CHIEF COMPLAINT: Altered mental status

PRESENT ILLNESS: This is a 80 y/o male with metastatic melanoma to the brain and
Parkinson's disease who was brought to the ED by his family by
ambulance on [**2196-9-19**] because several days of altered mental
status.
.
The pt has been c/o gradually worsening confusion, increased
movements, difficulty with speech and decreased fluid intake
(recent swallow eval recommending no thin liquids). His wife
noticed increased fatigue over the past couple days. One day PTA
he was not able to sit still in the church and was listing to
the right. His wife stated that he had a right facial droop
concerning for a stroke and he was transported to the ED at
[**Hospital1 18**].
.
In the ED, HR 68 BP 99/68 RR 20 SAT 97%, FS140. Seen by
neurology, who felt he was not having a stroke. Labs significant
for elebated troponin, CK, and CK-MB. UA negative. Head CT
negative for hemorrhage. Exam was negative for right facial
droop and listing to his right side. He had dyskinesia of
UE/LE/mouth but without focal weakness. There was right
flattening of nasolabial fold (but wife says this is his
longstanding baseline). He was given 0.5 mg Ativan and IV fluids
and admitted to the medicine service for further evaluation.

MEDICAL HISTORY: 1. Hypertension
2. Metastatic Melanoma with mets to the brain (bilateral
cerebral hemishpheres), liver, lungs, and spine. Had whole brain
radiation on [**2196-8-26**] for ten sessions. Finished on [**2196-9-16**].
3. Parkinson's Disease
4. Anemia (baseline 30-32)

MEDICATION ON ADMISSION: - Amantadine 200 mg twice a day.
- Norvasc 5 mg DAILY
- Vitamin C
- Calcium/calciferol 600+D
- Sinemet-CR 50/200  five times a day
- Stalevo 150 37.5 mg-15 five times a day
- Imipramine 10 mg [**Hospital1 **]
- Mirapex 1 mg TID
- Multivitamin DAILY
- Niacin 500 mg [**Hospital1 **]
- Ocuvite [**Hospital1 **]
- Bactrim DS [**Hospital1 **]

ALLERGIES: Levofloxacin / Keppra

PHYSICAL EXAM: VITALS: T 97.9  HR 55  BP 130/68  RR 20  Sat 97%RA  Pain 0/10
GENERAL: Ill appearing elderly male, poorly responsive at first
but able to open eyes and follow commands. Eyes dry and crusted
shut. Mucous membranes severely dry and tongue stuck within
[**Last Name (un) 22923**].
SKIN: Dry with multiple skin tears with bandages over them.
HEENT: NC/AT. Sclera Anicteric, EOMI w/ limited right movement,
PERRL.
NECK: Supple, no LAD, noraml carotid pulses, transmitted AS
murrmur. No JVD.
CHEST: CTA bilatearlly. No Wheezes/Rhonchi/Crackles. No
supraclavicular LAD. Bilateral axillary LAD.
HEART: RRR. Normal S1 and S2. [**12-29**] early peaking Systolic
creshendo / descreshendo murmur with audible S2.
ABDOMEN: Soft, non-tender, non-distended. +BS. No organomegaly,
No guarding, No rebound.
EXT: No edema. 2+ DP, PT Pulses.
NEURO:
Mental Status: Oriented to person, unable to orient to time and
location.
Cranial Nerves: II-XII intact
Muscle Strength: Increased tone. [**2-25**] UE and LE
Reflexes: +1 bic, pat

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Lives with his wife in [**Name (NI) **]. Has several children. Former
smoker, occassional alcohol.
Other encephalopathy,Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Hyperosmolality and/or hypernatremia,Dysphagia, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Anemia in neoplastic disease,Cardiac arrest
Encephalopathy NEC,Acute kidney failure NOS,Second malig neo liver,Secondary malig neo bone,Food/vomit pneumonitis,Urin tract infection NOS,Protein-cal malnutr NOS,Hyperosmolality,Dysphagia NOS,Dementia w Lewy bodies,Dementia w/o behav dist,Hypertension NOS,Anemia in neoplastic dis,Cardiac arrest
Admission Date:  [**2196-9-18**]              Discharge Date:   [**2196-9-30**]

Date of Birth:  [**2116-7-16**]             Sex:   M

Service: MEDICINE

Allergies:
Levofloxacin / Keppra

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Altered mental status

Major Surgical or Invasive Procedure:

