CHIEF COMPLAINT: presyncope

PRESENT ILLNESS: .
68 yo M with Stage III nonsmall cell lung cancer
(adenocarcinoma) with metastatic disease to brain discovered in
[**9-/2110**] after focal seizure s/p cyberknife and hx of complete
heart block s/p pacemaker who presents to the ED today after a
presyncopal episode.
.
Patient reports that he was walking out of CVS on th eday of
admission  and suddenly collapsed to the ground and was unable
to get up.  He denied any preceding symptoms such as chest pain,
palpitations, sob, lightheadedness or dizziness.  No focal
weakness.  Denies any LOC or head trauma.  No reported
confusion, bowel/bladder incontinence, tongue biting or
witnessed shaking.  Found to be hypotensive to 88/44 by EMS.
Denied any headaches, visual changes, muscle weakness or
parasthesias.  Patient reports he was in his usual state of
health prior to the fall.  No recent infections, cough, URI sx
or dysuria.  No abdominal pain, brbpr or melena.
.
 Wife [**Last Name (un) **] reported some concerns regarding her husband's
health over the weekend.  Wife said  he had "labored breathing"
and appeared unsteady on his feet.  He did not leave the house
this weekend.  She was planning on taking him to his primary
care today.  Also with decreased po intake.  Mild confusion that
has been present since starting chemo.
.
Of note, patient reported  isolated incident of tonic-clonic
right arm shaking two weeks ago that lasted approximately 60
seconds.  No LOC.  Patient had similar right arm seizure like
activity in [**Month (only) 359**] for which he was hospitalized and found to
have a new brain met.  He has since been on a decadron taper
that finished today and completed cyberknife.
.
In ED:  98  76P  110/42  20  95%RA; guaiac negative; given 2L NS
and hydrocortisone 100mg for presumed adrenal insufficiency; CXR
showed PNA - started on cefepime and vancomycin; Head CT showed
improvement of vasogenic edema; abdominal CT showed stable AAA
and no rp bleed
.
ROS as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: Oncology history:
DIAGNOSIS:
1. Stage III nonsmall cell lung cancer (adenocarcinoma) with a
potential T4N0 tumor (stage III, 7th TNM), EGFR wild-type
2. Metastatic disease to brain discovered in [**9-/2110**] after focal
seizure.

MEDICATION ON ADMISSION: Carvedilol 25mg [**Hospital1 **]
Dexamethasone taper - finished today, taper started [**2110-10-27**] with
4mg daily
Levetiracetam 1000mg [**Hospital1 **]
Lisinopril 10mg daily
Prilosec 20mg [**Hospital1 **]
Simvastatin 20mg daily
ASA 81mg daily
MVI

ALLERGIES: Hydrochlorothiazide / Norvasc

PHYSICAL EXAM: Admission physical exam:
98.5  106/68  68P  18  96%RA
Appearance: alert, NAD
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2  -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: diminished at bases
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, 5/5 strength, no pronator drift,
normal finger-to-nose, downgoing babinski, 2+ reflexes ue/le,
sensation grossly intact
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Rectal: guaiac negative in ED

FAMILY HISTORY: No fhx of lung cancer. Myocardial infarction in his father
sustained at the age of 68.  There is no history of premature
coronary artery disease.  No family history of malignancy.

SOCIAL HISTORY: Patient lives with wife, 6 children.  Retired engineer for
telephone company.  Distant tobacco, no alcohol currently (had
[**12-22**] manhattens daily previously), no illicits.
Pneumocystosis,Cerebral edema,Malignant neoplasm of bronchus and lung, unspecified,Secondary malignant neoplasm of brain and spinal cord,Hyposmolality and/or hyponatremia,Other pancytopenia,Hypoxemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Other alteration of consciousness,Heartburn,Swelling of limb,Abdominal aneurysm without mention of rupture,Hypotension, unspecified,Esophageal reflux,Displacement of thoracic intervertebral disc without myelopathy,Cardiac pacemaker in situ
Pneumocystosis,Cerebral edema,Mal neo bronch/lung NOS,Sec mal neo brain/spine,Hyposmolality,Other pancytopenia,Hypoxemia,Osteoarthros NOS-unspec,Hypertension NOS,Pure hypercholesterolem,Other alter consciousnes,Heartburn,Swelling of limb,Abdom aortic aneurysm,Hypotension NOS,Esophageal reflux,Thoracic disc displacmnt,Status cardiac pacemaker
Admission Date:  [**2110-11-17**]              Discharge Date:   [**2110-12-3**]

