:
The patient was noted to have anemia due to chronic GI bleeding.

Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3131**] MD [**MD Number(2) 3132**]

Completed by:[**2197-11-30**]
{'Malignant neoplasm of pyloric antrum,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,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: Newly-diagnosed adenocarcinoma of the proximal stomach.

PRESENT ILLNESS: The patient was initially referred to Dr. [**Last Name (STitle) 468**], who has asked
me to see him as I am now doing much of the gastric cancer
surgery at our institution.  The patient is a previously healthy
76 year-old Indian gentleman who reports an at
least 6 month history of upper abdominal discomfort and loss of
appetite.  He recently moved here from [**Location (un) 18296**], [**State 2690**] where he
was noted to be anemic several months ago.  He was advised to
undergo a colonoscopy, but that was deferred as he was moving to
the
[**Location (un) 86**] area.  At the urging of his son, he presented to you and
you performed initially a colonoscopy, which was reportedly
normal. You then did an upper endoscopy on [**9-14**] and
there
was apparently a large, irregular, ulcerating lesion in the
upper
stomach, which upon biopsy was consistent with a moderately to
poorly differentiated invasive adenocarcinoma.  The patient
denies abdominal pain or any increase in the girth of his
abdomen.  He does admit to a 5-pound weight loss over the last
several months.  He has had no nausea or vomiting and tolerates
food without difficulty.  In addition, he denies any black tarry
stools or frank blood in his bowel movements.  He has been
relatively fatigued and this has been attributed to his anemia.
He has not received a blood transfusion and is currently taking
iron supplements.
A Diagnostic laparoscopy was done on [**2197-10-2**], with
biopsies of anterior wall of the stomach and left lateral
segment of the liver, and peritoneal washings for cytology. The
staging was negative for any
other evidence of intraperitoneal disease.

MEDICAL HISTORY: HTN, hyperlipidemia, AdenoCA stomach, h/o TB (treated)

MEDICATION ON ADMISSION: Iron, laxative

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: blood pressure 124/58, pulse 65.  In general,
this is a thin appearing Indian gentleman who is a pleasant.
Sclerae are anicteric.  Neck and supraclavicular fossae are
supple without lymphadenopathy.  Lungs are clear to auscultation
bilaterally.  Heart is regular rate and rhythm.  Abdomen is soft
and nondistended without palpable mass or evidence of ascites.
Extremities show no edema.

FAMILY HISTORY: unremarkable for history of cancers.

SOCIAL HISTORY: The patient has never smoked and only
occasionally drinks alcohol.  He is a retired office worker and
lives in [**Location 70026**], [**State 350**]. 

### Response:
{'Malignant neoplasm of pyloric antrum,Iron deficiency anemia secondary to blood loss (chronic),Other and unspecified hyperlipidemia,Unspecified essential hypertension'}
