CHIEF COMPLAINT: body twitching and change in mental status

PRESENT ILLNESS: Pt is a 59 year old male with pancreatic cancer diagnosed last
[**Month (only) 359**], s/p Whipple's in [**2185-12-12**], who presents with90
minutes of R arm and leg twitching. Pt has been a bit fatigued
since his chemotherapy was started, but had no seizure-like
activity prior to yesterday, when his brother noted that his R
hand would shake intermittently. He didn't make much of it,
however, particularly as the pt's mental status seemed baseline.
This afternoon, the patient was at home and suddenly developed
diffuse R body rhythmic jerking. He seemed lucid to his brother
but was unable to produce speech, although he seemed to follow
simple commands. No LOC or loss of continence, no tongue biting.
He was brought to [**Hospital1 18**] for further evaluation.

MEDICAL HISTORY: HTN
PTSD
depression
plantar warts
genital herpes
GERD
duodenal ulcer H pylori negative

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: T afebrile, BP 115/60, HR 114, RR 19  O2 99 room air.

FAMILY HISTORY: M died of colon Ca at 55y/o
B died of pancreatic Ca at 40y/o

SOCIAL HISTORY: No tobacco now or in past.  Drinks about [**5-16**] glasses of wine per
week.  No recreational drugs.  Lives with his brother.  Retired
at this point for medical reasons, particularly PTSD (served in
[**Country 3992**]).  Worked as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] SW in the past.
Neoplasm of uncertain behavior of brain and spinal cord,Other convulsions,Malignant neoplasm of other specified sites of pancreas,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Mitral valve disorders,Posttraumatic stress disorder,Esophageal reflux,Unspecified essential hypertension
Unc beh neo brain/spinal,Convulsions NEC,Malig neo pancreas NEC,Mal neo lymph intra-abd,Mitral valve disorder,Posttraumatic stress dis,Esophageal reflux,Hypertension NOS
Admission Date:  [**2186-4-2**]              Discharge Date:   [**2186-4-15**]

Date of Birth:  [**2126-10-12**]             Sex:   M

Service: NEUROLOGY

Allergies:
Penicillins / Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 57490**]
Chief Complaint:
body twitching and change in mental status

Major Surgical or Invasive Procedure:
PICC line
MRI
MR Spectroscopy


History of Present Illness:
Pt is a 59 year old male with pancreatic cancer diagnosed last
[**Month (only) 359**], s/p Whipple's in [**2185-12-12**], who presents with90
minutes of R arm and leg twitching. Pt has been a bit fatigued
since his chemotherapy was started, but had no seizure-like
activity prior to yesterday, when his brother noted that his R
hand would shake intermittently. He didn't make much of it,
however, particularly as the pt's mental status seemed baseline.
This afternoon, the patient was at home and suddenly developed
diffuse R body rhythmic jerking. He seemed lucid to his brother
but was unable to produce speech, although he seemed to follow
simple commands. No LOC or loss of continence, no tongue biting.
He was brought to [**Hospital1 18**] for further evaluation.

Of note, his brother has noticed that over the past 2-3 weeks
the patient has been more forgetful and overall less "sharp,"
often forgetting words, having trouble naming simple objects and
often losing his train of thought. These changes were somewhat
ignored b/c they were thought ot be due to the chemotherapy.
Overall, otherwise, pt has been relatively well with no
intercurrent infections or illness.

Past Medical History:
HTN
PTSD
depression
plantar warts
genital herpes
GERD
duodenal ulcer H pylori negative

Social History:
No tobacco now or in past.  Drinks about [**5-16**] glasses of wine per
week.  No recreational drugs.  Lives with his brother.  Retired
at this point for medical reasons, particularly PTSD (served in
[**Country 3992**]).  Worked as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] SW in the past.

Family History:
M died of colon Ca at 55y/o
B died of pancreatic Ca at 40y/o

Physical Exam:
T afebrile, BP 115/60, HR 114, RR 19  O2 99 room air.

Initial exam performed while patient having rhythmic jerking,
likley partial seizures: at that time he was hypertonic, shaking
his R upper and bilateral lower extremities, following commands
but not producing speech.

