CHIEF COMPLAINT: Altered mental status.

PRESENT ILLNESS: Per Mr. [**Known lastname 97022**] wife, Mr. [**Name13 (STitle) 97023**] has been acting "strangly" for
the last month. He was staying at work all night or going into
work early.  He was unable to hold conversations or talking
about things that did not make sense.  Prior to that his wife
denies any changes in his mental status.  He has been seeing his
primary physcian who sent him for a neurology consult at the [**Hospital1 **].  He was found to be hypotensive by the
neurologist and told to stop his blood pressure meds.  He
continued to have low blood pressure and mental status changes,
and his PCP recommended coming to the emergency room at [**Hospital1 1535**].

MEDICAL HISTORY: Hypertension
Asthma
Incisional Hernia

MEDICATION ON ADMISSION: ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 2 puffs Q4 prn
FLUTICASONE 50 mcg Spray 2 sprays each nostril QD
Flovent 110 mcg 2 puffs [**Hospital1 **]; HCTZ
Lisinopril 1 QD; Simivastatin; ASPIRIN - 81 mg QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS:  Temperature 98.3 F, blood pressure 82/58, pulse
80, respiration 20, and oxygen saturation 94% in room air.
GENERAL:  WD/WN, comfortable, NAD.
HEENT:  Pupils: [**1-24**] bilaterally  EOMs full
NECK:  Supple.
LUNGS:  CTA bilaterally.
CARDIOVASCULAR:  RRR, S1/S2.
ABDOMEN:  Soft, NT, BS+
EXTREMITIES:  Warm and well-perfused.

FAMILY HISTORY: He denies any family history of heart disease or cancer.

SOCIAL HISTORY: The patient drinks 3 to 5 beers weekly.  He does not smoke
cigarettes.  He works at the [**Doctor Last Name 97024**].
Malignant neoplasm of frontal lobe,Cerebral edema,Iatrogenic cerebrovascular infarction or hemorrhage,Intracerebral hemorrhage,Memory loss,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anisocoria,Sixth or abducens nerve palsy,Unspecified essential hypertension,Asthma, unspecified type, unspecified
Malig neo frontal lobe,Cerebral edema,Iatrogen CV infarc/hmrhg,Intracerebral hemorrhage,Memory loss,Abn react-surg proc NEC,Anisocoria,Sixth nerve palsy,Hypertension NOS,Asthma NOS
Admission Date:  [**2152-6-23**]              Discharge Date:   [**2152-7-7**]

Date of Birth:  [**2094-9-17**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Altered mental status.

Major Surgical or Invasive Procedure:
Stereotactic brain biopsy on [**2152-6-26**].


History of Present Illness:
Per Mr. [**Known lastname 97022**] wife, Mr. [**Name13 (STitle) 97023**] has been acting "strangly" for
the last month. He was staying at work all night or going into
work early.  He was unable to hold conversations or talking
about things that did not make sense.  Prior to that his wife
denies any changes in his mental status.  He has been seeing his
primary physcian who sent him for a neurology consult at the [**Hospital1 **].  He was found to be hypotensive by the
neurologist and told to stop his blood pressure meds.  He
continued to have low blood pressure and mental status changes,
and his PCP recommended coming to the emergency room at [**Hospital1 1535**].

Past Medical History:
Hypertension
Asthma
Incisional Hernia

Social History:
The patient drinks 3 to 5 beers weekly.  He does not smoke
cigarettes.  He works at the [**Doctor Last Name 97024**].

Family History:
He denies any family history of heart disease or cancer.

Physical Exam:
VITAL SIGNS:  Temperature 98.3 F, blood pressure 82/58, pulse
80, respiration 20, and oxygen saturation 94% in room air.
GENERAL:  WD/WN, comfortable, NAD.
HEENT:  Pupils: [**1-24**] bilaterally  EOMs full
NECK:  Supple.
LUNGS:  CTA bilaterally.
CARDIOVASCULAR:  RRR, S1/S2.
ABDOMEN:  Soft, NT, BS+
EXTREMITIES:  Warm and well-perfused.

