CHIEF COMPLAINT: new left hemianopsia with cerbral hemorrheage and edema admitted
to ICU for medical management

PRESENT ILLNESS: 64 year old male with metastatic renal cell to brain, spine,
larynx, liver and lung, s/p avastin, recurrent pulmonary emboli
on lovenox, presented to the ED with worsening right sided
visual field loss. He reports intermittant blurry vision and
flashes of light accompanied by headaches x 2 1/2 weeks with
worsening symptoms over the past 6 days. Three days ago he had
severe bitemporal headache which he describes as [**5-12**] and
throbbing. Around the same time, he noted right sided
hemianopsia with "psychadelic" flashes of light and colors. On
the day of admission, he presented to an opthalmologist who
performed a dialated exam and determined that his vision loss
was not related to a primary occular lesion and recommended
presentation to the ED.
.
.
In the ED, initial vs were: 97.3 71 143/102 22 99%. He was
AAOx3, exam notible for right hemianopsia. CT head showed
progression of known left occipital/parietal mass with worsening
hemorrheage and edema (compared with MRI [**12-13**]. labs notible for
Na 129, Cr 1.4 (baseline 1.3), WBC 5.6 75% PMN, INR 1.1.
Neurosurgery was consulted who recommended blood pressure
control and FFP but did not recommend surgery or seizure
prophylaxis. Patient was given dexamethasone 10mg IV and 2 units
FFP and furosemide 20mg IV. 2 PIV. Vitals on transfer p68
bp136/88 sao2 96% on RA.
.
Upon arrival to ICU, patient reported [**2-9**] bifrontal headache
and continued right hemianopsia. He reported word finding
difficulites and short term memory loss over the past weeks to
months.
.
Review of sytems:
(+) increased hemoptysis in last week, and increased respiratory
secretions
(-) Denies numbness/tingling in his extremities, denies gait
instability, muscle weakness.Denies fever, chills, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits.

MEDICAL HISTORY: Bilateral pulmonary emboli [**2094**] and [**2112**]
Bilateral pulmonary embolism in [**2104**], [**8-/2113**], on long term
warfarin
Left lower pulmonary artery PE [**2119-2-20**] --> changed from warfarin
to lovenox
Resection of pulmonary metastasis [**2112**]
Resection of a subglottic metastasis requiring tracheotomy [**6-10**]
Hypertension since [**2112**]
BPH since [**2107**],
History of colonic adenomas [**2105**] and [**2110**], stable
Hx of pancreatic cyst [**2107**], stable
Stress fracture of right fibula [**2081**]
Left eye epithelial retina membrane [**1-/2118**] (slight distortion
of
lines of vision)
Umbilical hernia since [**2115**]
Depression since [**2115**]
Left forearm lipoma since [**2099**]
Diverticulosis since unknown
.
Oncology History:
- [**2111-11-2**], left lower lobe nodule found on routine scan.
- [**2111-12-3**], VATS procedure with resection of the lesion.
- [**2113-6-2**], pulmonary recurrence.
- [**2113-7-3**], pulmonary resection.
- [**2116-5-3**], multiple new lung nodules as well as bony sclerotic
lesions and liver lesion.
- [**2116-10-3**], one cycle of interleukin-2 therapy.
- [**2117-6-2**], removal of excess subglottic tissue and pathology
was consistent with metastatic renal carcinoma, larynx and
subglottic metastasis resection with a permanent tracheostomy.
- [**2117-11-14**], staging MRI mass in the posterior right
temporal lobe.
- [**2117-10-26**], CyberKnife radiosurgery to the left
posterior temporal lobe lesion.
- [**2117-11-2**], Sutent therapy, progressed on Sutent last dose
in [**2118-4-2**].
- [**2118-3-3**], gadolinium-enhanced lumbosacral spine MRI showed
left posterior vertebral body L1 metastasis.
- [**2118-5-23**], began Avastin, temsirolimus trial [**Numeric Identifier **].
- [**2118-9-2**], taken off the trial due to progression of
disease. New nodule seen on CT scan of torso.
- [**2118-9-26**], started Avastin monotherapy.
- [**2118-11-2**]:  Worsening back pain. MRI lumbar spine [**2118-11-7**]
showed epidural disease at L1.
- Last dose avastin [**2119-3-3**]

