CHIEF COMPLAINT: agitation

PRESENT ILLNESS: 59 yo woman with metastatic breast CA, recent admission [**9-17**] for
PE, presents initially with dyspnea and eventually intubated for
acute mental status change(fidgety, dyskinesia)
.
ED initial VS T 99.5 P97 BP123/98 R20 99% on RA. Toxicology was
initially consulted but did not think that she fit into any
toxidrome. Patient received 4mg ativan, 2.5mg haldol and 50mg of
benadryl. She got worse w/ benadryl. Patient was intubated in ED
for airway protection prior to CTA, which showed no evidence of
pulmonary embolism.  CT head was obtained given new left sided
weakness, which did not show any intracranial bleeding. EKG
normal. LP was not done.
.
She says that she remembers going to physical therapy on Monday
at 11am. Afterwards she took a nap and when she woke at 3pm she
felt "useless" and "sleepy". She took an oxycodone and soon
after found that she could not control her legs or arms. She
called her neighbor who brought her in to the [**Name (NI) **]. She does not
remember anything beyond this. She currently is having no
trouble moving her arms or legs. She does have some residual
weakness in her left leg ever since the pins were placed. She
has had some word finding difficulties for 6 months. She has had
no trouble with vision or other neurologic symptoms.
.
Her best friend and her neighbor, Ms [**Name (NI) 6483**] noted that she had
been feeling well until this morning.  She took her to the ED
and noticed that she was working hard to breath, has twiching in
one leg(cannot remember which) and appeared restless.

MEDICAL HISTORY: 1. Breast Cancer(patient of Dr. [**Last Name (STitle) 2036**]: metastatic to
bone(multiple vertebral bodies, lytic lesions seen throughout
the pelvis and lower lumbar spine ) Has lesions in brain which
are not consistant with metastasis, consistant with glioma.
Currrently on Xeloda and Zometa. Also uses large amount of pain
medication: MS Contin 100 QAM and 60 QHS, oxycodone 5mg prn.
2. pulmonary embolism on coumadin since [**9-17**].
3. recently treated with valtrex for HSV on positive anal
swab([**7-18**]) found due to diarrhea after radiation treatment
4. left femur rod

MEDICATION ON ADMISSION: coumadin 4mg
oxycontin 80 QAM and QHS
oxycodone 5mg Q4-6prn
Zometa Q 3 months
Xeloda

ALLERGIES: Morphine

PHYSICAL EXAM: T99.2 P95 BP133/65 R18
PS 5/5 FiO2 0.3
propofol 80mcg/kg/min
Gen- intubated, sedated, patient sit upright and tries to remove
tubes/lines when sedation switched off
HEENT- PERRLA, no facial/head trauma, moist mucus membrane, neck
supple, JVD not appreciable
CV- regular, no rubs/murmurs/gallop
RESP- CTAB
ABDOMEN- soft, does not appear tender, no bowel sounds
NEURO- PERRLA, minimally withdraw to painful stimuli, stiff,
upgoing toes bilaterally, no tremor, cannot elicit knee jerks

FAMILY HISTORY: Father died from MI at age 79
Mother died from Breast cancer in age 70's.

SOCIAL HISTORY: She is a real estate [**Doctor Last Name 360**]. Has an adopted daughter from [**Name (NI) **].
No tobacco, no etoh. Independent.
Drug-induced delirium,Malignant neoplasm of brain, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast
Drug-induced delirium,Malig neo brain NOS,Adv eff opiates,Long-term use anticoagul,Hx of breast malignancy
Admission Date:  [**2148-1-9**]              Discharge Date:   [**2148-1-12**]