NEUROLOGICAL EXAMINATION:
Mental status:  Awake and alert, cooperative with exam, flat
affect.
Orientation:  Oriented to person, place, and had difficulty with
date with time he was able to state [**2152-9-23**] than said [**6-23**].
Recall:  [**12-28**] objects at 5 minutes.
Language:  Speech fluent with good comprehension and repetition.
 Naming intact.  No dysarthria or paraphasic errors.

Cranial Nerves:
I:  Not tested
II:  Pupils equally round and reactive to light, 3 to 2 mm
bilaterally.  Visual fields are full to confrontation.
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
or
tremors.  Strength full power [**3-28**] throughout.  No pronator drift

Sensation:  Intact to light touch
Reflexes: B T Br Pa Ac
Right     2+      2+
Left      2+      2+

Toes downgoing bilaterally

Coordination:  Normal on finger-nose-finger

Pertinent Results:
MR HEAD W & W/O CONTRAST [**2152-6-23**]:
FINDINGS: There is a large frontal lobe mass identified
extending from corpus callosum to both frontal lobes with
central area of low T1 and high T2 signal with areas of low
signal on susceptibility images indicating small areas of
chronic blood products. There is an extensive enhancement
identified in the mass. The location and the appearance of the
mass are suggestive of a glioma or less likely a lymphoma.
Additionally, there is enhancement seen in the left frontal
sulci as well as in the basal cisterns and internal auditory
canals indicative of leptomeningeal spread of the neoplasm.
There is mass effect on the anterior horns of both lateral
ventricles. A prominent flow voids are identified adjacent to
the inferior aspect of the neoplasm indicative of hypertrophic
blood vessels or draining veins.

IMPRESSION: Large bifrontal neoplasm extending through the
corpus callosum
likely a primary neoplasm such as glioma or lymphoma.
Hypertrophic vessels
are visualized in the inferior aspect of the tumor, indicating
vascular supply and whatever the diagnosis of glioma.
Leptomeningeal extension of the neoplasm is identified through
the basal ganglia and internal auditory canal.

CT Torso [**2152-6-24**]:
FINDINGS:
CHEST: There are no pathologically enlarged thoracic lymph
nodes. There is
no pericardial or pleural effusion. There is mild dilatation of
the
esophagus. Lung windows demonstrate no nodules or masses. The
central
airways are patent, without endobronchial lesions. There are no
suspicious
osseous lesions.

ABDOMEN: The liver, spleen, kidneys, adrenal glands, pancreas,
and
gallbladder are normal. There are no pathologically enlarged
lymph nodes.
There is an umbilical hernia containing fat and small bowel,
without evidence of obstruction. There is no free fluid in the
abdomen. Delayed images demonstrate normal contrast excretion of
the kidneys bilaterally.

PELVIS: The bladder is decompressed with a Foley catheter. The
pelvic bowel loops are unremarkable. There is no free fluid.
There are no pathologically enlarged lymph nodes.

Bone windows demonstrate a lytic lesion in the posterior left
iliac bone with a thick sclerotic border. No other focal lesions
are identified. There are minimal degenerative changes of the
spine.

IMPRESSION:
1. No evidence of mass in the chest, abdomen or pelvis.
2. Umbilical hernia containing fat and small bowel.
3. Nonaggressive-appearing lesion within the posterior left
iliac bone,
unlikely to represent a metastatic lesion.
4. Mild esophageal dilatation.

CT HEAD W/O CONTRAST [**2152-6-25**]:
FINDINGS: Again noted is extensive hypodensity involving both
frontal lobes and the genu of the corpus callosum. There is
persistent mass effect on the bilateral frontal horns. Allowing
for differences in slice selection, there may be slight interval
increase in the diameter of the lateral ventricles. The left
lateral ventricle measures 14 mm compared to 10 mm previously
and the right lateral ventricle measures 14 mm compared to 12 mm
previously. There is no shift of normally midline structures or
evidence of uncal or transtentorial herniation. The 3rd and 4th
ventricles are preserved. There is no evidence of hemorrhagic
conversion. The [**Doctor Last Name 352**]-white matter differentiation is otherwise
preserved without evidence of infarction. The visualized portion
of the paranasal sinuses and mastoid air cells are well aerated.
No osseous abnormality is identified.