MEDICATION ON ADMISSION: Belacizumab - 25mg/mL Solution - 10 mg/kg every 2 weeks
Diphenhydramine - 25 mg [**12-4**] Capsule(s) by mouth at bedtime as
needed
ENOXAPARIN 120mg Q12Hours
Fenofibrate 200mg Daily
Finsasteride 5 mg Daily
Gabapentin 300 mg Capsule [**Hospital1 **]
Gabapentin 500 mg Capsule QHS
Hydrochlorothiazide 25 mg QAM
Terazosin 5 mg daily
Metoprolol tartarate 50 mg [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Oxycodone 5 mg 1-2 Tabs Q4h PRN
Oxycodone SR 10 mg Tablet 1 tab Q8H
Trazodone 50 mg Tablet QHS
Aacetaminophen 500mg-1000mg Q6-8 Hours PRN pain
Calcium carbonate Dosage uncertain
Calcium citrate Vitamin D3 315 mg-200 unit 2tabs daily
Ergocalciferol 1000 unit Capsule daiy
Fiber 4 tabs per day
Multivitamin daily
OMEGA-3 FATTY ACIDS 1,200 mg-144 mg daily
Senossides/docusate 8.6 mg/50 mg Tablet - 2 Tablet(s) by mouth
TID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T:99.2 BP:161/91 P:67 R: 18 O2:97 RA
General: Middle aged male appearing comfortable, occasional word
finding difficulty.
HEENT: EOMI PEERLA, MMM, oropharynx clear
Neck: trach collar in place, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatospleenomegaly.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
.
Mental status: Awake and alert, cooperative with exam, normal
affect. Poor short term memory ([**12-5**] recall at 5 min) Poor
concentration (unable to perform serial 7??????s)
Orientation: oriented to person, hospital, year:[**2088**],Oriented to
person, place, and date.
Language: occasional word finding difficulty.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 4 mm
bilaterally. Right homonymous hemianopsia is noted.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] throughout. No pronator drift
.
Cerebellum: intact heel to shin, no dysdiadokinesia
.
Sensation: Intact to light touch,
DTRs: 3+ Bilaterally in patella and biceps tendons.
Babinski downgoing bilaterally
.
On Discharge:
Vitals: 96.3 BP: 148/71, HR: 50, RR: 18, O2 93% RA
General: NAD,
HEENT: EOMI PEERLA, MMM, oropharynx clear, right temporal visual
field hemianopsia (stable)
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatosplenomegaly.
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: CN II-XII intact, Normal tone bilaterally. No abnormal
movements, tremors. Strength full power [**4-6**] throughout. No
pronator drift

FAMILY HISTORY: Father: congestive heart failure, Mother: leukemia.

SOCIAL HISTORY: Lives at home with wife in [**Name (NI) 13040**], two daughters. Retired
neuroscience researcher. Ambulates with a cane.
Intracerebral hemorrhage,Cerebral edema,Other pulmonary embolism and infarction,Acute kidney failure, unspecified,Other disorders of neurohypophysis,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Hemoptysis, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Lumbago,Homonymous bilateral field defects,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Depressive disorder, not elsewhere classified,Tracheostomy status,Personal history of malignant neoplasm of kidney
Intracerebral hemorrhage,Cerebral edema,Pulm embol/infarct NEC,Acute kidney failure NOS,Neurohypophysis dis NEC,Sec mal neo brain/spine,Secondary malig neo lung,Hemoptysis NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Lumbago,Homonymous hemianopsia,BPH w/o urinary obs/LUTS,Depressive disorder NEC,Tracheostomy status,Hx of kidney malignancy
Admission Date:  [**2119-3-16**]              Discharge Date:   [**2119-3-23**]

Date of Birth:  [**2054-8-21**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 65686**]
Chief Complaint:
new left hemianopsia with cerbral hemorrheage and edema admitted
to ICU for medical management

