CHIEF COMPLAINT: MS change.

PRESENT ILLNESS: The patient is a 76 year old woman with a history of high blood
pressure and cholesterol now presenting on transfer from
[**Hospital3 **] with decreased responsiveness and a question
of mass on head ct.  She is unable to give a history, so the
story is gathered from family members (sons) at her bedside.
Apparently, she has been in her usual state of health--she had
dinner last night with family members and was
talking/interacting normally.  This morning, she awoke, called a
family member and said she felt dizzy and couldn't breath.  She
called for an ambulance herself.  When EMS arrived, she was not
talking and appeared "dazed and confused".  She was taken to
[**Hospital1 2436**] ED. The son arrived shortly thereafter and found her
starring straight ahead, not responding to questions, and
"frothing at the mouth".  The ED staff was concerned for
seizures and gave her 4 mg of ativan and loaded her with
dilantin.  She was intubated for airway protection and sedated
with propofol.  They obtained a head ct which showed a left
parietal hypodensity with some "vasogenic edema".  She was
transferred to [**Hospital1 18**] ED for further management.

MEDICAL HISTORY: -high blood pressure
-high cholesterol
-depression
-fibromyalgia
-constipation
-asthma
-athritis
-glaucoma
-recovering alcoholic

MEDICATION ON ADMISSION: -ibuprofen
-norvasc 10 mg qd
-zoloft  150 mg qd
-zyrtec  100 mg qd
-lipitor  20 mg qd
-flexeril  10 mg qd
-risperidol 0.1 mg qhs for sleep
-quinine 260 mg qhs

ALLERGIES: Lisinopril / Penicillins / Haldol

PHYSICAL EXAM: Vitals:  98.6  95  200/123  18
General: older woman, lying intubated
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  non-tender, non-distended, bowel sounds present
Ext: warm, no edema
.
Neurologic Examination at admission (sedated on propofol): no
response to loud voice, moves arms toward sternal rub, not
following commands to squeeze hands or open eyes; no blink to
threat, pupils sluggishly reactive but equal 2 to 1 mm; +dolls
eye, +corneal, +gag reflex; symmetric tone in arms and legs,
some spontaneous mvt; withdraws to painful stimuli x4, no
obvious asymmetry; reflexes 2 in arms, 2 at knees, 1 at ankles,
toes downgoing b/l.
.
Exam following surgery:
MS: AAOx3, language fluent, dysarthric, repetition intact,
naming poor for low frequency objects. Following simple
commands.
CN: intact
M: no drift, FE weak, otherwise UE full strength bilaterally;
L-foot drop (likely peripheral but MRI-Lspine being scheduled);
IP weak (R>L), Q intact, H intact.
S: grossly intact to LT, cold, vibration
C: intact

FAMILY HISTORY: -no h/o seizures or strokes in the family

SOCIAL HISTORY: -lives by self, drives and is completely independent
-no smoking or alcohol use
-was primarily a housewife
Malignant neoplasm of parietal lobe,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Pneumonia, organism unspecified,Unspecified essential hypertension,Other acquired deformities of ankle and foot,Myalgia and myositis, unspecified,Other late effects of cerebrovascular disease, dysphagia,Other and unspecified alcohol dependence, in remission
Mal neo parietal lobe,Acute respiratry failure,Hyperosmolality,Pneumonia, organism NOS,Hypertension NOS,Acq ankle-foot def NEC,Myalgia and myositis NOS,Late ef CV dis dysphagia,Alcoh dep NEC/NOS-remiss
Admission Date:  [**2103-6-14**]              Discharge Date:   [**2103-6-26**]

Date of Birth:  [**2026-12-12**]             Sex:   F

Service: NEUROLOGY

Allergies:
Lisinopril / Penicillins / Haldol

Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
MS change.

Major Surgical or Invasive Procedure:
1.  Left sided craniotomy for resection.
2.  Intraoperative image guidance.
3.  Microscopic dissection.
4.  Duraplasty.

