CHIEF COMPLAINT: AMS

PRESENT ILLNESS: 70 y/o F with h/o stage IV L thoracic rhabdomyosarcoma s/p R
frontal mass resection of hemorrhagic brain mass on [**2176-1-12**] with
Dr. [**Last Name (STitle) **] presents with 1 day history of AMS, increasing
agitation and refusal of all POs at rehab facility. Her
Risperdal was recently discontinued due to concerning EKG
changes (no documentation). She was also found to have UTI but
was not treated as she was refusing po medications. She was
transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, initial vs were: 96.8 HR 64 BP 104/70 RR 16 SaO2 97
RA. On physical exam she was oriented X 1 with well healing
scalp. In order to sedate for scan 10 mg IM haldol, ativan 1 mg
was given and BP dropped to 80. Levophed was started through her
port. Patient was given ampicillin, ceftriaxone, 4 L NS for
concern of urosepsis. Mildly elevated lactate. Neurosurgery saw
patient and felt no active neurosurgery issues and recommended
admission to MICU. Vitals on transfer were BP 106/50 (0.6
levophed), HR 106, RR 24, 100% 2L.
 .
On admission patient is unable to give further history and
majority of history is through the chart.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: - Stage IV L thoracic rhabdomyosarcoma
- Currently receiving chemotherapy, L breast cancer - DCIS s/p
lumpectomy
- Right frontal brain lesion s/p resection [**2176-1-12**] (possible
met, hemorrhagic)

MEDICATION ON ADMISSION: Dalteparin 5000 units qd
Dexamethasone 2 mg TID
Docusate
Insulin Aspart sq before meals
Levetiracetam 1000 mg [**Hospital1 **]
Multivitamins
Nystatin
Pantoprazole 40 mg qd
Senna
Bactrim DS M,W, F
Xenaderm ointment [**Hospital1 **]
Tylenol every 4 hours prn
Albuterol NEB every 4 hours prn
Bisacodyl 10 mg qd prn
Hydromorphone 2mg q6 hours prn
Lactulose prn
Milk of Mag prn
Zofran 4mg every 8 hours prn

ALLERGIES: Codeine

PHYSICAL EXAM: General: Somnolent. Withdraws to pain.
Neuro: Pupils 2 mm -> 1 mm with light, respond equal b/l.
Withdraws to pain and moves all limbs spontaneously.
HEENT: dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: lungs clear throughout, poor effort
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: - Parents deceased from heart disease.
- Brother - colon cancer

SOCIAL HISTORY: - Lives with husband.
- Worked as a bookeeper in husband's law practice.
- Never smoked.
- Occasionally drinks champagne.
Streptococcal septicemia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Malignant neoplasm of connective and other soft tissue of thorax,Secondary malignant neoplasm of brain and spinal cord,Sepsis,Stricture and stenosis of esophagus,Stricture of artery,Other diseases of lung, not elsewhere classified
Streptococcal septicemia,Urin tract infection NOS,Delirium d/t other cond,Mal neo soft tis thorax,Sec mal neo brain/spine,Sepsis,Esophageal stricture,Stricture of artery,Other lung disease NEC
Admission Date:  [**2176-1-27**]              Discharge Date:   [**2176-2-2**]

Date of Birth:  [**2105-12-31**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 1990**]
Chief Complaint:
AMS

Major Surgical or Invasive Procedure:
none


History of Present Illness:
70 y/o F with h/o stage IV L thoracic rhabdomyosarcoma s/p R
frontal mass resection of hemorrhagic brain mass on [**2176-1-12**] with
Dr. [**Last Name (STitle) **] presents with 1 day history of AMS, increasing
agitation and refusal of all POs at rehab facility. Her
Risperdal was recently discontinued due to concerning EKG
changes (no documentation). She was also found to have UTI but
was not treated as she was refusing po medications. She was
transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, initial vs were: 96.8 HR 64 BP 104/70 RR 16 SaO2 97
RA. On physical exam she was oriented X 1 with well healing
scalp. In order to sedate for scan 10 mg IM haldol, ativan 1 mg
was given and BP dropped to 80. Levophed was started through her
port. Patient was given ampicillin, ceftriaxone, 4 L NS for
concern of urosepsis. Mildly elevated lactate. Neurosurgery saw
patient and felt no active neurosurgery issues and recommended
admission to MICU. Vitals on transfer were BP 106/50 (0.6
levophed), HR 106, RR 24, 100% 2L.
 .
On admission patient is unable to give further history and
majority of history is through the chart.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.


