CHIEF COMPLAINT: Pulmonary embolism

PRESENT ILLNESS: 51yoM with Stage IV gliosarcoma diagnosed last year s/p
resection at one site with a second site at brain stem deemed
inoperable s/p chemo and XRT/gamma knife, and hx of PE [**Month (only) 958**]
[**2122**] s/p coumadin finished few months ago, transferred from
[**Hospital3 **] with bilateral PEs in setting of week long
worsening symptoms of shortness of breath after a plane flight
from [**State 2690**] two weeks ago.

MEDICAL HISTORY: Stage IV gliosarcoma ([**2122**]) s/p resection, chemo, XRT with
inoperable lesion at brain stem
Left lung Pulmonary embolism ([**2122**])
Herpes
Pneumonia
Depression
GERD

MEDICATION ON ADMISSION: Zolpidem 10mg QHS
Gabapentin 300 mg QHS
Lamictal 300 mg XR QAM
Dilaudid 4 mg Q3-4 hours as needed for pain
Omeprazole 20 mg QHS
Valacyclovir 1 g daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
98.2, P 95, 98/80, R 16, O2 96RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, Right
pupil sluggish compared to left, Left homonymous hemianopsia
Neck: supple, JVP not elevated, no LAD
CV: Regular but tachy, normal S1 + S2, no loud S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: Mother: Cervical cancer
Father: CAD

SOCIAL HISTORY: Previously worked for Fidelity.  Ever since cancer and surgery
has been on disability.  Now writes fantasy novels.  Lives with
his partner, [**Name (NI) 65250**], in [**Location (un) 112267**], [**State 2690**].  Rest of family in
[**Location (un) 86**].  Denies smoking, Etoh, drugs
Other pulmonary embolism and infarction,Malignant neoplasm of brain stem,Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Esophageal reflux,Herpes simplex without mention of complication,Tachycardia, unspecified
Pulm embol/infarct NEC,Mal neo brain stem,Epilep NEC w/o intr epil,Esophageal reflux,Herpes simplex NOS,Tachycardia NOS
Admission Date:  [**2123-8-1**]              Discharge Date:   [**2123-8-7**]

Date of Birth:  [**2072-5-27**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Attending Info 8238**]
Chief Complaint:
Pulmonary embolism


Major Surgical or Invasive Procedure:
none

History of Present Illness:
51yoM with Stage IV gliosarcoma diagnosed last year s/p
resection at one site with a second site at brain stem deemed
inoperable s/p chemo and XRT/gamma knife, and hx of PE [**Month (only) 958**]
[**2122**] s/p coumadin finished few months ago, transferred from
[**Hospital3 **] with bilateral PEs in setting of week long
worsening symptoms of shortness of breath after a plane flight
from [**State 2690**] two weeks ago.

Last week, pt started feeling short of breath and it has become
more severe over past few days including shortness of breath
with showering and walking short disatnces. Pt went to LGH where
CTA revealed PE obstructing R main PA and LLL PA. Patient was
started on heparin and transferred here. In [**Name (NI) **], pt reports
having stool guaic which was negative.  Trops and BNP were WNL.
Pt subsequently admitted to ICU for tachycardia and RV strain.

Pt endorses 1/10 chest pain which he states is more like
substernal pressure, it has improved throughout the day.  He
denies pleurisy or inability to take deep breaths.  He denies
palpitations or lightheadedness.  He states that his main
symptoms have been dyspnea with small tasks and lots of fatigue.
 He states his previous PE last year in left lung had more
symptoms of pleurisy.

Patient denies any hemoptysis, fevers, chills. Does have chronic
headache which he states is unchanged from his normal which he
takes dilaudid for and states that he does have intermittent
periods of weakness. He reports there is a question of the
patient having a [**Doctor Last Name 11332**] mal seizure during his evaluation at the
outside hospital. Patient has a history of seizures and takes
lamictal. Notes that his left visual fields are not as clear as
his right.


Past Medical History:
Stage IV gliosarcoma ([**2122**]) s/p resection, chemo, XRT with
inoperable lesion at brain stem
Left lung Pulmonary embolism ([**2122**])
Herpes
Pneumonia
Depression
GERD



Social History:
Previously worked for Fidelity.  Ever since cancer and surgery
has been on disability.  Now writes fantasy novels.  Lives with
his partner, [**Name (NI) 65250**], in [**Location (un) 112267**], [**State 2690**].  Rest of family in
[**Location (un) 86**].  Denies smoking, Etoh, drugs


Family History:
Mother: Cervical cancer
Father: CAD


Physical Exam:
ADMISSION EXAM
98.2, P 95, 98/80, R 16, O2 96RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, Right
pupil sluggish compared to left, Left homonymous hemianopsia
Neck: supple, JVP not elevated, no LAD
CV: Regular but tachy, normal S1 + S2, no loud S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Other than visual deficit described above, CNs intact,
5/5 strength upper/lower extremities except iliopsoas which is
[**5-20**], grossly normal sensation, reflexes and gait deferred