History of Present Illness:
The patient is a 76 year old woman with a history of high blood
pressure and cholesterol now presenting on transfer from
[**Hospital3 **] with decreased responsiveness and a question
of mass on head ct.  She is unable to give a history, so the
story is gathered from family members (sons) at her bedside.
Apparently, she has been in her usual state of health--she had
dinner last night with family members and was
talking/interacting normally.  This morning, she awoke, called a
family member and said she felt dizzy and couldn't breath.  She
called for an ambulance herself.  When EMS arrived, she was not
talking and appeared "dazed and confused".  She was taken to
[**Hospital1 2436**] ED. The son arrived shortly thereafter and found her
starring straight ahead, not responding to questions, and
"frothing at the mouth".  The ED staff was concerned for
seizures and gave her 4 mg of ativan and loaded her with
dilantin.  She was intubated for airway protection and sedated
with propofol.  They obtained a head ct which showed a left
parietal hypodensity with some "vasogenic edema".  She was
transferred to [**Hospital1 18**] ED for further management.

Past Medical History:
-high blood pressure
-high cholesterol
-depression
-fibromyalgia
-constipation
-asthma
-athritis
-glaucoma
-recovering alcoholic

Social History:
-lives by self, drives and is completely independent
-no smoking or alcohol use
-was primarily a housewife

Family History:
-no h/o seizures or strokes in the family

Physical Exam:
Vitals:  98.6  95  200/123  18
General: older woman, lying intubated
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  non-tender, non-distended, bowel sounds present
Ext: warm, no edema
.
Neurologic Examination at admission (sedated on propofol): no
response to loud voice, moves arms toward sternal rub, not
following commands to squeeze hands or open eyes; no blink to
threat, pupils sluggishly reactive but equal 2 to 1 mm; +dolls
eye, +corneal, +gag reflex; symmetric tone in arms and legs,
some spontaneous mvt; withdraws to painful stimuli x4, no
obvious asymmetry; reflexes 2 in arms, 2 at knees, 1 at ankles,
toes downgoing b/l.
.
Exam following surgery:
MS: AAOx3, language fluent, dysarthric, repetition intact,
naming poor for low frequency objects. Following simple
commands.
CN: intact
M: no drift, FE weak, otherwise UE full strength bilaterally;
L-foot drop (likely peripheral but MRI-Lspine being scheduled);
IP weak (R>L), Q intact, H intact.
S: grossly intact to LT, cold, vibration
C: intact


