CHIEF COMPLAINT: Electrolyte abnormalities and change in
mental status.

PRESENT ILLNESS: A 41-year-old male, with a
history of renal cell cancer diagnosed in [**2145-11-1**], who
presented with seizure and found to have METS to the brain.
The patient had resection of the brain METS with residual
left hemiparesis.  He is status post stereotactic
radiosurgery on [**2145-12-15**] which was complicated by PTH
RP causing hypercalcemia, SIADH, and anxiety with recent
admission to [**Hospital1 18**] on [**2146-2-3**] with mental status
changes and hypercalcemia.  The patient now presented to the
clinic with electrolyte abnormalities.  On recent admission,
the patient's hypercalcemia was treated with hydration,
calcitonin and 90 mg of pamidronate on [**2146-2-18**] with
good effect.  The patient has a history of hypocalcemia after
receiving Zometa in the past, and his electrolytes were
carefully monitored.  The patient was started on Tums when
the patient's calcium fell below 9.

MEDICAL HISTORY: 1. Renal cell carcinoma diagnosed in [**2145-11-1**] with brain
METS, status post right frontal craniotomy in [**2145-11-1**],
SRS in [**2145-12-2**], which initially presented with seizures
and brain METS were found.
2. Hyponatremia.
3. SIADH.
4. Hypercalcemia.
5. PTH RP from RCC.
6. History of multiple UTIs and anxiety.

MEDICATION ON ADMISSION: 1. Sodium chloride 2 gm po tid.
2. Levetiracetam 1 gm po bid.
3. Protonix 40 mg po qd.
4. Nortriptyline 100 mg po hs.
5. Epogen 40,000 U subcu q Tuesday.
6. Dexamethasone 0.5 mg po qod for 7 days--last dose on [**2146-3-3**].
7. Calcitonin 200 U nasal spray qd.
8. Clonazepam 0.5 mg po q hs.
9. Colace 100 mg po bid prn.
10.Senna 1 tab po bid prn.
11.Bisacodyl 10 mg po qd prn.
12.Tylenol prn.
13.Insulin subcu--the patient has not needed it for the past
5 days.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: Temperature 98.2, blood pressure 105/64,
heart rate 108, respiration rate 16, satting 97% on room air.
The patient was generally a pleasant gentleman appearing his
stated age, in no apparent distress, and slow to respond to
questions.  The patient's sclerae were anicteric, and mucous
membranes were dry.  Examination of the heart showed that the
patient was tachycardic with regular rhythm.  S1 and S2 were
heard with no murmurs.  The patient had decreasing breath
sounds and crackles in bilateral bases.  Examination of the
back showed no CVA tenderness.  No lumbar spinal tenderness.
The patient's abdomen was soft with positive bowel sounds.
No HSM.  Mild left-sided tenderness.  Mild left-sided rib
tenderness.  Examination of the extremities revealed that the
patient had no edema and good pulses.

FAMILY HISTORY: No family history of renal cell cancer.

SOCIAL HISTORY: The patient lives with his girlfriend and
works as a paralegal.  The patient denies alcohol, tobacco,
or IV drug use.
Malignant neoplasm of kidney, except pelvis,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Hemorrhage complicating a procedure,Other convulsions,Acute pericarditis, unspecified,Unspecified protein-calorie malnutrition,Hypercalcemia,Other disorders of neurohypophysis
Malig neopl kidney,Mal neo lymph intra-abd,Hemorrhage complic proc,Convulsions NEC,Acute pericarditis NOS,Protein-cal malnutr NOS,Hypercalcemia,Neurohypophysis dis NEC
Admission Date:  [**2146-3-3**]       Discharge Date:  [**2146-3-14**]

Date of Birth:   [**2104-5-9**]       Sex:  M

Service:  UROLOGY

CHIEF COMPLAINT:  Electrolyte abnormalities and change in
mental status.