Date of Birth:  [**2042-4-5**]             Sex:   M

Service: MEDICINE

Allergies:
Hydrochlorothiazide / Norvasc

Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
presyncope

Major Surgical or Invasive Procedure:
PICC line placement

History of Present Illness:
.
68 yo M with Stage III nonsmall cell lung cancer
(adenocarcinoma) with metastatic disease to brain discovered in
[**9-/2110**] after focal seizure s/p cyberknife and hx of complete
heart block s/p pacemaker who presents to the ED today after a
presyncopal episode.
.
Patient reports that he was walking out of CVS on th eday of
admission  and suddenly collapsed to the ground and was unable
to get up.  He denied any preceding symptoms such as chest pain,
palpitations, sob, lightheadedness or dizziness.  No focal
weakness.  Denies any LOC or head trauma.  No reported
confusion, bowel/bladder incontinence, tongue biting or
witnessed shaking.  Found to be hypotensive to 88/44 by EMS.
Denied any headaches, visual changes, muscle weakness or
parasthesias.  Patient reports he was in his usual state of
health prior to the fall.  No recent infections, cough, URI sx
or dysuria.  No abdominal pain, brbpr or melena.
.
 Wife [**Last Name (un) **] reported some concerns regarding her husband's
health over the weekend.  Wife said  he had "labored breathing"
and appeared unsteady on his feet.  He did not leave the house
this weekend.  She was planning on taking him to his primary
care today.  Also with decreased po intake.  Mild confusion that
has been present since starting chemo.
.
Of note, patient reported  isolated incident of tonic-clonic
right arm shaking two weeks ago that lasted approximately 60
seconds.  No LOC.  Patient had similar right arm seizure like
activity in [**Month (only) 359**] for which he was hospitalized and found to
have a new brain met.  He has since been on a decadron taper
that finished today and completed cyberknife.
.
In ED:  98  76P  110/42  20  95%RA; guaiac negative; given 2L NS
and hydrocortisone 100mg for presumed adrenal insufficiency; CXR
showed PNA - started on cefepime and vancomycin; Head CT showed
improvement of vasogenic edema; abdominal CT showed stable AAA
and no rp bleed
.
ROS as per HPI, 10 pt ROS otherwise negative


Past Medical History:
Oncology history:
DIAGNOSIS:
1. Stage III nonsmall cell lung cancer (adenocarcinoma) with a
potential T4N0 tumor (stage III, 7th TNM), EGFR wild-type
2. Metastatic disease to brain discovered in [**9-/2110**] after focal
seizure.

CURRENT TREATMENT: Surveillance

TREATMENT:
1. Status post chest radiotherapy to 6600 cGy completed on
[**2109-4-1**].
2. Status post 2 cycles of cisplatin 50 mg/m2 D1, D8 and
etoposide 50 mg/m2 D1-D5 of a 28 day cycle on [**2109-2-18**] and
[**2109-3-18**].He started concurrent chemoradiation therapy on
[**2109-2-15**].  Day 8 cisplatin was held during cycle 1 for AAA
repair. Day 8 cisplatin was held during cycle 2 for
thrombocytopenia.
3. S/p cyberknife and decadron taper for brain mets

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Hyperlipidemia.
3.  Complete heart block status post pacemaker.
4.  Arthroscopic knee surgery.
5.  Arthritis
6.  Coronary artery disease
7.  Rosacea
8.  Status post endovascular aortic aneurysm repair on 03/[**2108**].


Social History:
Patient lives with wife, 6 children.  Retired engineer for
telephone company.  Distant tobacco, no alcohol currently (had
[**12-22**] manhattens daily previously), no illicits.