Major Surgical or Invasive Procedure:
IVC filter

History of Present Illness:
64 year old male with metastatic renal cell to brain, spine,
larynx, liver and lung, s/p avastin, recurrent pulmonary emboli
on lovenox, presented to the ED with worsening right sided
visual field loss. He reports intermittant blurry vision and
flashes of light accompanied by headaches x 2 1/2 weeks with
worsening symptoms over the past 6 days. Three days ago he had
severe bitemporal headache which he describes as [**5-12**] and
throbbing. Around the same time, he noted right sided
hemianopsia with "psychadelic" flashes of light and colors. On
the day of admission, he presented to an opthalmologist who
performed a dialated exam and determined that his vision loss
was not related to a primary occular lesion and recommended
presentation to the ED.
.
.
In the ED, initial vs were: 97.3 71 143/102 22 99%. He was
AAOx3, exam notible for right hemianopsia. CT head showed
progression of known left occipital/parietal mass with worsening
hemorrheage and edema (compared with MRI [**12-13**]. labs notible for
Na 129, Cr 1.4 (baseline 1.3), WBC 5.6 75% PMN, INR 1.1.
Neurosurgery was consulted who recommended blood pressure
control and FFP but did not recommend surgery or seizure
prophylaxis. Patient was given dexamethasone 10mg IV and 2 units
FFP and furosemide 20mg IV. 2 PIV. Vitals on transfer p68
bp136/88 sao2 96% on RA.
.
Upon arrival to ICU, patient reported [**2-9**] bifrontal headache
and continued right hemianopsia. He reported word finding
difficulites and short term memory loss over the past weeks to
months.
.
Review of sytems:
(+) increased hemoptysis in last week, and increased respiratory
secretions
(-) Denies numbness/tingling in his extremities, denies gait
instability, muscle weakness.Denies fever, chills, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits.

Past Medical History:
Bilateral pulmonary emboli [**2094**] and [**2112**]
Bilateral pulmonary embolism in [**2104**], [**8-/2113**], on long term
warfarin
Left lower pulmonary artery PE [**2119-2-20**] --> changed from warfarin
to lovenox
Resection of pulmonary metastasis [**2112**]
Resection of a subglottic metastasis requiring tracheotomy [**6-10**]
Hypertension since [**2112**]
BPH since [**2107**],
History of colonic adenomas [**2105**] and [**2110**], stable
Hx of pancreatic cyst [**2107**], stable
Stress fracture of right fibula [**2081**]
Left eye epithelial retina membrane [**1-/2118**] (slight distortion
of
lines of vision)
Umbilical hernia since [**2115**]
Depression since [**2115**]
Left forearm lipoma since [**2099**]
Diverticulosis since unknown
.
Oncology History:
- [**2111-11-2**], left lower lobe nodule found on routine scan.
- [**2111-12-3**], VATS procedure with resection of the lesion.
- [**2113-6-2**], pulmonary recurrence.
- [**2113-7-3**], pulmonary resection.
- [**2116-5-3**], multiple new lung nodules as well as bony sclerotic
lesions and liver lesion.
- [**2116-10-3**], one cycle of interleukin-2 therapy.
- [**2117-6-2**], removal of excess subglottic tissue and pathology
was consistent with metastatic renal carcinoma, larynx and
subglottic metastasis resection with a permanent tracheostomy.
- [**2117-11-14**], staging MRI mass in the posterior right
temporal lobe.
- [**2117-10-26**], CyberKnife radiosurgery to the left
posterior temporal lobe lesion.
- [**2117-11-2**], Sutent therapy, progressed on Sutent last dose
in [**2118-4-2**].
- [**2118-3-3**], gadolinium-enhanced lumbosacral spine MRI showed
left posterior vertebral body L1 metastasis.
- [**2118-5-23**], began Avastin, temsirolimus trial [**Numeric Identifier **].
- [**2118-9-2**], taken off the trial due to progression of
disease. New nodule seen on CT scan of torso.
- [**2118-9-26**], started Avastin monotherapy.
- [**2118-11-2**]:  Worsening back pain. MRI lumbar spine [**2118-11-7**]
showed epidural disease at L1.
- Last dose avastin [**2119-3-3**]

Social History:
Lives at home with wife in [**Name (NI) 13040**], two daughters. Retired
neuroscience researcher. Ambulates with a cane.

Family History:
Father: congestive heart failure, Mother: leukemia.