Pertinent Results:
[**2103-6-14**] 08:57PM BLOOD WBC-11.9* RBC-4.44 Hgb-13.4 Hct-38.1
MCV-86 MCH-30.3 MCHC-35.2* RDW-13.3 Plt Ct-257
[**2103-6-25**] 10:15AM BLOOD WBC-7.9 RBC-3.05* Hgb-9.4* Hct-27.7*
MCV-91 MCH-30.9 MCHC-34.0 RDW-13.7 Plt Ct-201
.
[**2103-6-14**] 08:57PM BLOOD PT-11.5 PTT-33.7 INR(PT)-1.0
[**2103-6-14**] 08:57PM BLOOD Plt Smr-NORMAL Plt Ct-257
[**2103-6-15**] 02:19AM BLOOD PT-11.8 PTT-32.0 INR(PT)-1.0
[**2103-6-25**] 10:15AM BLOOD Plt Ct-201
.
[**2103-6-14**] 08:57PM BLOOD Glucose-180* UreaN-16 Creat-1.3* Na-139
K-3.8 Cl-104 HCO3-23 AnGap-16
[**2103-6-25**] 10:15AM BLOOD Glucose-122* UreaN-13 Creat-0.8 Na-143
K-4.1 Cl-114* HCO3-19* AnGap-14
.
[**2103-6-16**] 03:02AM BLOOD ALT-14 AST-16 LD(LDH)-236 AlkPhos-104
Amylase-69 TotBili-0.4
[**2103-6-19**] 11:30AM BLOOD CK(CPK)-1504*
[**2103-6-19**] 05:55PM BLOOD CK(CPK)-1350*
[**2103-6-19**] 11:30AM BLOOD CK-MB-15* MB Indx-1.0 cTropnT-<0.01
[**2103-6-19**] 05:55PM BLOOD CK-MB-14* MB Indx-1.0 cTropnT-<0.01
.
[**2103-6-16**] 03:02AM BLOOD Triglyc-223* HDL-52 CHOL/HD-3.4
LDLcalc-79
[**2103-6-16**] 03:02AM BLOOD TSH-0.60
.
[**2103-6-15**] 02:19AM BLOOD Phenyto-6.3* [**2103-6-15**] 12:30PM BLOOD
Phenyto-8.1*
[**2103-6-25**] 10:15AM BLOOD Phenyto-6.1*
*  *  *  *
Head CT w/contrast [**2103-6-14**]:
FINDINGS:  In the posterior left frontal lobe, at the [**Doctor Last Name 352**]-white
matter
junction, there is a 2 cm rim mass with relatively thick
enhancing rim and
extensive surrounding vasogenic edema. There is no evidence for
acute
hemorrhage in the mass or elsewhere.  The overlying left frontal
sulci are
compressed secondary to edema, but there is no significant shift
of midline structures, and only minimal mass effect upon the
ipsilateral lateral ventricle.  There is no parenchymal or
meningeal enhancement elsewhere. The major vessels enhance
normally. There is no evidence of bone destructive lesion.
Mastoid air cells are well pneumatized. There is mucosal
thickening of the right maxillary sinus.
IMPRESSION:  2 cm rim-enhancing posterior left frontal lobe mass
with
surrounding vasogenic edema.
.
Torso CT [**2103-6-15**]:
CT CHEST:  Endotracheal and nasogastric tubes were noted.  There
is no
axillary, mediastinal, or hilar lymphadenopathy.  Aortic
calcifications are noted.  The heart, pericardium, and great
vessels are otherwise within normal limits.  There are sub
segmental bilateral lower lobe opacities.
CT ABDOMEN:  The liver, gallbladder, pancreas, spleen, adrenal
glands,
stomach, and bowel loops are within normal limits.  Tiny low
attenuation focus in the left kidney may represent a cyst but is
too small to be fully
characterized.  The kidneys are otherwise unremarkable.  There
is no free air or free fluid.  No mesenteric or retroperitoneal
lymphadenopathy is
identified.
CT PELVIS:  Foley catheter is noted in the bladder.  The uterus,
adnexa, and rectum are unremarkable.  Colonic diverticula are
noted without evidence of diverticulitis, most prominent in the
sigmoid colon.  There is no free fluid and no pelvic or inguinal
lymphadenopathy.
BONE WINDOWS:  There are no suspicious lytic or sclerotic
osseous lesions.
IMPRESSION:
1.  Bilateral lower lobe opacities more likely to represent a
small amount of aspiration than atelectasis.
2.  Diverticulosis without evidence of diverticulitis.
3.  No abnormalities identified as a potential source for the
potential cerebral abscess.
.
EEG [**2103-6-15**]:
IMPRESSION: EEG most consistent with a moderate encephalopathy
of toxic, metabolic, or anoxic etiology. The presence of
propofol suggests that this may be contributing to the overall
pattern. No evidence of ongoing seizures is seen at the time of
the recording.
.
Head MR/MRA [**2103-6-15**]:
FINDINGS:  BRAIN MRI:
The diffusion images demonstrate no evidence of acute infarct.
There is an area of brain edema seen in the left posterior
frontal lobe with rim enhancing approximately 2-cm lesion in the
subcortical region of the left frontal lobe. There are no other
foci of abnormal enhancement seen.  Mild mass effect is seen on
the adjacent sulci and the left lateral ventricle without
midline shift.  No definite other areas of abnormal enhancement
are seen.  There is no evidence of slow diffusion seen within
the center of this lesion. The ventricles are normal in size,
and there is no midline shift or hydrocephalus seen.  Mucosal
thickening is seen in the right maxillary sinus.
IMPRESSION:  Rim-enhancing left posterior frontal lobe
subcortical lesion with edema in the surrounding brain.  The
most likely diagnosis is metastatic disease.  In absence of
central restricted diffusion, abscess appears less likely.  The
location also is less favorable for primary brain neoplasm.
MRA OF THE HEAD:
The head MRA demonstrates normal flow signal within the arteries
of anterior and posterior circulation.
IMPRESSION:  Normal MRA of the head.
.
Head CT [**2103-6-18**]:
FINDINGS:  There is no  interval change in the extent of
vasogenic edema
involving the left frontal lobe compared to [**2103-6-14**].  There
is minimal
mass effect upon the ipsilateral lateral ventricle with
effacement of the
overlying left frontal sulci secondary to edema.  There is no
evidence for
intracranial hemorrhage, shift of normally midline structures or