Attempted PEG tube placement


History of Present Illness:
This is a 80 y/o male with metastatic melanoma to the brain and
Parkinson's disease who was brought to the ED by his family by
ambulance on [**2196-9-19**] because several days of altered mental
status.
.
The pt has been c/o gradually worsening confusion, increased
movements, difficulty with speech and decreased fluid intake
(recent swallow eval recommending no thin liquids). His wife
noticed increased fatigue over the past couple days. One day PTA
he was not able to sit still in the church and was listing to
the right. His wife stated that he had a right facial droop
concerning for a stroke and he was transported to the ED at
[**Hospital1 18**].
.
In the ED, HR 68 BP 99/68 RR 20 SAT 97%, FS140. Seen by
neurology, who felt he was not having a stroke. Labs significant
for elebated troponin, CK, and CK-MB. UA negative. Head CT
negative for hemorrhage. Exam was negative for right facial
droop and listing to his right side. He had dyskinesia of
UE/LE/mouth but without focal weakness. There was right
flattening of nasolabial fold (but wife says this is his
longstanding baseline). He was given 0.5 mg Ativan and IV fluids
and admitted to the medicine service for further evaluation.


Past Medical History:
1. Hypertension
2. Metastatic Melanoma with mets to the brain (bilateral
cerebral hemishpheres), liver, lungs, and spine. Had whole brain
radiation on [**2196-8-26**] for ten sessions. Finished on [**2196-9-16**].
3. Parkinson's Disease
4. Anemia (baseline 30-32)


Social History:
Lives with his wife in [**Name (NI) **]. Has several children. Former
smoker, occassional alcohol.

Family History:
Non contributory

Physical Exam:
VITALS: T 97.9  HR 55  BP 130/68  RR 20  Sat 97%RA  Pain 0/10
GENERAL: Ill appearing elderly male, poorly responsive at first
but able to open eyes and follow commands. Eyes dry and crusted
shut. Mucous membranes severely dry and tongue stuck within
[**Last Name (un) 22923**].
SKIN: Dry with multiple skin tears with bandages over them.
HEENT: NC/AT. Sclera Anicteric, EOMI w/ limited right movement,
PERRL.
NECK: Supple, no LAD, noraml carotid pulses, transmitted AS
murrmur. No JVD.
CHEST: CTA bilatearlly. No Wheezes/Rhonchi/Crackles. No
supraclavicular LAD. Bilateral axillary LAD.
HEART: RRR. Normal S1 and S2. [**12-29**] early peaking Systolic
creshendo / descreshendo murmur with audible S2.
ABDOMEN: Soft, non-tender, non-distended. +BS. No organomegaly,
No guarding, No rebound.
EXT: No edema. 2+ DP, PT Pulses.
NEURO:
Mental Status: Oriented to person, unable to orient to time and
location.
Cranial Nerves: II-XII intact
Muscle Strength: Increased tone. [**2-25**] UE and LE
Reflexes: +1 bic, pat


Pertinent Results:
[**2196-9-18**] 08:31PM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019
[**2196-9-18**] 08:31PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2196-9-18**] 04:30PM   GLUCOSE-113* UREA N-23* CREAT-1.1 SODIUM-141
POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-30 ANION GAP-14
[**2196-9-18**] 04:30PM   CK(CPK)-417*
[**2196-9-18**] 04:30PM   cTropnT-0.02*
[**2196-9-18**] 04:30PM   CK-MB-15* MB INDX-3.6
[**2196-9-18**] 04:30PM   CALCIUM-9.9 PHOSPHATE-3.5 MAGNESIUM-2.4
[**2196-9-18**] 04:30PM   WBC-8.1 RBC-3.06* HGB-10.4* HCT-31.9*
MCV-104* MCH-34.0* MCHC-32.6 RDW-16.4*
[**2196-9-18**] 04:30PM   NEUTS-81.2* LYMPHS-11.5* MONOS-5.0 EOS-1.8
BASOS-0.5
[**2196-9-18**] 04:30PM   PLT COUNT-351
[**2196-9-19**] - CXR - No definitive evidence for pneumonia. Interval
increase in size of pulmonary metastases.
MRI/MRA Head - [**2196-9-19**] -  In spite of the recent CT scan
report, the lesions suspected of being metastatic in etiology do
not exhibit overt enhancement, arguing against this diagnosis.
They do reveal susceptibility effects, which are consistent with
blood products or calcification. However, the CT scans do not
reveal calcification. In view of the patient's age, perhaps
these lesions represent ischemic/hemorrhagic events, rather than
metastatic lesions. Certainly, the present study, and even the
prior MR scan of [**2188-8-14**] exhibited areas of high T2
signal within the periventricular white matter of both cerebral
hemispheres, consistent with chronic small vessel infarction.
Diffusion-weighted images are normal. There is no mass effect or
shift of normally midline structures. Considering the eight
years between scans, there has been negligible change in
ventricular size.