Physical Exam:
Admission Physical Exam:
Vitals: T:99.2 BP:161/91 P:67 R: 18 O2:97 RA
General: Middle aged male appearing comfortable, occasional word
finding difficulty.
HEENT: EOMI PEERLA, MMM, oropharynx clear
Neck: trach collar in place, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatospleenomegaly.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
.
Mental status: Awake and alert, cooperative with exam, normal
affect. Poor short term memory ([**12-5**] recall at 5 min) Poor
concentration (unable to perform serial 7??????s)
Orientation: oriented to person, hospital, year:[**2088**],Oriented to
person, place, and date.
Language: occasional word finding difficulty.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 4 mm
bilaterally. Right homonymous hemianopsia is noted.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] throughout. No pronator drift
.
Cerebellum: intact heel to shin, no dysdiadokinesia
.
Sensation: Intact to light touch,
DTRs: 3+ Bilaterally in patella and biceps tendons.
Babinski downgoing bilaterally
.
On Discharge:
Vitals: 96.3 BP: 148/71, HR: 50, RR: 18, O2 93% RA
General: NAD,
HEENT: EOMI PEERLA, MMM, oropharynx clear, right temporal visual
field hemianopsia (stable)
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatosplenomegaly.
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: CN II-XII intact, Normal tone bilaterally. No abnormal
movements, tremors. Strength full power [**4-6**] throughout. No
pronator drift

Pertinent Results:
Admission labs ([**2119-3-16**]):
-WBC-5.3 RBC-4.42* Hgb-14.7 Hct-41.2 MCV-93 MCH-33.3* MCHC-35.7*
RDW-14.9 Plt Ct-180 Neuts-75.5* Lymphs-16.8* Monos-6.3 Eos-0.3
Baso-1.1
-PT-13.0 PTT-27.0 INR(PT)-1.1
-Fibrino-560*
-LMWH-1.16
-Glucose-117* UreaN-18 Creat-1.4* Na-129* K-4.5 Cl-98 HCO3-21*
AnGap-15
-Calcium-9.8 Phos-1.3* Mg-2.0
-Osmolal-276
-TSH-3.7
-Cortisol-15.6
.
Discharge Labs:
- WBC-8.4 RBC-4.55* Hgb-14.9 Hct-42.8 MCV-94 MCH-32.7* MCHC-34.7
RDW-14.5 Plt Ct-197
- Glucose-100 UreaN-21* Creat-1.0 Na-136 K-4.4 Cl-104 HCO3-22
AnGap-14
- Calcium-8.8 Phos-2.6* Mg-2.4
.
[**3-16**] CXR: Innumerable pulmonary nodules, relatively stable
compared to next preceding CT, compatible with metastases. No
focal opacification concerning for pneumonia.
.
[**3-16**] Admission CT Head: New intraparenchymal hemorrhage with
surrounding edema and mass effect centered on previous left
median occipital lobe metastasis.
.
[**3-16**] Repeat CT Head: 1. Stable left occipital intraparenchymal
hemorrhage with stable edema and mass effect.
.
[**2119-3-17**]: Duplex U/S bilaterally: No evidence of DVT in the right
or left lower extremity.
.
[**2119-3-20**]: MR HEAD: IMPRESSION: The left parietooccipital
hemorrhage is grossly similar in size compared with the CT of
the head performed [**2119-3-16**]. The surrounding mass effect
is not significantly changed. The ventricles are stable in size
and are not enlarged. The post-contrast sequence does not
demonstrate other foci of post-contrast T1 hyperintensity within
the brain parenchyma to suggest other lesion. The hemorrhage
produces intrinsic T1 hyperintensity which could mask underlying
enhancing lesion as seen on the prior MRI in [**Month (only) 404**] of this
year.