hydrocephalus.  Polypoid mucosal thickening is present in the
right maxillary sinus.  The remainder of the visualized
paranasal sinuses and mastoid air cells are well aerated.  There
is no evidence of bone destructive lesion.
IMPRESSION:  No  interval change in extent of left frontal lobe
vasogenic
edema.  No evidence of intracranial hemorrhage or shift of
normally midline structures.
.
EEG [**2103-6-19**]:
IMPRESSION: This is a markedly abnormal portable EEG due to the
presence of periodic lateralized epileptiform discharges (PLEDs)
over the entire left hemisphere and due to a slow and
disorganized background. The second abnormality suggests deep,
midline subcortical dysfunction and is consistent with a mild
encephalopathy. The first abnormality represents epileptiform
discharges. There was no continuous seizure activity recorded.
.
Bilat. lower extremity venous ultrasound [**2103-6-19**]:
LOWER EXTREMITY VENOUS ULTRASOUND (BILATERAL):  Grayscale,
color, and Doppler images of the right and left common femoral,
superficial femoral, and popliteal veins were obtained.  Normal
flow, compressibly, augmentation, and waveforms are
demonstrated.  No intraluminal thrombus is identified.
IMPRESSION: No deep venous thrombosis in right or left common
femoral,
superficial femoral, or popliteal veins.
.
Head MRI [**2103-6-20**]:
IMPRESSION:  Enhancing left posterior frontal lobe mass with
surrounding edema for stereotactic localization prior to
surgery.
.
Head CT [**2103-6-22**]:
FINDINGS:  Patient is status post resection of a left parietal
mass.  There is no interval change in the extent of vasogenic
edema involving the left frontal lobe compared to [**2103-6-18**].
There is a minimal amount of air and hemorrhage at the resection
site.  There is mild mass effect on the adjacent lateral
ventricle which is unchanged compared to the prior study.  No
other sites of intra- or extra-axial hemorrhage are identified.
Basal cisterns are not effaced.  Osseous windows demonstrate a
craniotomy defect in the left frontoparietal region.  There is
mild mucosal thickening within the maxillary sinuses.  The
mastoid air cells are well aerated.
IMPRESSION:  Status post resection of left parietal mass with
expected
postoperative changes as described above.  No interval change in
the extent of left frontal lobe vasogenic edema or mild mass
effect on the lateral ventricle.
.
Head MRI [**2103-6-24**]:
FINDINGS:  Pre-contrast study reveals T1 hyperintensity within
the left
temporal tumor resection bed as well as along the contiguous
convexity
surface.  Some of this signal abnormality also manifests
susceptibility,
primarily along its rim.  Presumably, the findings are
consistent with
postoperative hemorrhage, with the more superficial T1
hyperintensity,
possibly relating to surgical material (? Surgicel) placed along
the inner
surface of the craniotomy flap. Following contrast infusion,
there is minimal residual enhancement, although somewhat
irregular in contour, around the margins of the resection site.
This enhancement, while potentially postoperative, may also
represent residual tumor and obviously will require continuing
followup examinations to determine which diagnosis is correct.
There is persistent extensive surrounding edema, with mild
compression of the left lateral ventricle.  There is no
subfalcine herniation and there is no overt change in
ventricular size.
CONCLUSION:  Postoperative study, with findings as noted above.