DISCHARGE EXAM
98.5, P 100-110s, BP 90-100/50-60s, R 18, O2 96RA
Gen- alert, chronically ill appearing, NAD
Psych- does often appear tired/subdued but overall pleasant and
interactive
Head- prior cranial surgical scars noted
CV- tachycardic, regular, no m/g
Lung- CTAB
Abd- soft NT/ND
Gait- ginger and slow, heavy use of assist device (walker)

Pertinent Results:
[**2123-8-1**] 06:35PM BLOOD WBC-7.0 RBC-4.07* Hgb-13.4* Hct-39.0*
MCV-96 MCH-32.9* MCHC-34.3 RDW-15.7* Plt Ct-183
[**2123-8-7**] 07:55AM BLOOD WBC-3.8* RBC-3.46* Hgb-11.3* Hct-33.2*
MCV-96 MCH-32.6* MCHC-34.1 RDW-15.5 Plt Ct-214
[**2123-8-1**] 06:35PM BLOOD PT-10.8 PTT-107.6* INR(PT)-1.0
[**2123-8-5**] 07:45AM BLOOD PT-16.9* PTT-69.3* INR(PT)-1.6*
[**2123-8-6**] 08:05AM BLOOD PT-21.9* PTT-77.0* INR(PT)-2.1*
[**2123-8-7**] 07:55AM BLOOD PT-29.4* PTT-100.5* INR(PT)-2.8*
[**2123-8-6**] 08:15AM BLOOD Glucose-90 UreaN-4* Creat-0.7 Na-140
K-3.6 Cl-105 HCO3-28 AnGap-11
[**2123-8-1**] 06:35PM BLOOD cTropnT-<0.01
[**2123-8-2**] 03:14AM BLOOD cTropnT-<0.01
[**2123-8-1**] 06:35PM BLOOD proBNP-35

TTE [**8-2**]
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). Right ventricular
chamber size is normal. with focal basal free wall hypokinesis.
The diameters of aorta at the sinus, ascending and arch levels
are normal. The aortic valve leaflets (3) are mildly thickened
but aortic stenosis is not present. No aortic regurgitation is
seen. The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The tricuspid valve leaflets are
mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion. There is
an anterior space which most likely represents a prominent fat
pad.
IMPRESSION: Normal regional and global left ventricular systolic
function. The right ventricle appears mildly dilated with
hypokinesis of the basal to mid RV free wall. No significant
valvular abnormality seen. Resting tachycardia.

Lower extremity dopplers [**8-2**]: no DVT

EKG [**2123-8-6**]- sinus 101 bpm, slightly concave ST segments in II
and V6 < 1mm, low precordial voltages, otherwise no ST-T
abnormalities. Same as admission EKG [**8-1**]


Brief Hospital Course:
51M with gliosarcoma, prior PE, now admitted with new PE.

# Bilateral pulmonary emboli: Likely [**3-18**] to travel in setting of
malignancy and prior hypercoagulable state.  No evidence of
lower extremity thrombus on ultrasound study here. Treated with
heparin drip, bridged to warfarin. Initially admitted to ICU for
hemodynamic monitoring.  Echo did show RV dysfunction, however
patient was never hemodynamically unstable (aka no hypotension).
It was felt he did not warrant fibrinolytic therapy at any
point.
He was hypoxemic initially, and slowly titrated off; at
discharge, O2 sats 93-96% with ambulation.
He was also persistently tachycardic, see below.
He was bridged with heparin for 6 days total, with therapeutic
INR > 2 on the final 2 days. He was on 5mg daily, with INR
rising to 2.8 on day of discharge. Dose will be decreased to 4mg
on Sunday [**8-8**], and patient will follow up on Monday [**8-9**] with
our [**Hospital1 18**] [**Hospital 191**] [**Hospital3 **] for dosing, until he
returns to [**State 2690**] in a couple weeks. He should remain on lifelong
anticoagulation. The patient preferred to not use LMWH
injections.
I feel he is safe to fly back to [**State 2690**] if on therapeutic doses
of warfarin. I explained the risks of developing DVT with air
travel, and importance of recommendations to reduce risk
including hydration, regular leg stretches, and standing/walking
every hour.

# tachycardia- persistent sinus tachy 100-110s through the
admission, which did not improve despite hydration. Unknown if
he has a baseline elevated HR from his malignancy. More likely
is due to the PE with mild RV dysfunction. Given he did not have
persistent hypoxemia or hypotension, it was felt there is no
indication for repeat CT angiography or further therapy of his
PE aside from standard anticoagulation.