There does appear to be a posterior angulation of the odontoid
process relative to the body, a finding which was not observed
on the prior MR study. There does not appear to be any
prevertebral soft tissue swelling in this locale. Has there been
prior trauma? Certainly, no cervical spine imaging studies are
present on the PACS system to address this issue in greater
detail. It should also be mentioned that there is some loss of
definition of the atlanto-dental articulation. To clarify this
finding further, a CT scan is advised.

FINDINGS: The major vascular tributaries of the circle of [**Location (un) 431**]
are patent. There is limited imaging of the distal vasculature,
likely due to reduced cardiac stroke volume. There are no overt
areas of hemodynamically significant stenosis or aneurysm
identified.
[**2196-9-19**] CT Head -
1. No evidence of acute intracranial hemorrhage.

2. Two hyperdense lesions identified, stable since [**2196-8-23**],
and consistent with known metastatic disease. Evaluation for
additional metastatic lesions is limited on non-contrast head
CT. For restaging, CT with contrast or MRI of the brain can be
obtained on a nonemergent basis.
[**2196-9-19**] EEG - This is a normal routine EEG in the waking and
drowsy
states. No focal, lateralized, or epileptiform discharges were
noted.
[**2196-9-23**] Cspine XR - There is again seen a un-united fracture
involving the dens with the base of C2. The fracture gap
measures 5 mm, and this does not change with flexion or
extension. There is anterolisthesis of the superior fracture
fragment in relation to the base and angulation posteriorly;
also unchanged with flexion or extension views. Degenerative
changes of the remainder of the cervical spine is again seen and
unchanged, and the findings are most prominent at C4-5 and C5-6.


Brief Hospital Course:
This is a 80 y/o male with metastatic melanoma to the brain and
Parkinson's disease who was brought to the ED by his family on
[**2196-9-19**] because of several days of altered mental status. He
was transferred to the MICU on [**2196-9-19**] for hypoxia secondary to
aspiration and transferred back to the medicine floor on
[**2196-9-23**]. After his episode of aspiration pneumonia, his clinical
status worsened significantly with increased difficulty clearing
his secretions and declining mental status. Given patient's
clinical worsening and multiple meetings with the Primary Team
and Palliative care team,  comfort measures only were initiated
per the family's request. On Friday, [**9-30**], Mr. [**Known lastname 4223**]
died from likely cardiopulmonary arrest secondary to metastatic
melanoma and end stage Parkinson's Disease complicated by
aspiration pneumonia.  For further details, please see below.
.
1.  Metastatic Melanoma:
Likely progressive given woresening poor functional status. Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] was contact[**Name (NI) **] and the team spoke to radiation
oncology. Given progressive clinical worsening, patient was
changed to comfort measures with no further plans for
chemotherapy or radiation.
.
2.  Altered Mental Status:
The etiology of his initial altered mental status may have been
exacerbated by the whole brain radiation which he received prior
to admission, in addition to dehydration, acute renal failure,
metastatic brain lesions, worsening Parkinson's Disease, and
malnutrition.
.
3. Dysphagia
Patient had progressively worsening dysphagia over his
admission. An NG tube was placed by IR on [**2196-9-23**]. PEG tube
placement was attempted by IR on [**2196-9-26**] but could not be
completed secondary to overlying stool. Surgery was consulted to
evaluate for PEG placement, and they recommended an open
procedure. Given patient's worsening clinical status, surgery
was declined and patient was made comfort measures only very
shortly after.
.
4. Posterior displacemnt of odontoid process
During work-up of patient's altered mental status, head MRI
noted posterior displacement of odontoid process.  Cervical CT
spine was obtained [**2196-9-23**] which showed non-united fracture
involving the dens, with the base of C2. Cervical x-ray series
showed no change of fracture with flexion or extension and
anterolisthesis of the superior fracture fragment in relation to
the base and angulation posteriorly which does not changed with
flexion or extension views. His C-spine was cleared per
orthopedic spine consult service.
.
5. ARF:
Patient was admitted with acute renal failure with an elevated
creatinine to 1.1, thought likely secondary to hypovolemia.
Creatinine improved to .7 after hydration.
.
6.  Parkinson's Disease:
Patient continued his parkinson's medications, initially by PEG
tube and then by transdermal patch when PEG tube could not be
placed.
.