Brief Hospital Course:
The patient is a 76 year old woman with a history of high blood
pressure and cholesterol now presenting with decreased
responsivenss. Imaging shows rim enhancing lesion L-post frontal
lobe with vasogenic edema. She was intubated and sedated when
first seen in the ED. The differential for her lesion included a
neoplasm, infection, or stroke (would be atypical). A head CT
w/contrast performed in the ED showed that the mass was
contrast-enhancing which could be suggestive for tumor (primary
or metastatic) vs abscess.
.
ICU course
Patient was admitted to SICU. While intubated, she underwent a
head MRI which showed rim-enhancing left posterior frontal lobe
subcortical lesion with edema in the surrounding brain, and a
torso CT, part of a metastatic work up. The latter was negative
and showed only bilateral lower lobe opacities more likely to
represent a small amount of aspiration than atelectasis. An EEG
showed no seizure activity.
The patient was weaned off the ventilator and extubated on
hospitalization day (HD) 3. She was initially agitated and
received Haldol in the ICU. She reacted very strongly to this
medication as she remained somnolent and difficult to arouse for
several days. Initially concerned by the large amount of
perilesionnal brain swelling, she was kept "dry" and received no
IV fluids other than with her medication. She developed a free
water deficit as manifested by hypernatremia, hyperchloremia and
elevated BUN. Her urine output remained stable. Since she was
slowly progressing from a neuro standpoint, she was transferred
to the neuro stepdown unit where she was weaned off the Haldol
and rehydrated.

Floor course:
After transfer to the floor, her neurological status could be
better evaluated: she was alert, awake, oriented, able to speak,
no difficulty understanding or repeating words; she had no
pronator drift but a mild weakness (4+) of the finger extensors
on the R; she also appeared to have a deep perineal nerve palsy
(foot drop) on the left which was treated conservatively.
On HD 8, the patient was taken to the OR by neurosurgery in
order to biopsy and possibly resect the left fronto-parietal
mass. Frozen sections revealed a possible glioblastoma. The
lesion was resected to the extent of its visible limit. The post
operative course was uneventful. A head CT showed normal post
operative changes, no acute unexpected bleeding. The patient was
transferred from the PACU to the floor on POD 1. A post op MRI
w/gadolinium showed some postoperative blood and minimal
residual contrast enhancement, although somewhat irregular in
contour, around the margins of the resection site.  This
enhancement, while potentially postoperative, may also represent
residual tumor. From a neurological standpoint, the patient is
alert, oriented, has some mild word finding difficulties and
makes paraphasic errors. Her speech is dysarthric. Her
understanding and repetition are intact. From a motor
standpoint, she is unchanged compared to preop.
.
She will continue to wear a brace for her L-foot drop. An MRI of
the L-spine with gad is being scheduled at outpatient and will
be followed up at her next [**Hospital **] clinic visit.
.
She needs to continue on decadron that is being tapered. She
should take 3 q 8 hrs and taper per instructions to a goal of
2mg [**Hospital1 **] (until seen at neurosurg. clinic).
.
For seizure prophylaxis, she should continue Dilantin 200mg [**Hospital1 **]
until her Keppra dosing in at 1000mg [**Hospital1 **]. At that point,
dilantin should be weaned off in [**5-16**] days. The patient was
started on Keppra, currently taking [**Telephone/Fax (1) 36883**]. The goal is 1500mg
[**Hospital1 **]. Please increase the dose by 500mg every 5 days until she is
at the goal. She had no clinical seizures after her surgery.
.
CV:
For hypertension she was put on the following regimen:
metoprolol 75mg PO TID, amlodipine 10mg PO daily, lisinopril
10mg PO daily. She received hydralazine 10mg iv PRN. She ruled
out for MI per serial cardiac enzymes. An ECG showed NSR, no
strain.
.
Pulm:
The patient was extubated shortly after admission. CXR showed
evolving consolidation, with improvement on serial CXR. She had
a course of levaquin surrounding the brain surgery. Blood
cultures remained negative and she remained afebrile.
.
Anemia:
The patient is anemic (Hct at d/c 29). Part of her Hct drop can
be explained by the surgery an dilutionary effects of IVF as
well as repeat phlebotomy. Guiac stools are pending. If her Hct
does not improved, further workup (including GI workup) is
indicated. Guiac stools was negative on the day of discharge.
.
Depression:
Prior to admission the patient was taking 50mg Zoloft daily.
Prior to discharge this medications was resumed at a dose of
50mg daily. Please titrate the dose up slowly until 150mg daily.
.
Prophylaxis includes protonix, tylenol, hep sc, and a bowel
regimen.
.
FEN:
A speech and swallow evaluation indicated that she was safe for
a diet consisting of soft solids and nectar-thick liquids.
Speech-Language therapy was recommended at Rehab.
Upon transfer from the unit the patient had a hypernatremia that
was corrected with free H2O boluses through her NGT. Her Na has
remained stable.
.
The Pt was seen by PT and OT and will need their continued input
at rehab. Speech therapy is also recommended.


