CHIEF COMPLAINT: Unresponsive

PRESENT ILLNESS: 82yo female with past medical history of asthma was admitted
from an OSH with hypotension, altered mental status, and likely
metastatic brain lesions. History obtained primarily from OSH
records, notes, and ED records.

MEDICAL HISTORY: Asthma

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 93.7 / HR 86 / BP 122/76 / RR 24 / Pulse ox 97%
Vent Settings: AC with FiO2 .5, Set TV 500 with obs TV 472 by RR
24. PEEP 5
Gen: lying in bed, responsive to irritative stimuli, NAD
HEENT: dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS.  No HSM
EXT: No edema. 2+ DP pulses BL. dusky extremities but warm
SKIN: No rashes
NEURO: intermittently arousable. CN 2 intact but could not test
EOM. symmetric facies. Not cooperative with additional CN exam.
Decreased tone in all extremities but with spontaneous movement
of left upper and lower extremities.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Home: lives with son and daughter-in-law; recently immigrated
from [**Country 38213**], speaks Albanian
Occupation: unknown
Tobacco, EtOH, and Drugs: could not obtain history
Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Septic shock,Secondary malignant neoplasm of brain and spinal cord,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Other convulsions,Other malignant neoplasm without specification of site,Asthma, unspecified type, unspecified
Septicemia NOS,Acute respiratry failure,Acute kidney failure NOS,Hyperosmolality,Septic shock,Sec mal neo brain/spine,SIRS-noninf w ac org dys,Convulsions NEC,Malignant neoplasm NOS,Asthma NOS
Admission Date:  [**2154-9-27**]              Discharge Date:   [**2154-10-3**]

Date of Birth:  [**2072-2-2**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 330**]
Chief Complaint:
Unresponsive

Major Surgical or Invasive Procedure:
None

History of Present Illness:
82yo female with past medical history of asthma was admitted
from an OSH with hypotension, altered mental status, and likely
metastatic brain lesions. History obtained primarily from OSH
records, notes, and ED records.

On the day prior to admission, patient reported the sudden onset
of a severe headache for which she took approximately 7 advil
tablets. Shortly afterwards, she reportedly developed increasing
lethargy, vomiting, weakness, and subsequently became
unresponsive. EMS was called and took patient to [**Hospital1 10551**].

Upon arrival at [**Hospital3 **] at 1:45pm on [**2154-9-27**], BP 91/34,
HR 85, RR 18, and O2 sat 97% on 100% nonrebreather. Patient was
noted to be unresponsive and was intubated. She received
lidocaine 100mg IV x 1, pancuronium 1mg IV x 1, etomidate 20mg
IV x 1, and succinylcholine 100mg IV x 1. Shortly after
intubation she was noted to be hypotensive with SBP in the 50s
and she was started on dopamine gtt with improvement in SBPs to
70-80s. Initial head CT at [**Hospital3 **] noted a hyperdense
lesion in the right posterior temporal lobe with suggested
intraparenchymal hemorrhage versus metastatic lesion.  She was
then transferred to [**Hospital1 18**] for neurosurgical evaluation of
possible intraparenchymal bleed.  Additional medications
received at [**Hospital3 **] include zofran 4mg x 1 and
fosphenytoin loading dose.

Upon arrival at [**Hospital1 18**], radiology reviewed her imaging and found
her images most consistent with a metastatic lesion, concerning
for a primary adenocarcinoma. Clinically patient remained
unresponsive despite having not received any sedation in the
last 6-8 hours prior to arrival. Neurosurgery evaluated patient
and found her exam concerning for unresponsiveness and
posturing, although with no other acute surgical issues.
Neurology also evaluated patient and will be following closely.
While in the ED, she received Ceftriaxone 1gram IV, vancomycin
1gram IV, and 4L NS with 1600mL UOP.

Regarding likely metastatic lesion, unclear that patient has
ever had age-appropriate cancer screening, including mammogram
or colonoscopy.


Past Medical History:
Asthma

Social History:
Home: lives with son and daughter-in-law; recently immigrated
from [**Country 38213**], speaks Albanian
Occupation: unknown
Tobacco, EtOH, and Drugs: could not obtain history



Family History:
Noncontributory

Physical Exam:

T 93.7 / HR 86 / BP 122/76 / RR 24 / Pulse ox 97%
Vent Settings: AC with FiO2 .5, Set TV 500 with obs TV 472 by RR
24. PEEP 5
Gen: lying in bed, responsive to irritative stimuli, NAD
HEENT: dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS.  No HSM
EXT: No edema. 2+ DP pulses BL. dusky extremities but warm
SKIN: No rashes
NEURO: intermittently arousable. CN 2 intact but could not test
EOM. symmetric facies. Not cooperative with additional CN exam.
Decreased tone in all extremities but with spontaneous movement
of left upper and lower extremities.