IMPRESSION: Extensive hypodense lesion in the bilateral frontal
lobes with
slight interval increase in the diameter of the lateral
ventricles. Third and fourth ventricles remain patent and
basilar cisterns preserved.

Pathology Examination from steriotactic biopsy [**2152-6-26**]:
DIAGNOSIS:
1.  Brain, target point, stereotactic biopsy (A):
Glioblastoma multiforme, (WHO Grade IV); See note.
2.  Brain, -4, stereotactic biopsy (B):
Glioblastoma multiforme, (WHO Grade IV); See note.
3.  Brain -8, stereotactic biopsy (C):
Glioblastoma multiforme, (WHO Grade IV); See note.
4.  Brain, -12, stereotactic biopsy (D):
White matter infiltrated by glioma.
5.  Brain, -16, stereotactic biopsy (E):
White matter with reactive gliosis and rare atypical cells.
6.  Brain, -20, stereotactic biopsy (F):
White matter with reactive gliosis and rare atypical cells.

Note:  The tumor displays hypercellularity, vascular
proliferation, necrosis, and mitotic figures.

Gross:
The specimen is received in the O.R. in 11 parts, all labeled
with the patient's name, "[**Known firstname 449**] [**Known lastname **]"  and the medical record
number. Each part consists of a 0.1 x 0.1 x 0.1 cm fragment of
white soft tissue, except for the target point.

Part 1 is additionally labeled "target point" and measures 0.6
cm x 0.1 cm and is red in color. It is entirely submitted in
cassette A.

Part 2 is additionally labeled "-2" and is consumed entirely by
intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**]
is: "Malignant glioma".

Part 3 additionally labeled "-4", and is entirely submitted in
cassette B.

Part 4 is additionally labeled "-6", and is consumed entirely by
intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**]
is: "Malignant glioma".

Part 5 additionally labeled "-8", and is entirely submitted in
cassette C.

Part 6 is additionally labeled "-10", and is consumed entirely
by intraoperative smear diagnosis. Smear diagnosis by Dr.
[**First Name (STitle) 4223**] is: "Malignant glioma".

Part 7 is additionally labeled "-12", and is entirely submitted
in cassette D.

Part 8 is additionally labeled "-14" and is consumed entirely by
intraoperative smear diagnosis. Smear diagnosis by Dr. [**First Name (STitle) 4223**]
is: "White matter with reactive gliosis and rare atypical
cells".

Part 9 is additionally labeled "-16", and is entirely submitted
in cassette E.

Part 10 is additionally labeled "-18", and is consumed entirely
by intraoperative smear diagnosis. Smear diagnosis by Dr.
[**First Name (STitle) 4223**] is: "Reactive gliosis with scattered atypical cells".

Part 11 is additionally labeled "-20", and is entirely submitted
in cassette F.

CT Head without contrast post-op [**2152-6-26**]:
FINDINGS: There is a new left frontal burr hole for stereotactic
biopsy.
There is a small focus of new hemorrhage along the biopsy path
in the left
frontal lobe (2:18). Extensive vasogenic edema is again seen in
association with the known mass involving both frontal lobes and
the genu of corpus callosum, with unchanged mass effect on the
frontal horns of the
lateral ventricles. Overall, the ventricles are stable in size.
Mild
rightward shift of the anterior falx is stable.

There is a large mucus retention cyst in the right maxillary
sinus and a
possible polyp in the left nasal cavity, as before.

IMPRESSION:
Small amount of blood along the left frontal biopsy path. No
change in mass effect from the bifrontal mass.

MRI Head ([**2152-6-29**])
FINDINGS: Study is slightly limited due to patient motion during
examination.