Medications on Admission:
-ibuprofen
-norvasc 10 mg qd
-zoloft  150 mg qd
-zyrtec  100 mg qd
-lipitor  20 mg qd
-flexeril  10 mg qd
-risperidol 0.1 mg qhs for sleep
-quinine 260 mg qhs


Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
2. Albuterol Sulfate 0.083 % Solution Sig: [**2-12**]  Inhalation Q6H
(every 6 hours) as needed.
3. Ipratropium Bromide 0.02 % Solution Sig: [**2-12**]  Inhalation Q6H
(every 6 hours) as needed.
4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for pain, temp > 100.5.
5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical  QID
(4 times a day) as needed.
6. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.
7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection [**Hospital1 **] (2 times a day): until mobile.
8. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID
(4 times a day) as needed for thrush.
11. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

14. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO
TID (3 times a day).
15. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): please increase to 500mg am/1000mg pm today; then
increase with 500mg every 5th day until she is at 1500mg [**Hospital1 **].
16. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
17. Dexamethasone 2 mg Tablet Sig: 1.5 Tablets PO Q8H (every 8
hours) for 3 doses.
18. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every
8 hours) for 3 doses.
19. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
20. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): please titrate up slowly until she is back to her old
regimen of 150mg daily.
21. HydrALAZINE HCl 10 mg IV Q4H:PRN SBP>160
22. Dilantin 100 mg Capsule Sig: Two (2) Capsule PO twice a day:
please start weaning off in 5 days once her keppra dosing is at
1000mg [**Hospital1 **].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
1. L frontal high grade glioma (final pathology results pending)
2. seizures
3. hypertension
4. hypernatremia
5. dysphagia
6. possible pneumonia
7. anemia


Discharge Condition:
Stable.


Discharge Instructions:
Please take medications as prescribed. Follow recommendations
from speech&swallow regarding your diet.
.
Please contact us or the Emergency Department in case of any new
neurological symptom (weakness, numbness, tingling, speech
impairment, mental status change, seizure, etc), in case of
fever, or redness, swelling or drainage at the incision site, or
with any other symptom that may concern you.

Followup Instructions:
Please follow up at the [**Hospital **] clinic with Dr [**Last Name (STitle) 4253**]
[**7-2**] at 9am. Her office number is [**Telephone/Fax (1) 6574**]. An MRI of the
L-spine with gad will be scheduled as outpatient.
.
Please also schedule a follow up appointment with Dr [**Last Name (STitle) **],
neurosurgery, at 10 days. His office number is ([**Telephone/Fax (1) 88**].