HISTORY OF PRESENT ILLNESS:  A 41-year-old male, with a
history of renal cell cancer diagnosed in [**2145-11-1**], who
presented with seizure and found to have METS to the brain.
The patient had resection of the brain METS with residual
left hemiparesis.  He is status post stereotactic
radiosurgery on [**2145-12-15**] which was complicated by PTH
RP causing hypercalcemia, SIADH, and anxiety with recent
admission to [**Hospital1 18**] on [**2146-2-3**] with mental status
changes and hypercalcemia.  The patient now presented to the
clinic with electrolyte abnormalities.  On recent admission,
the patient's hypercalcemia was treated with hydration,
calcitonin and 90 mg of pamidronate on [**2146-2-18**] with
good effect.  The patient has a history of hypocalcemia after
receiving Zometa in the past, and his electrolytes were
carefully monitored.  The patient was started on Tums when
the patient's calcium fell below 9.

Since discharge, on [**2146-2-25**], the patient's labs had
been checked daily, and the patient has been on lasix prn and
Neutra-Phos, salt tablets, and Tums as needed.  Starting
[**2-28**], calcium was elevated, and the patient was told to
restart calcitonin.  Subcu injections were [**Last Name (LF) 16535**], [**First Name3 (LF) **]
the patient was taking nasal spray.  Despite taking the
calcitonin, the patient's calcium continued to increase, and
was elevated to 11.7 with albumin of 2.2, with corrected
calcium of approximately 13.2.

The patient's girlfriend reported that for the past one to
two days, the patient had had increasing lack of response to
questions, and decreased strength on the left side,
decreasing appetite, and increasing lethargy.  The patient
has no history of falls, and has normal bowel movements.  The
patient has been complaining of some left-sided abdominal
pain with positive low-grade fevers since discharge to
approximately 99??????.  The patient's girlfriend was concerned
and called Dr. [**Last Name (STitle) 1860**] who arranged for inpatient admission.

PAST MEDICAL HISTORY:
1. Renal cell carcinoma diagnosed in [**2145-11-1**] with brain
METS, status post right frontal craniotomy in [**2145-11-1**],
SRS in [**2145-12-2**], which initially presented with seizures
and brain METS were found.
2. Hyponatremia.
3. SIADH.
4. Hypercalcemia.
5. PTH RP from RCC.
6. History of multiple UTIs and anxiety.

ALLERGIES:  No known drug allergies.

MEDICATIONS ON ADMISSION:
1. Sodium chloride 2 gm po tid.
2. Levetiracetam 1 gm po bid.
3. Protonix 40 mg po qd.
4. Nortriptyline 100 mg po hs.
5. Epogen 40,000 U subcu q Tuesday.
6. Dexamethasone 0.5 mg po qod for 7 days--last dose on [**2146-3-3**].
7. Calcitonin 200 U nasal spray qd.
8. Clonazepam 0.5 mg po q hs.
9. Colace 100 mg po bid prn.
10.Senna 1 tab po bid prn.
11.Bisacodyl 10 mg po qd prn.
12.Tylenol prn.
13.Insulin subcu--the patient has not needed it for the past
5 days.

SOCIAL HISTORY:  The patient lives with his girlfriend and
works as a paralegal.  The patient denies alcohol, tobacco,
or IV drug use.

FAMILY HISTORY:  No family history of renal cell cancer.

PHYSICAL EXAM:  Temperature 98.2, blood pressure 105/64,
heart rate 108, respiration rate 16, satting 97% on room air.
The patient was generally a pleasant gentleman appearing his
stated age, in no apparent distress, and slow to respond to
questions.  The patient's sclerae were anicteric, and mucous
membranes were dry.  Examination of the heart showed that the
patient was tachycardic with regular rhythm.  S1 and S2 were
heard with no murmurs.  The patient had decreasing breath
sounds and crackles in bilateral bases.  Examination of the
back showed no CVA tenderness.  No lumbar spinal tenderness.
The patient's abdomen was soft with positive bowel sounds.
No HSM.  Mild left-sided tenderness.  Mild left-sided rib
tenderness.  Examination of the extremities revealed that the
patient had no edema and good pulses.