Family History:
No fhx of lung cancer. Myocardial infarction in his father
sustained at the age of 68.  There is no history of premature
coronary artery disease.  No family history of malignancy.

Physical Exam:
Admission physical exam:
98.5  106/68  68P  18  96%RA
Appearance: alert, NAD
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2  -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: diminished at bases
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, 5/5 strength, no pronator drift,
normal finger-to-nose, downgoing babinski, 2+ reflexes ue/le,
sensation grossly intact
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Rectal: guaiac negative in ED

Pertinent Results:
[**2110-11-17**] 06:45PM   cTropnT-<0.01
[**2110-11-17**] 04:57PM   LACTATE-1.4
[**2110-11-17**] 04:45PM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-NEG
[**2110-11-17**] 01:33PM   PT-13.0 PTT-26.0 INR(PT)-1.1
[**2110-11-17**] 01:10PM   GLUCOSE-159* UREA N-21* CREAT-0.9 SODIUM-127*
POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-22 ANION GAP-15
[**2110-11-17**] 01:10PM   cTropnT-<0.01
[**2110-11-17**] 01:10PM   WBC-3.7*# RBC-3.09* HGB-10.0*# HCT-28.4*
MCV-92 MCH-32.4* MCHC-35.3* RDW-13.6
[**2110-11-17**] 01:10PM   NEUTS-93.4* LYMPHS-5.0* MONOS-1.2* EOS-0.3
BASOS-0.1
.
[**2110-11-17**] BCx: negative
[**2110-11-17**] UCx: negative

[**2110-11-17**] EKG: 63 V-paced, no change from [**10-10**]
.
[**2110-11-17**] NCHCT:
1. No acute hemorrhage or mass effect.
2. Decreased area of vasogenic edema in left frontal vertex
compared to
[**2110-10-12**].
.
[**2110-11-17**] A/P CT WO Contrast:
1. Stable size of AAA, measuring 6.8 x 6.4 cm (compared to 6.9 x
6.2 cm on
[**10-14**]).

2. No retroperiotneal hematoma.
.
[**2110-11-17**] Pa/Lat CXR:
Bilateral upper lobe pneumonia.
.
[**2110-11-18**] CT chest without contrast:  IMPRESSION:
1. New severe alveolitis or other alveolar filling process
primarily
involving the upper lobes and therefore most likely connected to
prior radiation therapy denoted by longstanding paramediastinal
pulmonary fibrosis. The differential diagnosis includes delayed
cryptogenic organizing pneumonia, drug-induced pneumonitis
potentiated by prior radiation (given the appropriate clinical
history of ongoing chemotherapy, unknown to me). Diffuse
pulmonary
hemorrhage and widespread atypical pneumonia are alternative
possibilities.
2. Severe atherosclerosis, involving coronaries.
.
[**2110-11-19**] Immunoflourescent test for Pneumocystis jirovecii
(carinii)(Final
[**2110-11-20**]):   NEGATIVE for Pneumocystis jirovecii (carinii).
.
[**2110-11-19**]: B-GLUCAN
Fungitell (tm) Assay for (1,3)-B-D-Glucans
Results: >500 pg/mL*
Reference Ranges
Negative: Less than 60 pg/mL
  Indeterminate: 60 - 79 pg/mL
Positive: Greater than or equal to 80 pg/mL
.
[**2110-11-20**] Legionella Urinary Antigen:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
.
[**2110-11-21**] Immunoflourescent test for Pneumocystis jirovecii
(carinii) (Final
[**2110-11-24**]):   NEGATIVE for Pneumocystis jirovecii (carinii).
.
[**2110-11-21**] Chest xray: IMPRESSION: In addition to the biapical
radiation changes, there is likely overlying atypical organism
infection, possibly PCP, [**Name10 (NameIs) **] drug toxicity from chemotherapy that
has now spread to the left mid, left lower, and right lower lung
fields.
.
[**2110-11-24**] Ultrasound L upper extremity: IMPRESSION: No DVT in the
left upper extremity.
.
[**2110-11-25**] CT of C, T and L spine:
C Spine IMPRESSION:
No evidence of metastatic disease. Extensive degenerative disc
disease of the cervical spine, as described above.
T Spine IMPRESSION:
1. No evidence of spinal metastatic disease.
2. Diffuse bilateral ground-glass opacities are partially imaged
and are further characterized on CT exam of [**2110-11-18**].
Small bilateral pleural effusions, right greater than left,
appears slightly increased in size from prior.
3. Calcified disk protrusion at T6-7 with likely cord
compression.
L Spine IMPRESSION:
1. No evidence of metastatic disease. No suspicious lytic or
sclerotic
lesion is seen within the bones.
2. Stable appearance of the infrarenal abdominal aortic
aneurysm.
Numerous sigmoid colon diverticula without associated
inflammatory changes.