Date of Birth:  [**2088-3-3**]             Sex:   F

Service: MEDICINE

Allergies:
Morphine

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
agitation

Major Surgical or Invasive Procedure:
Intubation
Lumbar puncture


History of Present Illness:
59 yo woman with metastatic breast CA, recent admission [**9-17**] for
PE, presents initially with dyspnea and eventually intubated for
acute mental status change(fidgety, dyskinesia)
.
ED initial VS T 99.5 P97 BP123/98 R20 99% on RA. Toxicology was
initially consulted but did not think that she fit into any
toxidrome. Patient received 4mg ativan, 2.5mg haldol and 50mg of
benadryl. She got worse w/ benadryl. Patient was intubated in ED
for airway protection prior to CTA, which showed no evidence of
pulmonary embolism.  CT head was obtained given new left sided
weakness, which did not show any intracranial bleeding. EKG
normal. LP was not done.
.
She says that she remembers going to physical therapy on Monday
at 11am. Afterwards she took a nap and when she woke at 3pm she
felt "useless" and "sleepy". She took an oxycodone and soon
after found that she could not control her legs or arms. She
called her neighbor who brought her in to the [**Name (NI) **]. She does not
remember anything beyond this. She currently is having no
trouble moving her arms or legs. She does have some residual
weakness in her left leg ever since the pins were placed. She
has had some word finding difficulties for 6 months. She has had
no trouble with vision or other neurologic symptoms.
.
Her best friend and her neighbor, Ms [**Name (NI) 6483**] noted that she had
been feeling well until this morning.  She took her to the ED
and noticed that she was working hard to breath, has twiching in
one leg(cannot remember which) and appeared restless.

Past Medical History:
1. Breast Cancer(patient of Dr. [**Last Name (STitle) 2036**]: metastatic to
bone(multiple vertebral bodies, lytic lesions seen throughout
the pelvis and lower lumbar spine ) Has lesions in brain which
are not consistant with metastasis, consistant with glioma.
Currrently on Xeloda and Zometa. Also uses large amount of pain
medication: MS Contin 100 QAM and 60 QHS, oxycodone 5mg prn.
2. pulmonary embolism on coumadin since [**9-17**].
3. recently treated with valtrex for HSV on positive anal
swab([**7-18**]) found due to diarrhea after radiation treatment
4. left femur rod


Social History:
She is a real estate [**Doctor Last Name 360**]. Has an adopted daughter from [**Name (NI) **].
No tobacco, no etoh. Independent.


Family History:
Father died from MI at age 79
Mother died from Breast cancer in age 70's.

Physical Exam:
T99.2 P95 BP133/65 R18
PS 5/5 FiO2 0.3
propofol 80mcg/kg/min
Gen- intubated, sedated, patient sit upright and tries to remove
tubes/lines when sedation switched off
HEENT- PERRLA, no facial/head trauma, moist mucus membrane, neck
supple, JVD not appreciable
CV- regular, no rubs/murmurs/gallop
RESP- CTAB
ABDOMEN- soft, does not appear tender, no bowel sounds
NEURO- PERRLA, minimally withdraw to painful stimuli, stiff,
upgoing toes bilaterally, no tremor, cannot elicit knee jerks