Neuro exam revealed that the patient was oriented x 3.
Increasing lack of response to questions.  The patient
followed commands.  Pupils equal, round and reactive to
light.  Extraocular movements were intact.  Smile was
decreased on the left side. Tongue was midline.  Strength:
In upper extremities finger grip was [**4-6**] on the right, [**3-7**] on
the left, [**3-7**] shoulder shrug on the left.  Left lower
extremity - hip flexor [**3-7**], right was [**3-7**], and [**4-6**] right
dorsi plantar flexion and toe extension, and [**3-7**] left dorsi
plantar flexion and toe extension.

LABS:  Sodium 121, calcium 11.7, albumin 2.2.

HOSPITAL COURSE:  The patient was admitted to the medicine
service with change in mental status most likely due to
hypercalcemia and possible hyponatremia.  The patient's
mental status was watched by correcting the electrolyte
abnormalities.  The patient also was scheduled for
nephrectomy.  The patient's anemia was secondary most likely
to chronic disease and renal cell cancer.  The patient was
continued on Epogen.  Neuro exam showed residual left
hemiparesis from resection.  The patient has steroid induced
diabetes and was continued on fingersticks.  The patient was
put on a diabetic diet with IV fluids, and was continued to
be monitored.

On hospital day #2, the patient was put on 3% saline for
hyponatremia which the patient tolerated without any
difficulty.  The patient continued to complain of some dry
throat.  He was afebrile with stable blood pressure.  Heart
rates ran from 99-108, and taking in 260 cc PO and made 500
cc in urine.  The patient was continued to be monitored.  He
was on fluid restriction of 1,500 cc/D.  On hospital day #2,
both endocrine and renal services followed the patient,
managing electrolyte abnormalities.

On hospital #3, the patient had a right IJ placed without any
complications.  The patient remained afebrile, but continued
to be tachy at 109, otherwise doing well.  The patient's
sodium improved to 128 on treatment, and the patient was
otherwise stable.  The steroid was stopped, and the patient
was put on a house diet.  Also, the insulin was stopped.

On hospital day #4, the patient received 1 unit of blood for
a hematocrit of 25.4, and the patient's post-transfusion
hematocrit was 28.1.  The patient did not sleep well the
prior night and was more lethargic.  He remained afebrile
with stable vitals except for a heart rate at 113.  The
patient's abdomen was somewhat distended but nontender.  The
patient was preopped for the OR and was taken to the OR and
underwent a left nephrectomy for left renal mass.  The
patient was then admitted to Neuro SICU for management.  The
patient was intubated overnight and was continued on Ancef
for antibiotic.  Labs were checked to monitor the
electrolytes.

On postop day #1, the patient was continued on seizure meds
and propofol was weaned to extubate the patient.  The
patient's hemodynamics were stable, but still looked dry.
The patient's was weaned and extubated.  Chest tube was
removed.  The patient continued to be NPO with NG tube which
was removed.  The patient had decreased urine output
overnight.  The patient's IV fluid was changed to D5 1/2NS.
The patient remained afebrile, and Ancef was stopped.

On postop day #2, the patient had no complaints of pain.  He
had a soft, nontender abdomen with no erythema around the
incision.  The patient was continued on dilaudid for pain
management.  Hemodynamically, the patient was stable.  He was
started on sips.  The patient was continued on Epogen.  The
patient's A-line was removed, and the Foley was continued.

On postop day #3, the patient remained afebrile with stable
vital signs.  The patient was advanced to clear liquids and
continued on TPN.  The patient's labs were checked, and
sodium remained stable at 125 and calcium at 7.7.

On postop day #3, the patient was seen by neuro oncology who
recommended obtaining an MRI in [**2146-6-2**], and continue
current management.  On postop day #4, the patient remained
afebrile with stable vital signs.  The patient removed his
central line overnight which was replaced.  The patient was
continued on sodium tablets for treatment of hyponatremia.
On postop day #5, the patient was changed to PO pain meds.
The patient was put on fluid restriction and continued sodium
tablets for SIADH.

On postop day #6, the patient had emesis overnight, but the
nausea had improved with Zofran.  The patient had no
appetite.  The patient remained afebrile with tachys to 119,
otherwise with stable vital signs.  The patient was put on IV
fluids and continued on sodium tablets.  Magnesium was
repleted.  On postop day #7, the patient had no complaints of
nausea, vomiting, fever, chills.  The patient stated that he
had had flatus.  He remained afebrile with heart rate still
at 104 with the rest of the vitals remaining stable.  The
patient was alert and interactive.  Abdomen was soft,
nontender, nondistended.  The wound had no erythema.  The
patient's sodium was stable at 129.  Free calcium was stable
at 119.  Otherwise, the patient was doing well.