Repeat exam performed after ativan and dilantin given:
HEENT  thin, somewhat ill appearing male.
Neck  Increased tone overall in neck/shoulders, but neck supple
with no pain with flexion/extension, no thyromegaly, no [**Doctor First Name **], no
bruits
Chest  CTA B
CVS  RRR w/ 2/6 SEM at LSB.
ABD  soft, NTND, + BS. surgery site c/d/i.
EXT  no C/C/E, distal pulses full, no rashes or petechiae

Neuro
MS: awake, does not produce speech, follows simple commands but
only intermittently. makes poor eye contact. responds to name.
Able to show thumbs up, squeeze fingers, gaze horizontally
bilaterally to command but does not follow many commands and
unclear if he understands all fo them.
CN: I-- not tested; II,III-- PERRLA, VFF by confrontation;
III,IV,VI- EOMI w/o nystagmus, no ptosis; V--intact corneals,
VII-- face symmetric without weakness; VIII--hears finger rub
bilaterally
Motor: exam limited by pt compliance and level of understanding.
decreased bulk, increased tone throughout, no tremor, rigidity
or bradykinesia..
Pt moves all four extremities equally antigravity, would not
follow commands for strength testing except for grip, which is
[**6-15**] bilaterally.
Refl:
              |[**Hospital1 **]  |tri  |bra  |pat  |[**Doctor First Name **]  |toe |
            L | 2  | 2   | 2   | 2   | 2   | withdraws |
            R | 2  | 2   | 2   | 2   | 2   | dn |

[**Last Name (un) **]:   localizes to pinch in all 4 extremities.

Pertinent Results:
[**2186-4-14**] 05:55AM BLOOD WBC-7.8 RBC-3.24* Hgb-9.1* Hct-27.6*
MCV-85 MCH-28.3 MCHC-33.2 RDW-17.9* Plt Ct-361
[**2186-4-6**] 05:50AM BLOOD Neuts-60.2 Lymphs-35.6 Monos-4.0 Eos-0
Baso-0.2
[**2186-4-6**] 05:50AM BLOOD Anisocy-1+ Microcy-1+
[**2186-4-1**] 09:42PM BLOOD WBC-6.7 RBC-3.89* Hgb-10.9* Hct-32.1*
MCV-83 MCH-28.0 MCHC-33.9 RDW-15.4 Plt Ct-301
[**2186-4-11**] 06:00AM BLOOD PT-11.9 PTT-19.9* INR(PT)-0.9
[**2186-4-13**] 11:07AM BLOOD Ret Aut-3.7*
[**2186-4-14**] 05:55AM BLOOD Glucose-90 UreaN-11 Creat-0.5 Na-136
K-3.9 Cl-103 HCO3-27 AnGap-10
[**2186-4-1**] 09:42PM BLOOD Glucose-105 UreaN-14 Creat-0.7 Na-134
K-4.3 Cl-98 HCO3-24 AnGap-16
[**2186-4-13**] 06:54AM BLOOD ALT-44* AST-27 AlkPhos-90 Amylase-41
TotBili-0.2
[**2186-4-12**] 09:40AM BLOOD ALT-48* AST-18 AlkPhos-110 Amylase-169*
TotBili-0.2
[**2186-4-13**] 06:54AM BLOOD Lipase-63*
[**2186-4-12**] 09:40AM BLOOD Lipase-183*
[**2186-4-3**] 04:37AM BLOOD CK-MB-2 cTropnT-<0.01
[**2186-4-14**] 05:55AM BLOOD Calcium-8.5 Phos-3.4 Mg-1.9
[**2186-4-13**] 11:07AM BLOOD calTIBC-270 Ferritn-193 TRF-208
[**2186-4-1**] 10:15PM BLOOD Ammonia-25
[**2186-4-10**] 09:12AM BLOOD Vanco-10.4*

MRI [**4-2**]
Left frontal enhancing mass with surrounding edema. The
differential diagnosis is discussed above and includes malignant
glioma, primitive neuroectodermal tumor, lymphoma, and less
likely, encephalitis. The growth pattern is not typical of a
metastasis

TRANS ESOPHAGEAL ECHO
Mildly to moderately thickened mitral valve with moderate mitral

regurgitation and probable vegetation. No abscess seen.