Brief Hospital Course:
64 year old man with metastatic renal cell carcinoma admitted
with progressive headaches and right hemanopsia and found to
have worsening hemorrhagic mass in the left parietal/occipital
region and admitted to the ICU for medical management.
.
# Hemorrhagic brain metastasis: Patient with renal cell
carcinoma, known brain metastasis, and currently on Lovenox for
anticoagulation. Head CT on admission was remarkable for an
enlarged edematous and hemorrhagic mass extending into the
occipital and parietal lobes, which explained right homonymous
hemianopsia. Anticoagulation was stopped and Neurosurgery was
was consulted, who recommended no intervention until greater
than 2 weeks after his last dose of Avastin. He was admitted to
the [**Hospital Unit Name 153**] and monitored with serial neuro checks. Head CT was
repeated which showed no progression for hemorrheage/edema. His
blood pressure was initially controlled with a Nicardipine gtt
(goal sBP 120-140) and his head of bed was maintained >30
degrees. Repeat CT head imaging was stable. Per Neuro-Oncology
he was started on Nimodipine for prevention of vasospasm, Keppra
for seizure prophylaxis, and his Dexamethasone was decreased
from 6 mg to 4 mg q6h. He remained stable and was transferred to
the OMED service for further management.  His Dexamethasone was
tapered and he was discharged on Dexamethasone 4mg Daily.
Repeat MRI on [**2119-3-20**] showed stable intracranial process.  On
[**2119-3-22**] he had an episode of hypertension and was otherwise
asymptomatic.  He was restarted on his home medications -
hydrochlorothiazide 25mg PO daily and metoprolol tartrate 50mg
PO BID.  His nimodipine was changed to PRN, but he did not
require any doses and was not continued at the time of
discharge.  His Right Homonymous hemianopsia persisted and is
not expected to resolve.
.
# Increased intracranial pressure: Patient complained of
worsening headache on admission and was bradycardic and
hypertensive ([**1-5**] components of [**Location (un) **] triad). HOB was
maintained >30. Headache improved and experienced no change in
neurologic examination to suggest herniation or increased ICP.
Bradycardia and hypertension resolved.
.
# Hypertension: Given concern for acute hemorrheage we aimed to
maintain SBP 120-140. This was initially achieved with a
Nicardipine gtt, which was turned off on hospital day 2. He was
also initially continued on his outpatient Metoprolol Tartrate
50 [**Hospital1 **], which was held in the setting of starting Nimodipine for
vasospasm to prevent relative hypotension.  On [**2119-3-22**] he had an
episode of hypertension and was otherwise asymptomatic.  He was
restarted on his home medications - hydrochlorothiazide 25mg PO
daily and metoprolol tartrate 50mg PO BID.  His nimodipine was
changed to PRN, but he did not require any doses and was not
continued at the time of discharge.
.
# Pulmonary embolisms: Patient has a history of recurrent
pulmonary emboli, and was previously anticoagulated with
warfarin and then changed to Lovenox 3/[**2118**]. Given hemorrhagic
brain mets, future anticoagulation is contraindicated. Bilateral
lower extremity ultrasounds were negative for DVT. He underwent
placement of an IVC filter on [**3-17**] by Interventional Radiology
to prevent future clot propogation.
.
# Hemoptysis: Possibly related to multiple pulmonary metastasis
in the setting of anitcoagulation. New pulmonary embolism is
unlikely given absence of tachycardia or hypoxia. He was
provided with humidified oxygen. His O2 saturations remained
adequate on room air.
.
# Acute on Chronic Kidney disease: Baseline Cr appears to be
1.3-1.4. The patient's Cr was at baseline on admission, and
increased in the setting of diuresis. He was bolused 500 cc of
NS and repeat electrolytes revealed improvement in creatinine.
His creatinine remained stable for the rest of his hospital
stay.
.
# Hyponatremia: Thought to be secondary to SIADH given
underlying intracranial and pulmonary disease. Serum cortisol
was normal. Urine lytes revealed sodium avidity with a highly
concentrated urine, likely a mixed picture (dehydration with
underlying SIADH). He was given IVFs with subsequent improvment
in sodium.  At the time of discharge his Na was 136.
.
# Metastatic Renal Cell Carcinoma: Patient diagnosed with RCC
after biopsy of metastatic pulmonary lesion. He has metastatic
involvment of brain, spinal cord, lungs and larynx. In [**2116**] he
was treated with tracheostomy for laryngeal mass. Admission
chest xray showed worsening of pulmonary metastatic disease.
His hemorrhagic brain mass has been well controlled with steroid
therapy.  He has stabilized since admission and is doing well.
He will continue to receive dexamethasone in the outpatient
setting and follow up with his outpatient oncologists.
.
# Chronic low back pain with neuropathy: Patient is on
gabapentin and oxydonone for chronic low back pain and
neuropathy. Gabapentin was initially held on admission to avoid
sedating medications and pain was controled with oxycodone +
oxycontin at home dose.  His pain was relatively well controlled
and his gabapentin was restarted at the time of discharge.
.
Code: Full confirmed
Communication: Patient, Wife [**Telephone/Fax (2) 79328**]h [**Telephone/Fax (2) 79329**]c