The patient was seen by physical therapy and walked with
assistance.  The patient was tolerating diet without any
difficulty, had had flatus, and was not nauseous or vomiting
after taking the regular diet.  The patient was thus
discharged.

DISCHARGE STATUS:  Good.

DISCHARGE DIAGNOSES:
1. Status post left nephrectomy.
2. Papillary renal cell cancer,
3. Metastatic renal cell cancer to brain, status post
craniotomy.
4. Diabetes induced by steroid therapy.
5. Syndrome of inappropriate antidiuretic hormone.
6. Hyponatremia.

DISCHARGE MEDICATIONS:
1. Epogen 10,000 U subcu 3 x week, Monday, Wednesday,
Friday.
2. Nortriptyline 100 mg po q hs.
3. Clonazepam 0.5 mg po q hs.
4. Bisacodyl 10 mg po qd prn.
5. Levetiracetam 750 mg po bid.
6. Percocet 1-2 tabs q 4-6 h prn pain.
7. Protonix 40 mg po qd.
8. Sodium chloride 1 gm po tid.
9. Tylenol 325 mg po 1-2 tabs prn pain.
10.

FOLLOW-UP:
1. Please follow-up with Dr. [**Last Name (STitle) 4229**] in [**1-4**] weeks; please call
for follow-up appointment.
2. Please follow-up with Dr. [**Last Name (STitle) 1860**], nephrologist, in [**1-4**] weeks
at [**Hospital 2793**] Clinic; please call for follow-up appointment.
3. Please follow-up with Dr. [**First Name (STitle) **], endocrinologist, as needed
per recommendation by renal service.

DISCHARGE INSTRUCTIONS:  Please have labs checked three times
a week.  Please have chem-10 and ionized calcium checked.
Please have these results faxed to Dr. [**Last Name (STitle) 1860**] at ([**Telephone/Fax (1) 16536**].




                            [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 8916**]

Dictated By:[**Last Name (NamePattern1) 3118**]
MEDQUIST36

D:  [**2146-3-14**]  12:46
T:  [**2146-3-14**]  14:25
JOB#:  [**Job Number 16537**]


Name:  [**Known lastname 2596**], [**Known firstname **]                     Unit No:  [**Numeric Identifier 2597**]

Admission Date:  [**2146-3-3**]     Discharge Date:  [**2146-3-16**]

Date of Birth:   [**2104-5-9**]     Sex:  M

Service:  UROLOGY

ADDENDUM:  Since the last dictation the patient developed
chest pain starting below the sternum that was dull in
quality that was 6 out of 10 in intensity.  The initial
electrocardiogram did not show any significant signs of
ischemia, however, follow up electrocardiogram showed a
diffuse ST changes and pericarditis.  The patient states he
has had a history of pericarditis in the past and that the
pain was similar to that episode.  The patient was started on
Motrin 800 mg three times a day to continue for a maximum of
ten days or three days after the resolution of his symptoms.
The patient also had an echocardiogram, which showed no signs
of pericardial effusion and good EF greater then 55%.  The
patient also had a head MRI to evaluate for increasing
weakness in the left side.  The MRI showed that there was no
significant change compared to the prior MRI and the findings
were consistent with postoperative changes and there was no
new enhancing lesions.  Thus on postop day number nine the
patient was able to ambulate without difficulty and was
having bowel movements, tolerating po medications without
difficulties and was discharged to [**Hospital1 **] for further
continual laboratory checks request by the renal service and
to continue to monitor his resolution of pericarditis and
symptoms of chest pain.

New medications added to the previously dictated medication
list are Ibuprofen 800 mg po t.i.d. for a maximum of ten days
or three days after the resolution of the symptoms of chest
pain.