Again demonstrated is a heterogeneous mass located within
bilateral frontal lobes, and crossing the corpus callosum,
compatible with biopsy proven glioblastoma multiforme. This mass
measures grossly 6.5 cm x 4.6 cm, with central areas of
susceptibility, particularly within the left frontal region,
likely reflecting intratumoral hemorrhagic products from recent
biopsy. The mass is situated in the expected location of the A2
segments of the anterior cerebral arteries, which are not
clearly visualized.

There is associated significant vasogenic edema of bilateral
frontal lobes. Significant mass effect on the adjacent frontal
horns of the lateral ventricles and a rightward shift of
normally midline structures by
approximately 7 mm are not significantly changed.

Increased FLAIR signal and enhancement surrounding the left
lateral ventricular ependymal surface is noted. Abnormal
enhancement is also evident within the basal cisterns and in the
region of the thalamus/tectal junction. These findings suggest
subarachnoid spread of tumor with a
differential diagnosis of infection, if clinically appropriate.

No other foci of hemorrhage are identified. There is no infarct,
without
evidence of diffusion-weighted abnormality. Mucus-retention cyst
in the right maxillary sinus with mucosal thickening of the
ethmoid sinuses is noted.

IMPRESSION:

1. Large butterfly glioma in the frontal lobes, compatible with
known
glioblastoma multiforme, with associated significant mass effect
and vasogenic edema, unchanged.

2. Post-biopsy changes, including a small amount of intratumoral
hemorrhage.

3. Abnormal enhancement of the left lateral ventricular
ependymal surface, in the basal cisterns, and in the
thalamo-tectal junction. These findings could indicate
subarachnoid spread of tumor. However, a concomitant infection
could have a similar appearance and needs clinical correlation .
An MRI of the spine is recommended to assess for leptomeningeal
involvement of the spinal axis.

4. Incomplete visualization of the A2 segments of the anterior
cerebral arteries. A dedicated MRA or CTA is recommended to
assess for vascular patency.

CT head ([**2152-6-30**])

FINDINGS: Again demonstrated is a large bifrontal mass,
compatible with
biopsy-proven GBM, with significant mass effect on the adjacent
frontal horns of the lateral ventricles and rightward shift of
midline by approximately 7 mm. Surrounding low attenuation in
bilateral frontal lobes is compatible with vasogenic edema, with
a track of high density in the left frontal lobe compatible with
post-biopsy hemorrhagic tract. These findings are not
significantly changed from the prior study. The size of the
ventricular system is stable, without evidence of new
hydrocephalus. There are no other foci of intracranial
hemorrhage. No major vascular territorial infarction is
identified. Visualized paranasal sinuses and mastoid air cells
are normally aerated. Osseous structures reveal biopsy burr hole
in the left frontal bone.

IMPRESSION: No significant change in large bifrontal mass,
compatible with
biopsy-proven GBM, and associated significant mass effect on the
adjacent lateral ventricles and rightward shift of midline.

Brief Hospital Course:
The patient was admitted to the ICU for Q1 hour neuro checks
after he was found to have a very large bifrontal brain mass.
He had been given 1 dose of steroids at the outside hospital but
they were not continued here in anticipation of a steriotactic
brain biopsy.  The patient had a CT torso that did not show
evidence of metastatic disease. On [**2152-6-25**] his neurological
examination changed and he was unable to speak.  A stat head CT
showed increased edema in the frontal region.  At that time he
was started on steroids due to his worsening examination and
increased edema. Afterwards, he improved significantly and was
oriented x 3 and following commands.

On [**2152-6-26**], the patient had a steriotactic brain biopsy.  The
pathology revealed that the mass was a glioblastoma WHO Grade
IV.  Post-operatively the CT scan showed a new small hemorrhage
at the surgical bed.  He was transferred back to the ICU still
intubated.  The patient was started on mannitol.