MR SPECT
There is no change in the enhancing infiltrating mass in the
left frontal cortex, with surrounding vasogenic edema. There are
no new mass lesions.
Although the full multivoxel spectroscopy results are not
available, the single- voxel spectroscopy results demonstrate a
decreased NAA peak, but elevated choline, lactate/lipid, and
myoinositol peaks suggestive of a malignant tumor

CT ABD/PELVIS
1) Trace ascites.
2) Stable appearance of upper abdomen with no evidence of
recurrent disease.
3) Stable peripancreatic fat stranding and small lymph nodes.


Brief Hospital Course:
59 year old male with pancreatic cancer, presents in with right
sided arm and leg twitching c/w with partial status. Found to
have left frontal lobe mass.  He was initially admitted to the
ICU for ativan and EEG monitoring.

1. Neuro:
He was initially given ativan and loaded with dilantin for
seizure control.  He was started on IV decadron, 10mg IV, then
6mg q 4h.  His seizures became less frequent and resolved
completely by hospital day #3.  He was transfered to the
neurology floor on [**4-5**] where he was started on Keppra.  He has
slowly been transitioned from dilantin to Keppra without
recurrence of his seizures.  At time of discharge, his dilantin
was tapered to 100mg qd which he will continue for two days,
then discontinue.  He will continue on Keppra 1500mg [**Hospital1 **]. His
steroids were also slowly tapered of the course of his
admission.  He was on Decadron, which is currently 6mg po q 6
hours.  Will taper to 6mg po q 8h on discharge.

Differential diagnosis of left frontal mass included metastasis,
primary brain tumor, infection or stroke.  Imaging seems most
consistent with a primary CNS lesion such as glioma, PNET, or
lymphoma.  MRS [**Last Name (STitle) **] done to better evaluate etiology of this
lesion.  MRS [**Last Name (STitle) **] [**Name (STitle) 23765**] with tumor.  The patient refused LP
to look for malignant cells or infectious etiologies.  He was
evaluated by neuro-oncology and neurosurgery during his
admission.  He will follow up in brain tumor clinic for further
diagnostic work-up, including biopsy by Dr. [**First Name (STitle) **].

FOLLOW UP PLAN:
-Dilantin being tapered, off by Monday [**4-17**]
-Continue Decadron now tapered to 6mg q8 on d/c.
-Transitioning from dilantin to keppra (now at 1500BID)
-Will follow up in brain tumor clinic next week (Monday)

2. GI:  Pt did well from a GI perspective. Tolerated po intake.
He did have one episode of nausea/vomiting on [**4-11**] which was
associated with mildly elevated LFTs and [**Doctor First Name **]/lip.  KUB was OK.
Labs normalized.  He had a CT scan of the Abd/Pelvis which
showed no evidence of disease recurrence.
FOLLOW UP PLAN
-continue PPI, pancreatic enzymes
-follow up with Dr. [**Last Name (STitle) 100239**] next week

3. CV: TEE was done to evaluate for possiblity of endocarditis,
showed a tiny, mitral valve veg. Emperic abx (vanc and gent) was
begun, but later d/c'd (on [**2186-4-12**]) given very low suspicion for
endocarditis

4. ID:
-Started Vanco and Gent for ? endocarditis -d/c'd [**4-12**], has
remained afebrile since and blood cultures have been negative.
Also rec'd Levofloxacin x3 days (start [**4-2**]) for traumatic foley
insertion-now d/c'd.  Started dapsone for PCP [**Name Initial (PRE) **].

FOLLOW UP PLAN:
-dapsone for PCP [**Name9 (PRE) **] while on steroids and chemotherapy

5. Pancreatic CA:  s/p #4 of 8 of gemcitabine-unsure if wants to
continue chemo.  This decision pending prognosis of pancreatic
and brain lesion. CT showed no disease recurrence.

FOLLOW UP PLAN
-Follow up with DR. [**First Name (STitle) **] next week
-Will decide about next cycle of gemcitabine (#4 of 8) at next
week's appointment

7. Heme: HCt fluctuating, fe studies normal, guiaic trace
positive on Thursday. Will need repeat Hct next week at f/u with
PCP.

