CHIEF COMPLAINT: change in mental status

PRESENT ILLNESS: 82 year old male with known cerebellar mass. He was imaged
at the OSH and the mass has approximately doubled in size
headache, no dizziness, no n/v, no visual changes.

MEDICAL HISTORY: 1. Asthma
2. Osteoporosis
3. Osteoarthritis
4. s/p bilateral catarect surgery

MEDICATION ON ADMISSION: Albuterol Inhaler, Colace, Advair, FoLIC Acid, Levothyroxine
Sodium, Lorazepam, Metoclopramide, Pantoprazole, Risperidone,
Trazadone

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam upon admission:
T:96.3  BP:146/78     HR:104  RR:15     O2Sats:95% RA
Gen: Patient is pleaseant, coopertive with exam and does not
appear to be in pain
HEENT: Pupils: PERRL      EOMs-intact
Neck: Very kyphotic, but no tenderness to palpation.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place.
Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with his step-son who is his only child and his HCP, his
name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr. [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His
PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an
ex-smoker, smoking up to two packs per day (not known over the
number of years). Mr. [**Known lastname 61509**] does not drink alcohol. His bedroom
is on the [**Location (un) 1773**], and he normally manages his ADLs.
Malignant neoplasm of cerebellum nos,Atrioventricular block, complete,Hemiplegia, unspecified, affecting unspecified side,Body Mass Index less than 19, adult,Hypopotassemia,Other late effects of cerebrovascular disease, dysphagia,Dysphagia, oropharyngeal phase,Anemia, unspecified,Chronic obstructive asthma, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Osteoporosis, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified acquired hypothyroidism,Personal history of tobacco use
Mal neo cerebellum NOS,Atriovent block complete,Unsp hemiplga unspf side,BMI less than 19,adult,Hypopotassemia,Late ef CV dis dysphagia,Dysphagia, oropharyngeal,Anemia NOS,Chronic obst asthma NOS,Mental disor NEC oth dis,Osteoporosis NOS,Osteoarthros NOS-unspec,Hypothyroidism NOS,History of tobacco use
Admission Date:  [**2107-12-22**]              Discharge Date:   [**2107-12-30**]

Date of Birth:  [**2025-11-13**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
change in mental status

Major Surgical or Invasive Procedure:
None


History of Present Illness:
82 year old male with known cerebellar mass. He was imaged
at the OSH and the mass has approximately doubled in size
headache, no dizziness, no n/v, no visual changes.


Past Medical History:
1. Asthma
2. Osteoporosis
3. Osteoarthritis
4. s/p bilateral catarect surgery

Social History:
Lives with his step-son who is his only child and his HCP, his
name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr. [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His
PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an
ex-smoker, smoking up to two packs per day (not known over the
number of years). Mr. [**Known lastname 61509**] does not drink alcohol. His bedroom
is on the [**Location (un) 1773**], and he normally manages his ADLs.


Family History:
non-contributory

Physical Exam:
Exam upon admission:
T:96.3  BP:146/78     HR:104  RR:15     O2Sats:95% RA
Gen: Patient is pleaseant, coopertive with exam and does not
appear to be in pain
HEENT: Pupils: PERRL      EOMs-intact
Neck: Very kyphotic, but no tenderness to palpation.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place.
Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equal round, reactive to light. 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: Hard of hearing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Strength 5/5 throughout, except [**4-16**] left AT.
No pronator pronator drift.

+dysmmetria left side. Patient unable to mirror alternating hand
movements. Slower with left heel-to-shin compared to right.

Sensation: Grossly intact to light touch bilaterally.

Toes downgoing bilaterally

Upon discharge:
Exam unchanged


Pertinent Results:
MRI [**12-22**]:
The study is partially limited by motion artifacts. Allowing
these
limitations, the previously described right cerebellar mass is
again
visualized. The mass now measures 29 x 21 mm compared to 18 x 23
mm prior,
representing interval increase in size. In pre-contrast axial T1
images,
there is a hyperintense center with hypointense surrounding.
There is evidence of interval reduction of surrounding edema,
likely resolving edema from the [**2107-10-27**] biopsy. Again seen is
enhancement in the cerebellar sulci, representing leptomeningeal
seeding from the tumor.

IMPRESSION:
1. Right cerebellar mass, with appeareance of a malignant
hemorrhagic tumor, consistent with the known biopsy finding.
Interval increase in size. Decreased surrounding parenchymal
edema.
2. Persistent evidence of leptomeningeal seeding to the right
cerebellar
sulci.

Result of video swallow evaluation [**12-27**]:
RECOMMENDATIONS:
1. The safest recommendation is for the pt to remain NPO, as no
consistencies are without aspiration.
2. However, if the pt and his HCP wish to allow him to eat
against these recommendations given that the goals of care are
now hospice related, I would suggest a diet of honey thick
liquids and pureed solids, as these will result in the least
amount of aspiration.
3. Meds crushed with puree only until discussion with pt and HCP
regarding goals.
4. Q4 oral care.