In addition to the discharge instructions, please have
laboratories checked every day of chem 10, ionized calcium
and CBC until Friday and every other day until follow up with
Dr. [**Last Name (STitle) 2164**].  Please fax these results to [**Telephone/Fax (1) 2598**].  Please
leave the Steri-Strips on until they fall off.  The patient
may shower.  No baths.  No driving.






                          [**Doctor First Name **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 2599**]

Dictated By:[**Last Name (NamePattern1) 360**]

MEDQUIST36

D:  [**2146-3-16**]  10:41
T:  [**2146-3-16**]  10:40
JOB#:  [**Job Number 2600**]
{'Malignant neoplasm of kidney, except pelvis,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Hemorrhage complicating a procedure,Other convulsions,Acute pericarditis, unspecified,Unspecified protein-calorie malnutrition,Hypercalcemia,Other disorders of neurohypophysis'}


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: Electrolyte abnormalities and change in
mental status.

PRESENT ILLNESS: A 41-year-old male, with a
history of renal cell cancer diagnosed in [**2145-11-1**], who
presented with seizure and found to have METS to the brain.
The patient had resection of the brain METS with residual
left hemiparesis.  He is status post stereotactic
radiosurgery on [**2145-12-15**] which was complicated by PTH
RP causing hypercalcemia, SIADH, and anxiety with recent
admission to [**Hospital1 18**] on [**2146-2-3**] with mental status
changes and hypercalcemia.  The patient now presented to the
clinic with electrolyte abnormalities.  On recent admission,
the patient's hypercalcemia was treated with hydration,
calcitonin and 90 mg of pamidronate on [**2146-2-18**] with
good effect.  The patient has a history of hypocalcemia after
receiving Zometa in the past, and his electrolytes were
carefully monitored.  The patient was started on Tums when
the patient's calcium fell below 9.

MEDICAL HISTORY: 1. Renal cell carcinoma diagnosed in [**2145-11-1**] with brain
METS, status post right frontal craniotomy in [**2145-11-1**],
SRS in [**2145-12-2**], which initially presented with seizures
and brain METS were found.
2. Hyponatremia.
3. SIADH.
4. Hypercalcemia.
5. PTH RP from RCC.
6. History of multiple UTIs and anxiety.

MEDICATION ON ADMISSION: 1. Sodium chloride 2 gm po tid.
2. Levetiracetam 1 gm po bid.
3. Protonix 40 mg po qd.
4. Nortriptyline 100 mg po hs.
5. Epogen 40,000 U subcu q Tuesday.
6. Dexamethasone 0.5 mg po qod for 7 days--last dose on [**2146-3-3**].
7. Calcitonin 200 U nasal spray qd.
8. Clonazepam 0.5 mg po q hs.
9. Colace 100 mg po bid prn.
10.Senna 1 tab po bid prn.
11.Bisacodyl 10 mg po qd prn.
12.Tylenol prn.
13.Insulin subcu--the patient has not needed it for the past
5 days.

ALLERGIES: No known drug allergies.

PHYSICAL EXAM: Temperature 98.2, blood pressure 105/64,
heart rate 108, respiration rate 16, satting 97% on room air.
The patient was generally a pleasant gentleman appearing his
stated age, in no apparent distress, and slow to respond to
questions.  The patient's sclerae were anicteric, and mucous
membranes were dry.  Examination of the heart showed that the
patient was tachycardic with regular rhythm.  S1 and S2 were
heard with no murmurs.  The patient had decreasing breath
sounds and crackles in bilateral bases.  Examination of the
back showed no CVA tenderness.  No lumbar spinal tenderness.
The patient's abdomen was soft with positive bowel sounds.
No HSM.  Mild left-sided tenderness.  Mild left-sided rib
tenderness.  Examination of the extremities revealed that the
patient had no edema and good pulses.

FAMILY HISTORY: No family history of renal cell cancer.

SOCIAL HISTORY: The patient lives with his girlfriend and
works as a paralegal.  The patient denies alcohol, tobacco,
or IV drug use. 

### Response:
{'Malignant neoplasm of kidney, except pelvis,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Hemorrhage complicating a procedure,Other convulsions,Acute pericarditis, unspecified,Unspecified protein-calorie malnutrition,Hypercalcemia,Other disorders of neurohypophysis'}