Medications on Admission:
Belacizumab - 25mg/mL Solution - 10 mg/kg every 2 weeks
Diphenhydramine - 25 mg [**12-4**] Capsule(s) by mouth at bedtime as
needed
ENOXAPARIN 120mg Q12Hours
Fenofibrate 200mg Daily
Finsasteride 5 mg Daily
Gabapentin 300 mg Capsule [**Hospital1 **]
Gabapentin 500 mg Capsule QHS
Hydrochlorothiazide 25 mg QAM
Terazosin 5 mg daily
Metoprolol tartarate 50 mg [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Oxycodone 5 mg 1-2 Tabs Q4h PRN
Oxycodone SR 10 mg Tablet 1 tab Q8H
Trazodone 50 mg Tablet QHS
Aacetaminophen 500mg-1000mg Q6-8 Hours PRN pain
Calcium carbonate Dosage uncertain
Calcium citrate Vitamin D3 315 mg-200 unit 2tabs daily
Ergocalciferol 1000 unit Capsule daiy
Fiber 4 tabs per day
Multivitamin daily
OMEGA-3 FATTY ACIDS 1,200 mg-144 mg daily
Senossides/docusate 8.6 mg/50 mg Tablet - 2 Tablet(s) by mouth
TID

Discharge Medications:
1. AVASTIN 25 mg/mL Solution Sig: Ten (10) mg/kg Intravenous
Q2week.
2. Benadryl 25 mg Capsule Sig: [**12-4**] Capsules PO at bedtime as
needed for insomnia.
3. fenofibrate 50 mg Capsule Sig: Four (4) Capsule PO once a
day.
4. finasteride 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a
day.
6. gabapentin 100 mg Capsule Sig: Five (5) Capsule PO at
bedtime.
7. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
11. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO Q8H (every 8 hours).
12. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as
needed for insomnia.
13. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO
every 6-8 hours as needed for pain.
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day
for 1 days.
15. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
PO DAILY (Daily) as needed for constipation.
19. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: Two (2)
Tablet PO once a day.
20. ergocalciferol (vitamin D2) 400 unit Tablet Sig: Two (2)
Tablet PO once a day.
21. Fiber-Tabs 625 mg Tablet Sig: Four (4) Tablet PO once a day.

22. multivitamin     Tablet Sig: One (1) Tablet PO once a day.
23. Omega 3-6-9 1,200 mg Capsule Sig: One (1) Capsule PO once a
day.
24. terazosin 5 mg Capsule Sig: One (1) Capsule PO once a day.
25. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] Nursing & Therapy Center - [**Location 1268**] ([**Location (un) 86**] Center
for Rehabilitation and Sub-Acute Care)

Discharge Diagnosis:
Primary Diagnosis:
Hemorrhagic lesion in the brain
.
Secondary Diagnosis:
metastatic Renal Cell Cancer
Hypertension
Bradycardia
Pulmonary embolus
Hemoptysis


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 are being discharged from [**Hospital1 1170**].  It was a pleasure taking care of you.  You were
admitted to the hospital because of increasing headache and loss
of vision on the right side.  We found that the lesion in your
brain was hemorrhaging and your lovenox was stopped and you were
started on IV steroids and medications to control your blood
pressure.  You were initially admitted to the intensive care
unit for monitoring.  Your blood pressure remained well
controlled and you were transferred to the regular floor.  We
are tapering your steroids and have switched you back to your
home blood pressure medications.  Repeat MRI on [**2119-3-20**] showed
that the bleeding in the brain has remained stable and is not
getting worse.  You were seen by physical therapy and it was
felt you would be safest and best if you were discharged to
Rehab for strength and gait training.  You will follow up with
your outpatient oncologists for further care.
.
The following medications were STARTED:
Dexamethasone 4mg by mouth Daily
Keppra 500mg by mouth twice a day
Miralax 17gm by mouth Daily if you are not having bowel
movements
.
The following medication was STOPPED:
Lovenox 120mg two times a day
.
Please continue your other medications as prescribed.