Brief Hospital Course:
1. Hypoxic Respiratory Failure, progressive alveolar process:
This is a 68 year old gentleman with CHB s/p PPM and Stage IV
NSCLC (adenoCa) with a single brain metastasis s/p cyberknife
one month ago and subsequent decadron taper terminating on the
day of admission.  He presented to the ED following a
presyncopal episode during which he was found to be hypotensive
by EMS.  This hypotension resolved without intervention prior to
his arrival in the ED where he was given broad spectrum
antibiotics (HCAP coverage) for bilateral apical infiltrates and
stress dose steroids for potential adrenal insufficiency.

He was admitted to the general medical floor. A Head CT with
contrast demonstrated improvement of his vasogenic edema and
abdominal CT demonstated a stable AAA. CT scan of the chest on
the evening of admission demonstrated new severe alveolitis or
other alveolar filling process primarily involving the upper
lobes, but also with patchy involement in other lung fields. The
differential diagnosis entertained included COP as a late term
sequelae of the chest radiation he had received one year prior,
atypical PCP with particular concern for PCP, [**Name10 (NameIs) **] less likely
possiblities such as hypersensitivity pneumonitis, vasculitides,
and pulmonary hemmorhage.

He had no oxygen requirement on the day of admission despite
pronounced findings on chest CT. He developed rapidly
progressive hypoxemia. On HD2, he required 2L by nasal cannula
to maintain O2 sats in the low 90s. In addition to the
vancomycin and cefepime he had been receiving since admission,
he was started on azithromycin and high dose IV bactrim with
steroids (to empirically cover PCP and also potentially
steroid-responsive inflammatory lung diseases such as COP).
Pulmonary was consulted regarding bronchoscopy, but this was
cancelled given his worsening oxygen requirement which
progressed despite empiric treatments.  He was transferred to
the medical ICU on [**11-22**] as he began to require a non-rebreather
to maintain sats in the low 90s.
  On admission to ICU, it was noted that pneumonitis
hypersensitivity panel, [**Doctor First Name **] and ANCA were negative. Sputum was
negative for PCP x 2.  However, B-glucan was grossly elevated to
>500, galactomannam was elevated at 0.5, and LDH was elevated up
to 754, suspicion was high for PCP pneumonia and patient was
started on bactrim DS and steroids.  He improved greatly over
several days, weaned down to 5L NC, at which time he was
transferred back to the floor.  He completed a 7 day course of
broad spectrum antibiotics (vancomycin, cefepime and
azithromycin) to cover for HCAP.
  The patient's oxygenation steadily improved on bactrim and
prednisone although he continues to require supplement O2 ( 5
lits ) per nasal cannula.As below, pt developed transaminitis
and pan-cytopenia while on bactrim. CBC, lfts and chem 10 will
need to be followed closely at the outside faciliy and pt will
also be followed by the [**Hospital **] clinic.