Completed by:[**2103-6-26**]
{'Malignant neoplasm of parietal lobe,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Pneumonia, organism unspecified,Unspecified essential hypertension,Other acquired deformities of ankle and foot,Myalgia and myositis, unspecified,Other late effects of cerebrovascular disease, dysphagia,Other and unspecified alcohol dependence, in remission'}


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: MS change.

PRESENT ILLNESS: The patient is a 76 year old woman with a history of high blood
pressure and cholesterol now presenting on transfer from
[**Hospital3 **] with decreased responsiveness and a question
of mass on head ct.  She is unable to give a history, so the
story is gathered from family members (sons) at her bedside.
Apparently, she has been in her usual state of health--she had
dinner last night with family members and was
talking/interacting normally.  This morning, she awoke, called a
family member and said she felt dizzy and couldn't breath.  She
called for an ambulance herself.  When EMS arrived, she was not
talking and appeared "dazed and confused".  She was taken to
[**Hospital1 2436**] ED. The son arrived shortly thereafter and found her
starring straight ahead, not responding to questions, and
"frothing at the mouth".  The ED staff was concerned for
seizures and gave her 4 mg of ativan and loaded her with
dilantin.  She was intubated for airway protection and sedated
with propofol.  They obtained a head ct which showed a left
parietal hypodensity with some "vasogenic edema".  She was
transferred to [**Hospital1 18**] ED for further management.

MEDICAL HISTORY: -high blood pressure
-high cholesterol
-depression
-fibromyalgia
-constipation
-asthma
-athritis
-glaucoma
-recovering alcoholic

MEDICATION ON ADMISSION: -ibuprofen
-norvasc 10 mg qd
-zoloft  150 mg qd
-zyrtec  100 mg qd
-lipitor  20 mg qd
-flexeril  10 mg qd
-risperidol 0.1 mg qhs for sleep
-quinine 260 mg qhs

ALLERGIES: Lisinopril / Penicillins / Haldol

PHYSICAL EXAM: Vitals:  98.6  95  200/123  18
General: older woman, lying intubated
Neck: supple
Lungs: clear to auscultation
CV: regular rate and rhythm
Abdomen:  non-tender, non-distended, bowel sounds present
Ext: warm, no edema
.
Neurologic Examination at admission (sedated on propofol): no
response to loud voice, moves arms toward sternal rub, not
following commands to squeeze hands or open eyes; no blink to
threat, pupils sluggishly reactive but equal 2 to 1 mm; +dolls
eye, +corneal, +gag reflex; symmetric tone in arms and legs,
some spontaneous mvt; withdraws to painful stimuli x4, no
obvious asymmetry; reflexes 2 in arms, 2 at knees, 1 at ankles,
toes downgoing b/l.
.
Exam following surgery:
MS: AAOx3, language fluent, dysarthric, repetition intact,
naming poor for low frequency objects. Following simple
commands.
CN: intact
M: no drift, FE weak, otherwise UE full strength bilaterally;
L-foot drop (likely peripheral but MRI-Lspine being scheduled);
IP weak (R>L), Q intact, H intact.
S: grossly intact to LT, cold, vibration
C: intact

FAMILY HISTORY: -no h/o seizures or strokes in the family

SOCIAL HISTORY: -lives by self, drives and is completely independent
-no smoking or alcohol use
-was primarily a housewife 

### Response:
{'Malignant neoplasm of parietal lobe,Acute respiratory failure,Hyperosmolality and/or hypernatremia,Pneumonia, organism unspecified,Unspecified essential hypertension,Other acquired deformities of ankle and foot,Myalgia and myositis, unspecified,Other late effects of cerebrovascular disease, dysphagia,Other and unspecified alcohol dependence, in remission'}