On [**2152-6-27**], the patient was extubated and his neurological
examination was improved.  His mannitol and steroids were weaned
and he was transferred to the neuro step-down unit.  He
continued to be stable as the weaning of both mannitol and
steroids continued and was transferred out of step-down to the
floor on [**2152-6-28**].  In the afternoon of [**2152-6-29**] (after
radiation planning appointment), he was found to have
significant aniscoria (right greater than left) and sixth
cranial nerve palsy.  Head CT was repeated; and found to have
significantly worsened edema.  He was given a one time dose of
mannitol 50 gm, re-loaded with Decadron 10 mg, and continued on
Decadron 4 mg every 6 hours.  Given his marked neurological
decline, palliative care was again urgently consulted to assist
with appropriate planning.  At this time, the family changed his
code status to include no cardiac compressions, defibrillation,
or CPR; they agree to chemical code only.  In subsequent hours,
his neurological examination significantly improved to the point
that he could possibly be discharged.  In the setting of his
progressive decline, and sensitivity to increasd steroids,
emergent whole brain radiation was sought.  Pursuant to this
plan, he was transferred to the [**Hospital Ward Name 516**] 7 [**Hospital Ward Name 1950**] [**Hospital1 **]
under the Neuro-Oncology Service on [**2152-7-2**] to make
arrangements for this to occur.

From [**2152-7-3**] to [**2152-7-7**], he received 5 of 22 total treatments
of whole brain radiation.  He also began temozolomide while
in-house.  He was started on Bactrim prophylaxis since he was on
both radiation and temozolomide.  His neurological examination
remained stable during this time with mild right greater than
left anisicoria (1 mm difference), with brisk pupillary
reflexes.  He remained oriented x 2 (difficulty with date) and
with 1/3 recall after 5 minutes.  He had poor attention and poor
comprehension of his disease.

He was discharged on Decadron 4 mg every 6 hours, with proton
pump inhibitor, bowel regimen, and instructions to ambulate
frequently in an attempt to prevent DVT.  He was also discharged
on [**Month/Day/Year 13401**].  He is scheduled for follow-up on [**2152-7-10**].

Medications on Admission:
ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 2 puffs Q4 prn
FLUTICASONE 50 mcg Spray 2 sprays each nostril QD
Flovent 110 mcg 2 puffs [**Hospital1 **]; HCTZ
Lisinopril 1 QD; Simivastatin; ASPIRIN - 81 mg QD

Discharge Medications:
1. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing.

2. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
3. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily).  Disp:*30 Tablet(s)* Refills:*0*
4. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours). Disp:*100 Tablet(s)* Refills:*0*
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*14 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
7. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.  Disp:*30 Tablet, Delayed Release (E.C.)(s)*
Refills:*0*
9. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.  Disp:*30 Tablet(s)* Refills:*0*
10. Polyethylene Glycol 3350 100 % Powder Sig: One (1) dose PO
DAILY (Daily) as needed for constipation.  Disp:*1 month supply*
Refills:*0*
11. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day as needed for nausea.
Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0*
12. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day.
13. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
14. [**Hospital1 13401**] 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*0*

Discharge Disposition:
Home With Service

Facility:
Visiting Nurse [**First Name8 (NamePattern2) **] [**Last Name (Titles) 86**]

Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Glioblastoma multiforme

Discharge Condition:
Neurologically stable; R sided anisicoria, oriented x 2.

Discharge Instructions:
You were admitted to the hospital on [**2152-6-23**] with confusion.
You were found to have a brain tumor.  You had a brain biopsy on
[**2152-6-26**].  The sutures have already been removed.  You had 5
treatments of radiation so far and you have gotten 3 days of
temozolomide chemotherapy.  You can take zofran ODT as needed
for nausea.

You are being discharged on steroids because of the swelling in
your brain.  You must take omeprazole to avoid stomach
irritation with steroids.  You must take a bowel regimen to make
sure you have a bowel movement everyday while you are on
steroids.  If you do not have a bowel movement in two days call
your doctor.  You must also be sure to walk around at least 5
times per day to avoid clots in your legs.

You are also being discharged on [**Last Name (LF) 13401**], [**First Name3 (LF) **] anti-seizure
medication, as you may be more prone to seizures now that you
have a brain tumor.

You are being discharged on Bactrim to prevent infection now
that you are getting radiation and chemotherapy.