His hospitalization was also notable for:
2. Concern for adrenal insufficiency which prompted ED
physicians to give stress dose steroids.  His AM cortisol over
24 hours after stress dose steroids were stopped was 20, making
this very unlikely.Pt is being d/c on prednisone ( as part of
treatment for PCP [**Name Initial (PRE) 1064**]) and will need a slow taper after
completion of treatment dose.
.
3. Hyponatremia: His serum sodium dropped as low as 125 but pt
remained asymptomatic. Likely causes included  some element of
SIADH secondary to lung inflammation/NSCLC  and this was likely
exacerbated by mild hypovolemia as his sodium did increase with
normal saline. Treated with high sodium diet, mild fluid
restriction and intermittant IVF as required by his volume
status.Pt being d/c with low dose of oral supplemental salt.
.
4. Pancytopenia: On admission, His thrombocytopenia and
leukopenia improved without intervention and was attributed to
acute illness. However, his anemia recurred mostly likley from
myelosuppression due to high dose bactrim and he required 2
units PRBCs on [**2110-11-30**] and [**2110-12-1**]. Iron studies, B12 and
folate did not show deficiencies and work up did not support
hemolysis.On d/c plts are trending down and levels need to be
followed closely as an outpt.
.
5. NSCLC/ Code Status: Initially the patient was listed as
DNR/DNI, but given his progressive oxygen requirement from a
potentially reversible/treatable process and his relatively good
response thus far from an oncologic point-of-view, this was
discussed with the patient and his wife [**Name (NI) 382**] on [**2110-11-20**] by the
hospitalist caring for him and he was switched to FULL CODE. The
patient's son was also present for this conversation.
.
6. Lower extremity weakness: Patient complained of progressively
worsening weakness.  Non contrast head CT showed no worsening of
his brain mets.  A CT spine (patient's pace maker is NOT
compatible with MRI) showed no mets in the spinal cord but did
reveal cord impingement due to DJD at T6. The patient was seen
in consultation with neuro oncology who felt that this
radiologic finding was not causing clinical symptoms, had been
documented on prior studies and was stable. Differential
diagnosis included neuromuscular process, paraneoplastic
process, and deconditioning given prolonged hospitalization. TSH
and  CPK levels were wnl.Symptoms did improve spontaneously and
likely cause is deconditioning due to prolonged hospital stay
including ICU admission. Pt will need PT.
.
7. Hyperkalemia: Likely due to high dose bactrim. In the acute
circumstance the patient received kayexalate on two occasions.
Long term the issue was managed by decreasing the patient's
carvedilol dose, adding low torsemide every other day with or
without IV hydration depending on the patient's volume status.Pt
being d/c on a low K diet and electroltyes will need to be
monitored as an outpt.
.
8. Transaminitis with elevated alkaline phos and normal
bilirubin: The patient was assymptomatic and these laboratory
changes were thought most likely due to drug effect. Hepatitis
serologies pending on d/c. The patient's statin was discontinued
and his keppra was changed to zonisamide. High dose bactrim may
also be contributing and dose reduced after dsicussion with the
ID service .
.
9. Stage III NSCLC / brain mets: Repeat Head CT with contrast
showing no new lesions, edema decreased. Pt will continue f/u
with primary oncologist.
.
10. History of Seizures: Secondary to brain mets.As above, DC'd
keppra, started Zonisamide due to elevated LFT's.
.
10. HTN: Held home meds on admission. DECREASED carvedilol
(coreg) 12.5 mg [**Hospital1 **] --> 3.125 [**Hospital1 **] to allow every other day
torsemide to manage hyperkalemia. BP remained stable on this
dose after discontinuation of torsemide but may need to titrated
back up.
.
11. GERD:  Continued omeprazole.
.
12. HLD: Given his transaminitis, discontinued simvastatin.
.
13. Acute delerium at night: managed with Haldol 0.5-1 mg QHS
with marked improvement though not complete resolution. He
remained oriented during the day.
.
14. Left upper extremity edema: etiology unclear. ultrasound
negative.


Emergency contact: [**Name (NI) **] (wife) [**Telephone/Fax (1) 78434**] (H),
[**Telephone/Fax (1) 78435**] (C).