Past Medical History:
- Stage IV L thoracic rhabdomyosarcoma
- Currently receiving chemotherapy, L breast cancer - DCIS s/p
lumpectomy
- Right frontal brain lesion s/p resection [**2176-1-12**] (possible
met, hemorrhagic)

Social History:
- Lives with husband.
- Worked as a bookeeper in husband's law practice.
- Never smoked.
- Occasionally drinks champagne.

Family History:
- Parents deceased from heart disease.
- Brother - colon cancer

Physical Exam:
General: Somnolent. Withdraws to pain.
Neuro: Pupils 2 mm -> 1 mm with light, respond equal b/l.
Withdraws to pain and moves all limbs spontaneously.
HEENT: dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: lungs clear throughout, poor effort
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

Pertinent Results:
Labs on Admission:
[**2176-1-26**] 10:45PM BLOOD WBC-5.3# RBC-3.78* Hgb-11.4* Hct-35.0*
MCV-93 MCH-30.3 MCHC-32.7 RDW-16.3* Plt Ct-205
[**2176-1-26**] 10:45PM BLOOD PT-13.2 PTT-26.9 INR(PT)-1.1
[**2176-1-26**] 10:45PM BLOOD Glucose-113* UreaN-36* Creat-0.8 Na-141
K-4.1 Cl-107 HCO3-20* AnGap-18
[**2176-1-26**] 10:45PM BLOOD ALT-22 AST-25 AlkPhos-53 TotBili-0.5
[**2176-1-26**] 10:45PM BLOOD Albumin-3.8 Calcium-9.5 Phos-3.2# Mg-2.0

Labs on Discharge:
[**2176-2-2**] 05:18AM BLOOD WBC-3.6* RBC-3.32* Hgb-10.0* Hct-31.1*
MCV-94 MCH-30.2 MCHC-32.2 RDW-16.6* Plt Ct-175
[**2176-2-2**] 05:18AM BLOOD Glucose-118* UreaN-12 Creat-0.6 Na-141
K-4.1 Cl-108 HCO3-24 AnGap-13
[**2176-2-2**] 05:18AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND
[**2176-2-2**] 05:18AM BLOOD B-GLUCAN-PND

Micro:
[**2176-1-27**]  URINE CULTURE-FINAL {PROBABLE ENTEROCOCCUS}
[**2176-1-27**]  MRSA SCREEN NEG
[**2176-1-27**]  BLOOD CULTURE -NEG
[**2176-1-31**]: Blood Cultures- PENDING

Studies:

[**2176-1-30**] Radiology CTA CHEST:
1. No evidence of pulmonary embolism.
2. Massive mediastinal and left hilar tumor with obvious mass
effect and compression or infiltration of the left and the right
main pulmonary artery, the pulmonary veins, the esophagus, and
the left main bronchus. Subsequent perihilar partly cavitated
parenchymal consolidation.
3. Multiple bilateral mainly subpleural nodular opacities, the
biggest one of which is located in the left upper lobe and this
cavitated, containing a soft tissue structure. This lesion could
be representing Aspergillus colonization.
4. Bilateral paramediastinal areas of subtle fibrosis could be
the sequela of mediastinal radiation.
5. Small left pleural effusion.
6. 7-mm liver hypodensity, status post rib fractures, sclerotic
rib and T-spine lesion, potentially representing metastasis.

ECG [**2176-1-31**]: Sinus tachycardia. Left atrial abnormality. Right
ventricular conduction delay. Compared to the previous tracing
of [**2176-1-30**] the anterolateral ST-T wave abnormalities persist
without diagnostic interim change.


Brief Hospital Course:
70 y/o F s/p R frontal mass resection on [**2176-1-12**] for metastatic
rhabdomyosarcoma presents with UTI and AMS.

# Altered Mental Status: Mrs [**Known lastname 69844**] had a Head CT that showed
stable changes s/p resection.  The location of the resection may
account for some of her neurological symptoms, her acute
agitation was likely from UTI/delirium.  She had no cough or
infiltrate on CXR to suggest pneumonia.  Sodium and calcium
within normal limits.  Mental status improved although
pleasantly confused.  She respond well to zyprexa when agitated
and is easily redirectable.  Resperiadone was stopped due to
concern for EKG changes (namely QT prolongation).  She required
continous fluid support, continous IVF of NS at 125cc/hr with
periodic bolus of 1L over 2 hours PRN.  Because she runs
negative usually with her ins and out.  Please avoid unnecessary
tethers, lines and reorient frequently.

# UTI: Enterococcus in urine sensitive to Ampicillin,
Nitrofurantoin, Vancomycin.  We reconfirmed the infection with
UA positive and UCx + for Enterococcus.  She is to be continued
on ampicillin IV for 14 days (Day 1 of antibiotic was
[**2176-1-27**]).