Followup Instructions:
Department: BMT/ONCOLOGY UNIT
When: MONDAY [**2119-3-27**] at 10:30 AM [**Telephone/Fax (1) 447**]
Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**]
Campus: EAST     Best Parking: Main Garage

Department: RADIOLOGY
When: SUNDAY [**2119-4-2**] at 1:15 PM
With: RADIOLOGY MRI [**Telephone/Fax (1) 327**]
Building: [**Hospital6 29**] [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROLOGY
When: MONDAY [**2119-4-3**] at 10:30 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**]
Building: [**Hospital6 29**] [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Intracerebral hemorrhage,Cerebral edema,Other pulmonary embolism and infarction,Acute kidney failure, unspecified,Other disorders of neurohypophysis,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Hemoptysis, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Lumbago,Homonymous bilateral field defects,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Depressive disorder, not elsewhere classified,Tracheostomy status,Personal history of malignant neoplasm of kidney'}


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: new left hemianopsia with cerbral hemorrheage and edema admitted
to ICU for medical management

PRESENT ILLNESS: 64 year old male with metastatic renal cell to brain, spine,
larynx, liver and lung, s/p avastin, recurrent pulmonary emboli
on lovenox, presented to the ED with worsening right sided
visual field loss. He reports intermittant blurry vision and
flashes of light accompanied by headaches x 2 1/2 weeks with
worsening symptoms over the past 6 days. Three days ago he had
severe bitemporal headache which he describes as [**5-12**] and
throbbing. Around the same time, he noted right sided
hemianopsia with "psychadelic" flashes of light and colors. On
the day of admission, he presented to an opthalmologist who
performed a dialated exam and determined that his vision loss
was not related to a primary occular lesion and recommended
presentation to the ED.
.
.
In the ED, initial vs were: 97.3 71 143/102 22 99%. He was
AAOx3, exam notible for right hemianopsia. CT head showed
progression of known left occipital/parietal mass with worsening
hemorrheage and edema (compared with MRI [**12-13**]. labs notible for
Na 129, Cr 1.4 (baseline 1.3), WBC 5.6 75% PMN, INR 1.1.
Neurosurgery was consulted who recommended blood pressure
control and FFP but did not recommend surgery or seizure
prophylaxis. Patient was given dexamethasone 10mg IV and 2 units
FFP and furosemide 20mg IV. 2 PIV. Vitals on transfer p68
bp136/88 sao2 96% on RA.
.
Upon arrival to ICU, patient reported [**2-9**] bifrontal headache
and continued right hemianopsia. He reported word finding
difficulites and short term memory loss over the past weeks to
months.
.
Review of sytems:
(+) increased hemoptysis in last week, and increased respiratory
secretions
(-) Denies numbness/tingling in his extremities, denies gait
instability, muscle weakness.Denies fever, chills, rhinorrhea or
congestion. Denied shortness of breath. Denied chest pain.
Denied nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel or bladder habits.

MEDICAL HISTORY: Bilateral pulmonary emboli [**2094**] and [**2112**]
Bilateral pulmonary embolism in [**2104**], [**8-/2113**], on long term
warfarin
Left lower pulmonary artery PE [**2119-2-20**] --> changed from warfarin
to lovenox
Resection of pulmonary metastasis [**2112**]
Resection of a subglottic metastasis requiring tracheotomy [**6-10**]
Hypertension since [**2112**]
BPH since [**2107**],
History of colonic adenomas [**2105**] and [**2110**], stable
Hx of pancreatic cyst [**2107**], stable
Stress fracture of right fibula [**2081**]
Left eye epithelial retina membrane [**1-/2118**] (slight distortion
of
lines of vision)
Umbilical hernia since [**2115**]
Depression since [**2115**]
Left forearm lipoma since [**2099**]
Diverticulosis since unknown
.
Oncology History:
- [**2111-11-2**], left lower lobe nodule found on routine scan.
- [**2111-12-3**], VATS procedure with resection of the lesion.
- [**2113-6-2**], pulmonary recurrence.
- [**2113-7-3**], pulmonary resection.
- [**2116-5-3**], multiple new lung nodules as well as bony sclerotic
lesions and liver lesion.
- [**2116-10-3**], one cycle of interleukin-2 therapy.
- [**2117-6-2**], removal of excess subglottic tissue and pathology
was consistent with metastatic renal carcinoma, larynx and
subglottic metastasis resection with a permanent tracheostomy.
- [**2117-11-14**], staging MRI mass in the posterior right
temporal lobe.
- [**2117-10-26**], CyberKnife radiosurgery to the left
posterior temporal lobe lesion.
- [**2117-11-2**], Sutent therapy, progressed on Sutent last dose
in [**2118-4-2**].
- [**2118-3-3**], gadolinium-enhanced lumbosacral spine MRI showed
left posterior vertebral body L1 metastasis.
- [**2118-5-23**], began Avastin, temsirolimus trial [**Numeric Identifier **].
- [**2118-9-2**], taken off the trial due to progression of
disease. New nodule seen on CT scan of torso.
- [**2118-9-26**], started Avastin monotherapy.
- [**2118-11-2**]:  Worsening back pain. MRI lumbar spine [**2118-11-7**]
showed epidural disease at L1.
- Last dose avastin [**2119-3-3**]