DO NOT DRIVE.  DO NOT DO ANY HEAVY LIFTING. YOU ARE AT AN
INCREASED RISK FOR FALLING WITH YOUR BRAIN TUMOR AND CONFUSION.
You are being sent home with a VNA for help with your
medications and for a home safety evaluation.

You will be contining your radiation and chemotherapy as an
outpatient.

General Instructions and Information:
??????  Take your pain medicine as prescribed.
??????  Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????  Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????  Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????  You have been discharged on [**First Name3 (LF) 13401**] (Levetiracetam) as
anti-seizure medication.
??????  You are being sent home on steroid medications, so make sure
you are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation.  Make sure to take your steroid medication with
meals, or a glass of milk.
??????  DO NOT DRIVE
??????  Make sure to continue to use your incentive spirometer while
at home.  CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF
THE FOLLOWING
??????  New onset of tremors or seizures.
??????  Any confusion or change in mental status.
??????  Any numbness, tingling, weakness in your extremities.
??????  Pain or headache that is continually increasing, or not
relieved by pain medication.
??????  Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
??????  Fever greater than or equal to 101?????? F.

Followup Instructions:
Follow-Up Appointment Instructions

You have an appointment in the Brain [**Hospital 341**] Clinic on [**2152-7-10**] at
9:30 a.m.  The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 516**]
of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building on the [**Location (un) 858**].  Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.

When  you go to radiation treatment on Monday, please talk to
the nurses about seeing a social worker so [**Name2 (NI) **] can be set up.
{'Malignant neoplasm of frontal lobe,Cerebral edema,Iatrogenic cerebrovascular infarction or hemorrhage,Intracerebral hemorrhage,Memory loss,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anisocoria,Sixth or abducens nerve palsy,Unspecified essential hypertension,Asthma, unspecified type, 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: Altered mental status.

PRESENT ILLNESS: Per Mr. [**Known lastname 97022**] wife, Mr. [**Name13 (STitle) 97023**] has been acting "strangly" for
the last month. He was staying at work all night or going into
work early.  He was unable to hold conversations or talking
about things that did not make sense.  Prior to that his wife
denies any changes in his mental status.  He has been seeing his
primary physcian who sent him for a neurology consult at the [**Hospital1 **].  He was found to be hypotensive by the
neurologist and told to stop his blood pressure meds.  He
continued to have low blood pressure and mental status changes,
and his PCP recommended coming to the emergency room at [**Hospital1 1535**].

MEDICAL HISTORY: Hypertension
Asthma
Incisional Hernia

MEDICATION ON ADMISSION: ALBUTEROL SULFATE 90 mcg HFA Aerosol Inhaler - 2 puffs Q4 prn
FLUTICASONE 50 mcg Spray 2 sprays each nostril QD
Flovent 110 mcg 2 puffs [**Hospital1 **]; HCTZ
Lisinopril 1 QD; Simivastatin; ASPIRIN - 81 mg QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VITAL SIGNS:  Temperature 98.3 F, blood pressure 82/58, pulse
80, respiration 20, and oxygen saturation 94% in room air.
GENERAL:  WD/WN, comfortable, NAD.
HEENT:  Pupils: [**1-24**] bilaterally  EOMs full
NECK:  Supple.
LUNGS:  CTA bilaterally.
CARDIOVASCULAR:  RRR, S1/S2.
ABDOMEN:  Soft, NT, BS+
EXTREMITIES:  Warm and well-perfused.

FAMILY HISTORY: He denies any family history of heart disease or cancer.

SOCIAL HISTORY: The patient drinks 3 to 5 beers weekly.  He does not smoke
cigarettes.  He works at the [**Doctor Last Name 97024**]. 

### Response:
{'Malignant neoplasm of frontal lobe,Cerebral edema,Iatrogenic cerebrovascular infarction or hemorrhage,Intracerebral hemorrhage,Memory loss,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Anisocoria,Sixth or abducens nerve palsy,Unspecified essential hypertension,Asthma, unspecified type, unspecified'}