# Brain Ca, Gliosarcoma: Pt has recently undergone gamma knife
and states that he is waiting to hear back from his radiation
oncologist as to what further treatments will be done.  He has
Stage IV disease and there is disease in the brain stem which is
inoperable.  He had a CT head at OSH with no evidence of bleed.
Neuroncology at [**Hospital1 **] and outpatient rad onc both felt
anti-coagulation was safe. No further inpatient issues.

# Mood- social work consulted in hospital, and there was concern
for patient having low motivation and possibly situational
depression in context of his illness. He may benefit from
further eval of this and possibly a stimulating anti-depressant
medication if appropriate.

# Gait- noted to rely heavily on use of walker, and have slight
difficulty with independent transfers. Unchanged from
pre-admission. Physical therapy not consulted given patient
declines rehab placement and plans to return to [**State 2690**] soon.

STABLE ISSUES

# Hx of seziures: Patient was continued on his home lamictal
# GERD: Patient was continued on his home omeprazole
# Herpes: Acyclovir was exchanged for Valacyclovir due to
formulary issues
.
TRANSITIONAL ISSUES
- INR monitoring

Medications on Admission:
Zolpidem 10mg QHS
Gabapentin 300 mg QHS
Lamictal 300 mg XR QAM
Dilaudid 4 mg Q3-4 hours as needed for pain
Omeprazole 20 mg QHS
Valacyclovir 1 g daily


Discharge Medications:
1. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
4. lamotrigine 300 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO once a day.
5. Valtrex 1 g Tablet Sig: One (1) Tablet PO once a day.
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).

7. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day:
contact [**Hospital3 **] on [**8-9**] for further dosing.
Disp:*10 Tablet(s)* Refills:*0*
8. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Pulmonary embolism


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
You were admitted for a new blood clot in your lungs. You should
take warfarin 4mg on Sunday [**8-8**], and then get in contact with
the [**Hospital 18**] [**Hospital 2786**] clinic on Monday [**8-9**]. You should
remain on coumadin indefinitely.

Your resting heart rate was elevated. If you develop
lightheadedness or palpitations, you should return to the
hospital.

It is safe to fly home to [**State 2690**] as long as your coumadin dose is
fully therapeutic. If the coumadin levels are below the goal, it
may be unsafe to fly.  If you do fly, you should stay very well
hydrated, stretch your legs while seated, and walk up the aisle
every hour to promote blood circulation.

Followup Instructions:
With [**Hospital3 **] [**Hospital3 **] on Monday
[**8-9**]. Their number is ([**Telephone/Fax (1) 10844**].

Your temporary primary care doctor while you stay in [**Location (un) 86**] will
be the physician that cared for you in the hospital, Dr. [**Last Name (STitle) **]
[**Name (STitle) **]. His clinic phone number, where the [**Hospital 2786**]
clinic is located, is [**Telephone/Fax (1) 2010**].
{'Other pulmonary embolism and infarction,Malignant neoplasm of brain stem,Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Esophageal reflux,Herpes simplex without mention of complication,Tachycardia, 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: Pulmonary embolism

PRESENT ILLNESS: 51yoM with Stage IV gliosarcoma diagnosed last year s/p
resection at one site with a second site at brain stem deemed
inoperable s/p chemo and XRT/gamma knife, and hx of PE [**Month (only) 958**]
[**2122**] s/p coumadin finished few months ago, transferred from
[**Hospital3 **] with bilateral PEs in setting of week long
worsening symptoms of shortness of breath after a plane flight
from [**State 2690**] two weeks ago.

MEDICAL HISTORY: Stage IV gliosarcoma ([**2122**]) s/p resection, chemo, XRT with
inoperable lesion at brain stem
Left lung Pulmonary embolism ([**2122**])
Herpes
Pneumonia
Depression
GERD

MEDICATION ON ADMISSION: Zolpidem 10mg QHS
Gabapentin 300 mg QHS
Lamictal 300 mg XR QAM
Dilaudid 4 mg Q3-4 hours as needed for pain
Omeprazole 20 mg QHS
Valacyclovir 1 g daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM
98.2, P 95, 98/80, R 16, O2 96RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, Right
pupil sluggish compared to left, Left homonymous hemianopsia
Neck: supple, JVP not elevated, no LAD
CV: Regular but tachy, normal S1 + S2, no loud S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: Mother: Cervical cancer
Father: CAD

SOCIAL HISTORY: Previously worked for Fidelity.  Ever since cancer and surgery
has been on disability.  Now writes fantasy novels.  Lives with
his partner, [**Name (NI) 65250**], in [**Location (un) 112267**], [**State 2690**].  Rest of family in
[**Location (un) 86**].  Denies smoking, Etoh, drugs 

### Response:
{'Other pulmonary embolism and infarction,Malignant neoplasm of brain stem,Other forms of epilepsy and recurrent seizures, without mention of intractable epilepsy,Esophageal reflux,Herpes simplex without mention of complication,Tachycardia, unspecified'}