MEDICATION ON ADMISSION: Belacizumab - 25mg/mL Solution - 10 mg/kg every 2 weeks
Diphenhydramine - 25 mg [**12-4**] Capsule(s) by mouth at bedtime as
needed
ENOXAPARIN 120mg Q12Hours
Fenofibrate 200mg Daily
Finsasteride 5 mg Daily
Gabapentin 300 mg Capsule [**Hospital1 **]
Gabapentin 500 mg Capsule QHS
Hydrochlorothiazide 25 mg QAM
Terazosin 5 mg daily
Metoprolol tartarate 50 mg [**Hospital1 **]
Omeprazole 20 mg [**Hospital1 **]
Oxycodone 5 mg 1-2 Tabs Q4h PRN
Oxycodone SR 10 mg Tablet 1 tab Q8H
Trazodone 50 mg Tablet QHS
Aacetaminophen 500mg-1000mg Q6-8 Hours PRN pain
Calcium carbonate Dosage uncertain
Calcium citrate Vitamin D3 315 mg-200 unit 2tabs daily
Ergocalciferol 1000 unit Capsule daiy
Fiber 4 tabs per day
Multivitamin daily
OMEGA-3 FATTY ACIDS 1,200 mg-144 mg daily
Senossides/docusate 8.6 mg/50 mg Tablet - 2 Tablet(s) by mouth
TID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission Physical Exam:
Vitals: T:99.2 BP:161/91 P:67 R: 18 O2:97 RA
General: Middle aged male appearing comfortable, occasional word
finding difficulty.
HEENT: EOMI PEERLA, MMM, oropharynx clear
Neck: trach collar in place, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatospleenomegaly.
GU: foley in place
Ext: warm, well perfused, 2+ pulses, no edema
.
Mental status: Awake and alert, cooperative with exam, normal
affect. Poor short term memory ([**12-5**] recall at 5 min) Poor
concentration (unable to perform serial 7??????s)
Orientation: oriented to person, hospital, year:[**2088**],Oriented to
person, place, and date.
Language: occasional word finding difficulty.
.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to 4 mm
bilaterally. Right homonymous hemianopsia is noted.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-6**] throughout. No pronator drift
.
Cerebellum: intact heel to shin, no dysdiadokinesia
.
Sensation: Intact to light touch,
DTRs: 3+ Bilaterally in patella and biceps tendons.
Babinski downgoing bilaterally
.
On Discharge:
Vitals: 96.3 BP: 148/71, HR: 50, RR: 18, O2 93% RA
General: NAD,
HEENT: EOMI PEERLA, MMM, oropharynx clear, right temporal visual
field hemianopsia (stable)
Neck: JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  Obese soft, non-tender, non-distended, bowel sounds
normoactive no hepatosplenomegaly.
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: CN II-XII intact, Normal tone bilaterally. No abnormal
movements, tremors. Strength full power [**4-6**] throughout. No
pronator drift

FAMILY HISTORY: Father: congestive heart failure, Mother: leukemia.

SOCIAL HISTORY: Lives at home with wife in [**Name (NI) 13040**], two daughters. Retired
neuroscience researcher. Ambulates with a cane. 

### Response:
{'Intracerebral hemorrhage,Cerebral edema,Other pulmonary embolism and infarction,Acute kidney failure, unspecified,Other disorders of neurohypophysis,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Hemoptysis, unspecified,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Lumbago,Homonymous bilateral field defects,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Depressive disorder, not elsewhere classified,Tracheostomy status,Personal history of malignant neoplasm of kidney'}