Medications on Admission:
Carvedilol 25mg [**Hospital1 **]
Dexamethasone taper - finished today, taper started [**2110-10-27**] with
4mg daily
Levetiracetam 1000mg [**Hospital1 **]
Lisinopril 10mg daily
Prilosec 20mg [**Hospital1 **]
Simvastatin 20mg daily
ASA 81mg daily
MVI

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
6. haloperidol 0.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for confusion.
7. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. zonisamide 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. prednisone 20 mg Tablet Sig: Two (2) Tablet PO QAM (once a
day (in the morning)) for 1 days.
10. prednisone 20 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)) for 8 days: will need taper after
[**2110-12-13**]- to discuss with primary oncologist.
11. insulin lispro 100 unit/mL Solution Sig: Two (2) units
Subcutaneous ASDIR (AS DIRECTED): per sliding scale.
12. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: 2.5
Tablets PO every six (6) hours for 11 days.
13. sodium chloride 1 gram Tablet Sig: One (1) Tablet PO QOD ().



Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] [**Location (un) 1121**]

Discharge Diagnosis:
PCP (pneumoncystis) pneumonia
Lung cancer with brain metastases
Elevated Liver function tests
Hyperkalemia (high potassium)
Hypoxemia (low oxygen)
Hyponatremia (low sodium)
Diffuse weakness
Degenerative joint disease
Left arm swelling
Delerium at night
High blood pressure
High cholesterol
Heart burn
pan-cytopenia


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


Discharge Instructions:
You were admitted with shortness of breath from PCP
(pneumoncystis) pneumonia that required intensive care unit
monitoring for your oxygen levels. You are being treated with 3
weeks of bactrim antibiotics with prednisone steroid medication
and you have been steadily improving. You have continued to need
oxygen, but this is expected to improve over time. Your strength
has been improving and tests did not reveal a cause for
weakness.You liver function tests have been elevated so your
statin has been stopped and your anti seizure medication has
been changed.Your potassium has been high probably from the
bactrim antibiotic you need for your pneumonia. This has been
treated with a water pill (toresamide), IV fluids, and
decreasing your carvedilol blood pressure medication.You have
received 2 blood transfusions for anemia with good response. You
have had confusion at night time that has been treated with
Haldol at bedtime.
pending results: hepatitis serologies

Followup Instructions:
F/U blood pressure-carvedilol may need to be titrated up.
F/U CBC and chem 10 in 2 days and then at least twice a week.
Results to be faxed to Dr [**Last Name (STitle) 10351**] , fax # [**Telephone/Fax (1) 34802**]
## Pt will be contact[**Name (NI) **] for f/u with the [**Hospital **] clinic , if you do
not hear from them  please contact [**Telephone/Fax (1) 457**] to set a f/u in
[**4-26**] days.
Department: [**Location (un) 2352**] PHYSICAL THERAPY
When: MONDAY [**2110-12-8**] at 2:00 PM
With: [**Name (NI) 78436**] [**Name (NI) 33923**], PT [**Telephone/Fax (1) 4832**]
Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) **]
Campus: OFF CAMPUS     Best Parking: Free Parking on Site

Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2110-12-25**] at 11:00 AM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, PHD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: THURSDAY [**2110-12-25**] at 11:30 AM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 593**], MD [**0-0-**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Pneumocystosis,Cerebral edema,Malignant neoplasm of bronchus and lung, unspecified,Secondary malignant neoplasm of brain and spinal cord,Hyposmolality and/or hyponatremia,Other pancytopenia,Hypoxemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Other alteration of consciousness,Heartburn,Swelling of limb,Abdominal aneurysm without mention of rupture,Hypotension, unspecified,Esophageal reflux,Displacement of thoracic intervertebral disc without myelopathy,Cardiac pacemaker in situ'}