FOLLOW UP PLAN
-Repeat CBC at F/U with Dr. [**Last Name (STitle) 4844**]

8. Communication: With brother [**Name (NI) **] [**Telephone/Fax (1) 108253**] or [**Telephone/Fax (1) 108254**]



Discharge Medications:
1. Pantoprazole Sodium 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*
2. Lipram-CR5  Oral
3. Escitalopram Oxalate 10 mg Tablet Sig: Two (2) Tablet PO
DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
QHS: PRN as needed.
Disp:*30 Suppository(s)* Refills:*0*
5. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
6. Dapsone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO once a day for 2 days: Continue for 2 days, then stop.
Disp:*2 Capsule(s)* Refills:*0*
8. Simethicone 80 mg Tablet, Chewable Sig: 0.5-1 Tablet,
Chewable PO QID (4 times a day) as needed.
Disp:*80 Tablet, Chewable(s)* Refills:*0*
9. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2)
ML Intravenous  DAILY (Daily) as needed.
Disp:*50 ML(s)* Refills:*0*
10. Decadron 4 mg Tablet Sig: 1.5 Tablets PO every eight (8)
hours.
Disp:*135 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Critical Care Systems

Discharge Diagnosis:
Seizure
Left frontal lobe mass
Pancreatic CA


Discharge Condition:
Improved-no seizures

Discharge Instructions:
Please continue to take your medications as directed.  You will
be tapered off of dilantin over the next two days.  Please take
100mg by mouth once daily on Satuday and Sunday, then
discontinue.  You should notify either Dr.[**Last Name (STitle) 7994**] or Dr. [**Last Name (STitle) **]
if you have any increase in the frequency of seizures
([**Telephone/Fax (1) 38349**].

Followup Instructions:
1. Brain [**Hospital 341**] Clinic-Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Where: [**Hospital 4054**] NEUROLOGY Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2186-4-17**]
4:00

2. Oncology-Provider: [**First Name11 (Name Pattern1) 396**] [**Last Name (NamePattern4) 397**], MD Where: [**Hospital 273**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2186-4-21**]
1:30

3. Primary Care-Dr. [**Last Name (STitle) 4844**] Tuesday, [**4-25**] at 9:00AM
[**Telephone/Fax (1) 250**]

4. Surgery-Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Where: [**Hospital 273**] SURGICAL SPECIALTIES Phone:[**Telephone/Fax (1) 2833**]
Date/Time:[**2186-4-21**] 10:30
{'Neoplasm of uncertain behavior of brain and spinal cord,Other convulsions,Malignant neoplasm of other specified sites of pancreas,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Mitral valve disorders,Posttraumatic stress disorder,Esophageal reflux,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: body twitching and change in mental status

PRESENT ILLNESS: Pt is a 59 year old male with pancreatic cancer diagnosed last
[**Month (only) 359**], s/p Whipple's in [**2185-12-12**], who presents with90
minutes of R arm and leg twitching. Pt has been a bit fatigued
since his chemotherapy was started, but had no seizure-like
activity prior to yesterday, when his brother noted that his R
hand would shake intermittently. He didn't make much of it,
however, particularly as the pt's mental status seemed baseline.
This afternoon, the patient was at home and suddenly developed
diffuse R body rhythmic jerking. He seemed lucid to his brother
but was unable to produce speech, although he seemed to follow
simple commands. No LOC or loss of continence, no tongue biting.
He was brought to [**Hospital1 18**] for further evaluation.

MEDICAL HISTORY: HTN
PTSD
depression
plantar warts
genital herpes
GERD
duodenal ulcer H pylori negative

MEDICATION ON ADMISSION: 

ALLERGIES: Penicillins / Sulfa (Sulfonamides)

PHYSICAL EXAM: T afebrile, BP 115/60, HR 114, RR 19  O2 99 room air.

FAMILY HISTORY: M died of colon Ca at 55y/o
B died of pancreatic Ca at 40y/o

SOCIAL HISTORY: No tobacco now or in past.  Drinks about [**5-16**] glasses of wine per
week.  No recreational drugs.  Lives with his brother.  Retired
at this point for medical reasons, particularly PTSD (served in
[**Country 3992**]).  Worked as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] SW in the past. 

### Response:
{'Neoplasm of uncertain behavior of brain and spinal cord,Other convulsions,Malignant neoplasm of other specified sites of pancreas,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Mitral valve disorders,Posttraumatic stress disorder,Esophageal reflux,Unspecified essential hypertension'}