# Tachycardia: Tachycardia is persistent. Patient report
baseline low BP 90-100's.  The source of her tachycardia may be
due to dehydration, infection, underlying malignancy, steroid
side effects.  Patient runs negative I/O, unknown cause.
Notable for serum OSM is 283, Urine Osm is 496.  Imaging study
suggest pulmonary vasculature and airway compromise by the
tumor.  This is like the reason for her underlying tachycardia.
On CT scan, we noted the extend of the tumor and findings
suggest a fungal ball in her LUL.  Interventional pulmonology
recommended no intervention at this time.  We sent fungal
markers which are pending at the time of discharge.  Patient's
VSS, hemodynamically stable, no sign of infection, no + blood
cultures.  Barium swallow was done to eval for extrinsic
compression of the chest mass on the esophagus.  Results pending
at the time of discharge.  I discussed this with her primary
care MD at the time of discharge, as well as the ? of
aspirgillus colonization of the lt. apex of the lung.

# s/p right frontal mass resection: CT head changes consistent
with post-op peroid, no acute changes. Neurosurgery evaluated in
ED and felt no acute neurosurg issues.  She was place on heparin
SQ ppx, dexamethasone, and keppra.  Xenaderm ointment to scar on
scalp.  Insulin sliding scale and bactrium for PCP prophylaxis
while on dexamethasone.

# Malignancy: Patient with history of stage IV thoracic
rhabdomyosarcoma currently on chemotherapy.  Path from right
frontal lesion confirms metastatic rhabdomyosarcoma. Also
history of L breast cancer - DCIS s/p lumpectomy.  Patient's
oncological care is deferred to family and oncologist.  She is
to follow up with her outpatient oncologist after discharge.

# Concern for aspiration:
The nursing staff became concerned that Ms. [**Known lastname 69844**] might not be
swallowing her pills safely.  She therefore had a speech and
swallow evaluation in coordination with a study of her
esophagus.  Contrast was able to get through her esophagus,
although it was noted to have some external compression from her
tumor.  Per speech and swallow recommendations, she should be on
a PO diet of ground solids and thin liquids; no mixed
consistencies including solid cereal in milk or whole pills with
water.  Her medications should be given crushed in puree and she
should have 1:1 supervision with all POs.  Encourage small bites
and sips and maintain aspiration precautions.

# Access: double-lumen port

# Communication: husband ([**Doctor Last Name **]: [**Numeric Identifier 83791**]/[**Numeric Identifier 83792**])

# Code: DNR/DNI

Medications on Admission:
Dalteparin 5000 units qd
Dexamethasone 2 mg TID
Docusate
Insulin Aspart sq before meals
Levetiracetam 1000 mg [**Hospital1 **]
Multivitamins
Nystatin
Pantoprazole 40 mg qd
Senna
Bactrim DS M,W, F
Xenaderm ointment [**Hospital1 **]
Tylenol every 4 hours prn
Albuterol NEB every 4 hours prn
Bisacodyl 10 mg qd prn
Hydromorphone 2mg q6 hours prn
Lactulose prn
Milk of Mag prn
Zofran 4mg every 8 hours prn

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO M, W, F ().
3. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for fever/pain.
4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1)  Inhalation Q6H (every 6 hours) as
needed for SOB.
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. port line care
Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
8. port line care
Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
Indwelling Port (e.g. Portacath), heparin dependent: When
de-accessing port, instill Heparin as above per lumen.
9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
10. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
Tablet, Rapid Dissolve(s)
12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
14. insulin
Insulin SC  (per Insulin Flowsheet)
      Sliding Scale
15. Ampicillin Sodium 2 gram Recon Soln Sig: One (1) Recon Soln
Injection Q6H (every 6 hours) for 7 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Hospital1 8**]

Discharge Diagnosis:
Urosepsis
Altered Mental Status
Tachycardia
s/p right frontal mass resection
Malignancy


Discharge Condition:
Mental Status:Confused - always
Level of Consciousness:Alert and interactive
Activity Status:Out of Bed with assistance to chair or
wheelchair


Discharge Instructions:
You came to the hospital with altered mental status and findings
of urinary tract infection.  We treated your infection and
provided you with fluid support.  You recovered and was in
stable condition.  We did find on imaging studies that you have
an extensive tumor in your lung, which compress the great
vessels from the heart to the lungs and obstructed the left main
wind pipe.  We think this is the reason for you to be
continously tachycardic.  You responded to intravenous fluid.
We believe you need to get continous fluid support as you pee
out alot more than you taking in.  You were discharged in stable
conditions.

Please follow up with you oncologist for further oncologic care.
 You need to figure out additional treatment.