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: presyncope

PRESENT ILLNESS: .
68 yo M with Stage III nonsmall cell lung cancer
(adenocarcinoma) with metastatic disease to brain discovered in
[**9-/2110**] after focal seizure s/p cyberknife and hx of complete
heart block s/p pacemaker who presents to the ED today after a
presyncopal episode.
.
Patient reports that he was walking out of CVS on th eday of
admission  and suddenly collapsed to the ground and was unable
to get up.  He denied any preceding symptoms such as chest pain,
palpitations, sob, lightheadedness or dizziness.  No focal
weakness.  Denies any LOC or head trauma.  No reported
confusion, bowel/bladder incontinence, tongue biting or
witnessed shaking.  Found to be hypotensive to 88/44 by EMS.
Denied any headaches, visual changes, muscle weakness or
parasthesias.  Patient reports he was in his usual state of
health prior to the fall.  No recent infections, cough, URI sx
or dysuria.  No abdominal pain, brbpr or melena.
.
 Wife [**Last Name (un) **] reported some concerns regarding her husband's
health over the weekend.  Wife said  he had "labored breathing"
and appeared unsteady on his feet.  He did not leave the house
this weekend.  She was planning on taking him to his primary
care today.  Also with decreased po intake.  Mild confusion that
has been present since starting chemo.
.
Of note, patient reported  isolated incident of tonic-clonic
right arm shaking two weeks ago that lasted approximately 60
seconds.  No LOC.  Patient had similar right arm seizure like
activity in [**Month (only) 359**] for which he was hospitalized and found to
have a new brain met.  He has since been on a decadron taper
that finished today and completed cyberknife.
.
In ED:  98  76P  110/42  20  95%RA; guaiac negative; given 2L NS
and hydrocortisone 100mg for presumed adrenal insufficiency; CXR
showed PNA - started on cefepime and vancomycin; Head CT showed
improvement of vasogenic edema; abdominal CT showed stable AAA
and no rp bleed
.
ROS as per HPI, 10 pt ROS otherwise negative

MEDICAL HISTORY: Oncology history:
DIAGNOSIS:
1. Stage III nonsmall cell lung cancer (adenocarcinoma) with a
potential T4N0 tumor (stage III, 7th TNM), EGFR wild-type
2. Metastatic disease to brain discovered in [**9-/2110**] after focal
seizure.

MEDICATION ON ADMISSION: Carvedilol 25mg [**Hospital1 **]
Dexamethasone taper - finished today, taper started [**2110-10-27**] with
4mg daily
Levetiracetam 1000mg [**Hospital1 **]
Lisinopril 10mg daily
Prilosec 20mg [**Hospital1 **]
Simvastatin 20mg daily
ASA 81mg daily
MVI

ALLERGIES: Hydrochlorothiazide / Norvasc

PHYSICAL EXAM: Admission physical exam:
98.5  106/68  68P  18  96%RA
Appearance: alert, NAD
Eyes: eomi, perrl, anicteric
ENT: OP clear s lesions, mmm, no JVD, neck supple
Cv: +s1, s2  -m/r/g, no peripheral edema, 2+ dp/pt bilaterally
Pulm: diminished at bases
Abd: soft, nt, nd, +bs
Msk: 5/5 strength throughout, no joint swelling, no cyanosis or
clubbing
Neuro: cn 2-12 grossly intact, 5/5 strength, no pronator drift,
normal finger-to-nose, downgoing babinski, 2+ reflexes ue/le,
sensation grossly intact
Skin: no rashes
Psych: appropriate, pleasant
Heme: no cervical [**Doctor First Name **]
Rectal: guaiac negative in ED

FAMILY HISTORY: No fhx of lung cancer. Myocardial infarction in his father
sustained at the age of 68.  There is no history of premature
coronary artery disease.  No family history of malignancy.

SOCIAL HISTORY: Patient lives with wife, 6 children.  Retired engineer for
telephone company.  Distant tobacco, no alcohol currently (had
[**12-22**] manhattens daily previously), no illicits. 

### Response:
{'Pneumocystosis,Cerebral edema,Malignant neoplasm of bronchus and lung, unspecified,Secondary malignant neoplasm of brain and spinal cord,Hyposmolality and/or hyponatremia,Other pancytopenia,Hypoxemia,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified essential hypertension,Pure hypercholesterolemia,Other alteration of consciousness,Heartburn,Swelling of limb,Abdominal aneurysm without mention of rupture,Hypotension, unspecified,Esophageal reflux,Displacement of thoracic intervertebral disc without myelopathy,Cardiac pacemaker in situ'}