On [**12-29**]:
K 3.2

On [**12-30**]:
K 4.0


Brief Hospital Course:
The patient was adirect admit from an OSH for increased size of
his cerebellar mass. He was in the ICU until a stepdown bed
became available for him. The patient was neurologically stable
for his stay here. He was evaluated by medicine for complete
heart block. The EP team did not recommend a pacemaker due to
his prognosis. They also requested that he did not be given any
beta blockers, given his heart block. The medical team did not
recommend any follow-up with them after discharge.

Mr. [**Known lastname 61509**] was transferred to a regular floor since he was
neurologically stable and since there were no interventions for
his heart block. It was determined that he would not undergo any
neurosurgery during this hospitalization. Palliative care was
consulted who recommended longterm care placement for comfort
care. PT and OT evaluated him and agreed with the plan.
Speech/swallow did a video swallow evaluation and recommended a
modified diet for comfort.

On [**12-29**] he was ready for discharge however his potassium was
low. Due to pharmacy delays he did not receive his potassium
repletion until the afternoon and this was too late for him to
be transferred. Therefore on [**12-30**] in the morning he was
discharged.

Medications on Admission:
Albuterol Inhaler, Colace, Advair, FoLIC Acid, Levothyroxine
Sodium, Lorazepam, Metoclopramide, Pantoprazole, Risperidone,
Trazadone


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a
day).
4. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed.
5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
7. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Trazodone 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
10. Risperidone 1 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 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).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 25759**] & Rehab Center - [**Location (un) **]

Discharge Diagnosis:
Cerebellar Mass
Complete Heart Block
Anemia
Hypokalemia


Discharge Condition:
Neurologically stable


Discharge Instructions:
General Instructions/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.
??????	 If you have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
??????	If you are being sent home on steroid medication, 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.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	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
-Follow up with Dr. [**Last Name (STitle) **] in 4 weeks with a head CT. Call
[**Telephone/Fax (1) 1669**] to make an appointment.



Completed by:[**2107-12-30**]
{'Malignant neoplasm of cerebellum nos,Atrioventricular block, complete,Hemiplegia, unspecified, affecting unspecified side,Body Mass Index less than 19, adult,Hypopotassemia,Other late effects of cerebrovascular disease, dysphagia,Dysphagia, oropharyngeal phase,Anemia, unspecified,Chronic obstructive asthma, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Osteoporosis, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified acquired hypothyroidism,Personal history of tobacco use'}


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: change in mental status

PRESENT ILLNESS: 82 year old male with known cerebellar mass. He was imaged
at the OSH and the mass has approximately doubled in size
headache, no dizziness, no n/v, no visual changes.

MEDICAL HISTORY: 1. Asthma
2. Osteoporosis
3. Osteoarthritis
4. s/p bilateral catarect surgery

MEDICATION ON ADMISSION: Albuterol Inhaler, Colace, Advair, FoLIC Acid, Levothyroxine
Sodium, Lorazepam, Metoclopramide, Pantoprazole, Risperidone,
Trazadone

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Exam upon admission:
T:96.3  BP:146/78     HR:104  RR:15     O2Sats:95% RA
Gen: Patient is pleaseant, coopertive with exam and does not
appear to be in pain
HEENT: Pupils: PERRL      EOMs-intact
Neck: Very kyphotic, but no tenderness to palpation.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place.
Speech fluent with good comprehension and repetition.
No dysarthria or paraphasic errors.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with his step-son who is his only child and his HCP, his
name is [**Name (NI) **] [**Name (NI) 36913**] and his cell phone number is: [**Telephone/Fax (1) 79899**]. According to Mr. [**Last Name (Titles) 36913**], his step-father is DNR/DNI. His
PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) 27542**] at [**Location (un) **]. He is an
ex-smoker, smoking up to two packs per day (not known over the
number of years). Mr. [**Known lastname 61509**] does not drink alcohol. His bedroom
is on the [**Location (un) 1773**], and he normally manages his ADLs. 

### Response:
{'Malignant neoplasm of cerebellum nos,Atrioventricular block, complete,Hemiplegia, unspecified, affecting unspecified side,Body Mass Index less than 19, adult,Hypopotassemia,Other late effects of cerebrovascular disease, dysphagia,Dysphagia, oropharyngeal phase,Anemia, unspecified,Chronic obstructive asthma, unspecified,Other persistent mental disorders due to conditions classified elsewhere,Osteoporosis, unspecified,Osteoarthrosis, unspecified whether generalized or localized, site unspecified,Unspecified acquired hypothyroidism,Personal history of tobacco use'}