Medications on Admission:
- Amantadine 200 mg twice a day.
- Norvasc 5 mg DAILY
- Vitamin C
- Calcium/calciferol 600+D
- Sinemet-CR 50/200  five times a day
- Stalevo 150 37.5 mg-15 five times a day
- Imipramine 10 mg [**Hospital1 **]
- Mirapex 1 mg TID
- Multivitamin DAILY
- Niacin 500 mg [**Hospital1 **]
- Ocuvite [**Hospital1 **]
- Bactrim DS [**Hospital1 **]

Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Primary:
1. Metastatic Melanoma.
2. Brain Metastasis.
3. Aspiration Pneumonia.
4. Delirium.
5. Malnutrition.
6. Parkinson's Disease.
7. Hypertension.
8. Old C2 fracture with retrolisthesis of C1 on C2.


Discharge Condition:
Died

Discharge Instructions:
none

Followup Instructions:
None
{'Other encephalopathy,Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Hyperosmolality and/or hypernatremia,Dysphagia, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Anemia in neoplastic disease,Cardiac arrest'}


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: Altered mental status

PRESENT ILLNESS: This is a 80 y/o male with metastatic melanoma to the brain and
Parkinson's disease who was brought to the ED by his family by
ambulance on [**2196-9-19**] because several days of altered mental
status.
.
The pt has been c/o gradually worsening confusion, increased
movements, difficulty with speech and decreased fluid intake
(recent swallow eval recommending no thin liquids). His wife
noticed increased fatigue over the past couple days. One day PTA
he was not able to sit still in the church and was listing to
the right. His wife stated that he had a right facial droop
concerning for a stroke and he was transported to the ED at
[**Hospital1 18**].
.
In the ED, HR 68 BP 99/68 RR 20 SAT 97%, FS140. Seen by
neurology, who felt he was not having a stroke. Labs significant
for elebated troponin, CK, and CK-MB. UA negative. Head CT
negative for hemorrhage. Exam was negative for right facial
droop and listing to his right side. He had dyskinesia of
UE/LE/mouth but without focal weakness. There was right
flattening of nasolabial fold (but wife says this is his
longstanding baseline). He was given 0.5 mg Ativan and IV fluids
and admitted to the medicine service for further evaluation.

MEDICAL HISTORY: 1. Hypertension
2. Metastatic Melanoma with mets to the brain (bilateral
cerebral hemishpheres), liver, lungs, and spine. Had whole brain
radiation on [**2196-8-26**] for ten sessions. Finished on [**2196-9-16**].
3. Parkinson's Disease
4. Anemia (baseline 30-32)

MEDICATION ON ADMISSION: - Amantadine 200 mg twice a day.
- Norvasc 5 mg DAILY
- Vitamin C
- Calcium/calciferol 600+D
- Sinemet-CR 50/200  five times a day
- Stalevo 150 37.5 mg-15 five times a day
- Imipramine 10 mg [**Hospital1 **]
- Mirapex 1 mg TID
- Multivitamin DAILY
- Niacin 500 mg [**Hospital1 **]
- Ocuvite [**Hospital1 **]
- Bactrim DS [**Hospital1 **]

ALLERGIES: Levofloxacin / Keppra

PHYSICAL EXAM: VITALS: T 97.9  HR 55  BP 130/68  RR 20  Sat 97%RA  Pain 0/10
GENERAL: Ill appearing elderly male, poorly responsive at first
but able to open eyes and follow commands. Eyes dry and crusted
shut. Mucous membranes severely dry and tongue stuck within
[**Last Name (un) 22923**].
SKIN: Dry with multiple skin tears with bandages over them.
HEENT: NC/AT. Sclera Anicteric, EOMI w/ limited right movement,
PERRL.
NECK: Supple, no LAD, noraml carotid pulses, transmitted AS
murrmur. No JVD.
CHEST: CTA bilatearlly. No Wheezes/Rhonchi/Crackles. No
supraclavicular LAD. Bilateral axillary LAD.
HEART: RRR. Normal S1 and S2. [**12-29**] early peaking Systolic
creshendo / descreshendo murmur with audible S2.
ABDOMEN: Soft, non-tender, non-distended. +BS. No organomegaly,
No guarding, No rebound.
EXT: No edema. 2+ DP, PT Pulses.
NEURO:
Mental Status: Oriented to person, unable to orient to time and
location.
Cranial Nerves: II-XII intact
Muscle Strength: Increased tone. [**2-25**] UE and LE
Reflexes: +1 bic, pat

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Lives with his wife in [**Name (NI) **]. Has several children. Former
smoker, occassional alcohol. 

### Response:
{'Other encephalopathy,Acute kidney failure, unspecified,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Pneumonitis due to inhalation of food or vomitus,Urinary tract infection, site not specified,Unspecified protein-calorie malnutrition,Hyperosmolality and/or hypernatremia,Dysphagia, unspecified,Dementia with lewy bodies,Dementia in conditions classified elsewhere without behavioral disturbance,Unspecified essential hypertension,Anemia in neoplastic disease,Cardiac arrest'}