Pertinent Results:
[**2154-9-27**] Blood Cx pending x 2
[**2154-9-28**] Urine Cx pending

OSH STUDIES:
- CT Chest/Abdomen/Pelvis - [**2154-9-27**] - no abnormality identified
within the chest, abdomen, or pelvis to account for loss of
consciousness; mild dependent atelectasis within the lung;
abdominal examination is normal.
- CT Head - [**2154-9-27**] - 11mm round hyperdense focus centered at
the [**Doctor Last Name 352**]-white junction of the posterior right temporal lobe,
seen in association with vasogenic edema. ? hemorrhagic
metastasis or focal parenchymal bleed.

[**Hospital1 18**] STUDIES:
- ECG [**2154-9-27**] - NSR at 85 bpm with no ST changes
- Head CT - [**2154-9-27**] - 1.  1.1-cm hyperdense lesion with
surrounding edema seen in the right temporal lobe, suggestive of
metastatic lesion.  2.  Linear hyperattenuation seen at the
posterior right lateral ventricle, possibly representing venous
filling, however, assessment for hemorrhage is limited by
intravenous contrast.
- Head MRI - [**2154-9-28**] - final read pending
- CXR - [**2154-9-28**] - final read pending


Brief Hospital Course:
The patient is an 82 yo F with asthma admitted with hypotension
and altered mental status found to have profound metabolic
acidosis (lactate 7).  She was also found to have a brain
lesion, with possible hemorragic component based on imaging at
the OSH. She was treated aggressively with a bicarbonate drip to
correct her acidosis.  Her lactate trended down and her gap
closed.  Initially she was intubated and on pressors for
hypotension.  She was started on broad spectrum antibiotics
(ceftriaxone/vancomycin) because of concern for sepsis.
Cultures were all negative.  It was thought that the patient may
have had a seizure from the brain lesion.  The patient was
quickly extubated and maintained her pressures off pressors.
She was started on keppra [**Hospital1 **].  The neurosurgeons evaluated the
lesion and felt that a brain biopsy of the lesion would be
necessary for diagnosis.  The patient and her family the decided
on DNR/DNI/CMO.  Arrangements were made for the family to be
discharged home with hospice care and plans for the patient to
fly to [**Country 38213**] (her home) in the near future.

Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*0*
2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO TID (3 times a day) as needed: Give 1 tab 30
minutes prior to airline flight to [**Country 38213**]. [**Month (only) 116**] take additional
tab as needed. Hold for sedation.
Disp:*10 Tablet, Rapid Dissolve(s)* Refills:*1*
3. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*360 Tablet(s)* Refills:*1*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] VNA in [**Location (un) 5087**]

Discharge Diagnosis:
Primary Diagnosis:
Altered mental status
Brain lesion


Discharge Condition:
Stable; tolerating PO's, mental status clear


Discharge Instructions:
You were admitted to the hospital with altered mental status and
were found to have a lesion in your brain.  Because of this
lesion you may have suffered a seizure.  In order to know
exactly what the lesion is, you would have had to have a brain
biopsy which you and you family declined.  You should continue
on the anti-seizure medication we have prescribed for you.

We have also prescribed a number of other medications to help
you be comfortable.
1. Percocet - This is a pill for pain.  Please take [**1-1**] pills as
you need to control you pain.  Please do not take more that
every 4 hours.
2. Keppra - This is a pill to prevent seizures.  Please take 1
pill twice a day.
3. Zydis - This is a pill to help with anxiety.  Please take
this is you are feeling anxious or agitated.  It is a pill that
will disolve under your tongue.  It might help if you took one
of these prior to your flight to [**Country 38213**].

Followup Instructions:
Please follow up with your primary care doctor as needed.  You
are being provided with the phone numbers for visting nurses to
assist you prior to your dpearture for [**Country 38213**].
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Septic shock,Secondary malignant neoplasm of brain and spinal cord,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Other convulsions,Other malignant neoplasm without specification of site,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: Unresponsive

PRESENT ILLNESS: 82yo female with past medical history of asthma was admitted
from an OSH with hypotension, altered mental status, and likely
metastatic brain lesions. History obtained primarily from OSH
records, notes, and ED records.

MEDICAL HISTORY: Asthma

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T 93.7 / HR 86 / BP 122/76 / RR 24 / Pulse ox 97%
Vent Settings: AC with FiO2 .5, Set TV 500 with obs TV 472 by RR
24. PEEP 5
Gen: lying in bed, responsive to irritative stimuli, NAD
HEENT: dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS.  No HSM
EXT: No edema. 2+ DP pulses BL. dusky extremities but warm
SKIN: No rashes
NEURO: intermittently arousable. CN 2 intact but could not test
EOM. symmetric facies. Not cooperative with additional CN exam.
Decreased tone in all extremities but with spontaneous movement
of left upper and lower extremities.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: Home: lives with son and daughter-in-law; recently immigrated
from [**Country 38213**], speaks Albanian
Occupation: unknown
Tobacco, EtOH, and Drugs: could not obtain history 

### Response:
{'Unspecified septicemia,Acute respiratory failure,Acute kidney failure, unspecified,Hyperosmolality and/or hypernatremia,Septic shock,Secondary malignant neoplasm of brain and spinal cord,Systemic inflammatory response syndrome due to noninfectious process with acute organ dysfunction,Other convulsions,Other malignant neoplasm without specification of site,Asthma, unspecified type, unspecified'}