Please note we made the following changes to your medications.

Followup Instructions:
Please follow your oncologist Carolin Block, ([**Telephone/Fax (1) 83793**],
regarding your oncologic care.





Name:  [**Known lastname 13317**],[**Known firstname **]                      Unit No:   [**Numeric Identifier 13318**]

Admission Date:  [**2176-1-27**]              Discharge Date:   [**2176-2-2**]

Date of Birth:  [**2105-12-31**]             Sex:   F

Service: MEDICINE

Allergies:
Codeine

Attending:[**First Name3 (LF) 429**]
Addendum:
Pt.s discharge diagnosis of 'urosepsis' is actually: sepsis due
to urinary tract infection, enterococcal.

Pt. was admitted with altered mental status, enterococcal
urinary tract infection, and developed hyotension requiring
pressors, IVF, and treatment of urinary tract infection with
parenteral antibiotics, all consistent with sepsis due to
bacterial urinary tract infection.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **] [**Hospital1 15**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 430**] MD [**MD Number(2) 431**]

Completed by:[**2176-2-23**]
{'Streptococcal septicemia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Malignant neoplasm of connective and other soft tissue of thorax,Secondary malignant neoplasm of brain and spinal cord,Sepsis,Stricture and stenosis of esophagus,Stricture of artery,Other diseases of lung, not elsewhere classified'}


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: AMS

PRESENT ILLNESS: 70 y/o F with h/o stage IV L thoracic rhabdomyosarcoma s/p R
frontal mass resection of hemorrhagic brain mass on [**2176-1-12**] with
Dr. [**Last Name (STitle) **] presents with 1 day history of AMS, increasing
agitation and refusal of all POs at rehab facility. Her
Risperdal was recently discontinued due to concerning EKG
changes (no documentation). She was also found to have UTI but
was not treated as she was refusing po medications. She was
transferred to [**Hospital1 18**] for further evaluation.
.
In the ED, initial vs were: 96.8 HR 64 BP 104/70 RR 16 SaO2 97
RA. On physical exam she was oriented X 1 with well healing
scalp. In order to sedate for scan 10 mg IM haldol, ativan 1 mg
was given and BP dropped to 80. Levophed was started through her
port. Patient was given ampicillin, ceftriaxone, 4 L NS for
concern of urosepsis. Mildly elevated lactate. Neurosurgery saw
patient and felt no active neurosurgery issues and recommended
admission to MICU. Vitals on transfer were BP 106/50 (0.6
levophed), HR 106, RR 24, 100% 2L.
 .
On admission patient is unable to give further history and
majority of history is through the chart.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies nausea, vomiting, diarrhea, constipation, abdominal pain,
or changes in bowel habits. Denies dysuria, frequency, or
urgency. Denies arthralgias or myalgias. Denies rashes or skin
changes.

MEDICAL HISTORY: - Stage IV L thoracic rhabdomyosarcoma
- Currently receiving chemotherapy, L breast cancer - DCIS s/p
lumpectomy
- Right frontal brain lesion s/p resection [**2176-1-12**] (possible
met, hemorrhagic)

MEDICATION ON ADMISSION: Dalteparin 5000 units qd
Dexamethasone 2 mg TID
Docusate
Insulin Aspart sq before meals
Levetiracetam 1000 mg [**Hospital1 **]
Multivitamins
Nystatin
Pantoprazole 40 mg qd
Senna
Bactrim DS M,W, F
Xenaderm ointment [**Hospital1 **]
Tylenol every 4 hours prn
Albuterol NEB every 4 hours prn
Bisacodyl 10 mg qd prn
Hydromorphone 2mg q6 hours prn
Lactulose prn
Milk of Mag prn
Zofran 4mg every 8 hours prn

ALLERGIES: Codeine

PHYSICAL EXAM: General: Somnolent. Withdraws to pain.
Neuro: Pupils 2 mm -> 1 mm with light, respond equal b/l.
Withdraws to pain and moves all limbs spontaneously.
HEENT: dry MM
Neck: supple, JVP not elevated, no LAD
Lungs: lungs clear throughout, poor effort
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen:  soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: - Parents deceased from heart disease.
- Brother - colon cancer

SOCIAL HISTORY: - Lives with husband.
- Worked as a bookeeper in husband's law practice.
- Never smoked.
- Occasionally drinks champagne. 

### Response:
{'Streptococcal septicemia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Malignant neoplasm of connective and other soft tissue of thorax,Secondary malignant neoplasm of brain and spinal cord,Sepsis,Stricture and stenosis of esophagus,Stricture of artery,Other diseases of lung, not elsewhere classified'}