Pertinent Results:
EKG: NSR 94, nl axis, nl intervals, no ST/T wave changes
.
Imaging:
[**1-8**] CT head: IMPRESSION: No intracranial hemorrhage.
Note added at attending review: I think the abnormality in the
right frontal lobe could relate to leptomengeal metastasis. The
enhancing lesion in the right side of the sphenoid bone, either
benign soft tissue or metastatic sisease is stable. There are
two enhancing lesions in the frontal bones which may be slightly
more sistinct than formerly. They probably reflect bone
metastases.
.
[**1-8**] CT Chest: IMPRESSION: No evidence of pulmonary embolism.
.
[**2148-1-9**] CXR: No evidence of acute cardiopulmonary disease.
.
[**2148-1-11**] Brain MRI: No evidence of metastatic disease. Unchanged
abnormal increased FLAIR signal within the parasagittal right
frontal lobe, supporting the diagnosis of low intermediate grade
glioma rather than metastatic disease.
.
Spinal fluid: Negative for malignant cells
.
[**2148-1-12**] 05:20AM BLOOD WBC-4.5 RBC-3.81* Hgb-12.8 Hct-36.1
MCV-95 MCH-33.6* MCHC-35.5* RDW-20.8* Plt Ct-202
[**2148-1-8**] 06:15PM BLOOD WBC-3.7*# RBC-4.08* Hgb-13.3 Hct-38.7
MCV-95 MCH-32.6* MCHC-34.4 RDW-20.8* Plt Ct-257
[**2148-1-8**] 06:15PM BLOOD Neuts-71.3* Lymphs-21.8 Monos-5.9 Eos-0.5
Baso-0.5
[**2148-1-12**] 05:20AM BLOOD Plt Ct-202
[**2148-1-12**] 05:20AM BLOOD PT-19.8* PTT-31.1 INR(PT)-1.9*
[**2148-1-9**] 02:39AM BLOOD PT-29.5* PTT-35.9* INR(PT)-3.1*
[**2148-1-9**] 02:39AM BLOOD Gran Ct-3490
[**2148-1-12**] 05:20AM BLOOD Glucose-103 UreaN-6 Creat-0.4 Na-141
K-3.6 Cl-107 HCO3-23 AnGap-15
[**2148-1-12**] 05:20AM BLOOD Calcium-8.5 Phos-2.0* Mg-2.4
[**2148-1-8**] 06:15PM BLOOD Calcium-9.4 Phos-1.8* Mg-2.3
[**2148-1-9**] 02:39AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
Ms. [**Known lastname 732**] is a 59 year old female with metastatic breast cancer
with recent hospitalization for PE who presents with dyspnea and
acute agitation.
.
#. Acute agitation, mental status changes: The differential
diagnosis on admission was alcohol withdrawal, meningitis,
encephalitis, brain tumors, non-convulsive seizures, and stroke.
 Urine and serum tox were negative on admission and CT was
negative for intracranial bleed.  Ms. [**Known lastname 732**] was intubated in
the ED as above and admitted to the ICU where she was started on
CTX/Vanco/Ampicillin/Acyclovir for possible meningitis or
encephalitis.  An LP was done while she was in the unit which
showed 1 WBC.  DFA was also sent which returned negative.
Antibiotics were discontinued after results of the LP returned.
She had an MRI head done to assess for encephalitis or tumor.
The MRI showed no evidence of metastatic disease and presence of
a low intermediate grade glioma - no change from prior.  She was
extubated and feeling well, back to baseline mental status so
she was called out to the floor on [**2-10**].  At that time the
patient's mental status was at baseline.  She had a poor memory
of the events of the past three days.  Given the patient's
leukopenia and immunosuppresion w/ chemotherapy, concern re:
encephalitis and less likely meningitis.  Patient had been
treated for HSV recently as well.  HSV PCR was negative and
acyclovir was stopped on [**1-12**].  She was discharged to home
mentating appropriately with a reduced dose of oxycontin and a
taper of fluoxetine.
.
# Respiratory distress:  Ms. [**Known lastname 732**] was intubated for agitation,
no underlying lung pathology.  She was rapidly weaned and
extubated.  On discharge she was able to breathe comfortably on
room air.
.
# PE: Ms. [**Known lastname 732**] had been admitted for pulmonary embolism of
RUL, RLL, LLL on [**2147-9-18**].  The CT on this admission showed no
evidence of pulmonary embolism.  INR on admission was 3.1.  On
the day of discharge it was 1.9.  Coumadin 4mg was given nightly
while in house and she was discharged on 2mg nightly.  She
continued to have appropriate oxygen saturation on room air.
.
#. Metastatic breast cancer: Ms. [**Known lastname 732**] is followed by Dr.
[**Last Name (STitle) 2036**].  She receives Zomeda q3months and Xeloda.  She was also
noted to be leukopenic, NOT neutropenic, which was attributed to
her chemotherapy.  Pain control was continued with oxycodone
20mg [**Hospital1 **] which is a lower dose than she had been taking as an
outpatient as she was interested in weaning down the dose.  This
regimen was effective while in house, however, patient reports
increased difficulty with physical therapy.  She will follow up
with Dr. [**Last Name (STitle) 2036**] as an outpatient.
.
#. Depression: As an outpatient, she had been taking Fluoxetine,
however she did not receive this during the initial days of her
hospitalization.  She expresses interest in coming off of this
medication and was discharged with a weaning dose.
.
#. FEN:  She was kept on a regular diet while in the hospital.
She was also noted to be hypophosphatemic and was repleted as
needed.
.
#. PPx: She was continued on coumadin and given a bowel regimen
and proton pump inhibitor.
.
FULL code


Medications on Admission:
coumadin 4mg
oxycontin 80 QAM and QHS
oxycodone 5mg Q4-6prn
Zometa Q 3 months
Xeloda


Discharge Medications:
1. Warfarin 2 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).

2. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
4. Fluoxetine 10 mg Tablet Sig: One (1) Tablet PO once a day for
7 days.
Disp:*7 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis:
Mental status changes
Breast cancer, metastatic to bone

Secondary diagnosis:
h/o pulmonary embolism


Discharge Condition:
Fair.  The patient is at her baseline mental status.  She is
making voluntary movements with all limbs, denies pain, and is
afebrile.


Discharge Instructions:
You were admitted for agitation and change in the way you were
behaving.  Scans including CT and MRI of your head showed no
changes from prior scans.  You were initially treated with
antibiotics, however a spinal tap showed no signs of infection
and antibiotics were stopped.

Please take all medications as prescribed.  Changes to your
medications include:
1. Your oxycontin has been reduced to 20mg twice daily.
2. Your fluoxetine will be tapered over the next week.  You will
take 10mg for 7 days and then can stop the medication
completely.  If you begin to have symptoms of diarrhea,
dizziness, headache, tremor, anxiety, or confusion you should
restart the dose you had previously been taking.

Please continue to take your coumadin.

If you begin to experience any fevers, chills, limb shaking,
urinary or fecal incontinence, or any other concerning symptoms
please call your doctor or 911 immediately.

Followup Instructions:
You have the following appointments already scheduled:

1. ORHTO XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2148-1-22**] 9:20
2. [**Name (NI) **] [**Name (NI) 65710**], PT Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2148-1-18**]
11:00
3. [**Name (NI) **] [**Name (NI) 65710**], PT Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2148-1-15**]
10:30

Please follow up with your primary doctor this week.
Please follow up with Dr. [**Last Name (STitle) 2036**] as soon as possible.
{'Drug-induced delirium,Malignant neoplasm of brain, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast'}


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: agitation

PRESENT ILLNESS: 59 yo woman with metastatic breast CA, recent admission [**9-17**] for
PE, presents initially with dyspnea and eventually intubated for
acute mental status change(fidgety, dyskinesia)
.
ED initial VS T 99.5 P97 BP123/98 R20 99% on RA. Toxicology was
initially consulted but did not think that she fit into any
toxidrome. Patient received 4mg ativan, 2.5mg haldol and 50mg of
benadryl. She got worse w/ benadryl. Patient was intubated in ED
for airway protection prior to CTA, which showed no evidence of
pulmonary embolism.  CT head was obtained given new left sided
weakness, which did not show any intracranial bleeding. EKG
normal. LP was not done.
.
She says that she remembers going to physical therapy on Monday
at 11am. Afterwards she took a nap and when she woke at 3pm she
felt "useless" and "sleepy". She took an oxycodone and soon
after found that she could not control her legs or arms. She
called her neighbor who brought her in to the [**Name (NI) **]. She does not
remember anything beyond this. She currently is having no
trouble moving her arms or legs. She does have some residual
weakness in her left leg ever since the pins were placed. She
has had some word finding difficulties for 6 months. She has had
no trouble with vision or other neurologic symptoms.
.
Her best friend and her neighbor, Ms [**Name (NI) 6483**] noted that she had
been feeling well until this morning.  She took her to the ED
and noticed that she was working hard to breath, has twiching in
one leg(cannot remember which) and appeared restless.

MEDICAL HISTORY: 1. Breast Cancer(patient of Dr. [**Last Name (STitle) 2036**]: metastatic to
bone(multiple vertebral bodies, lytic lesions seen throughout
the pelvis and lower lumbar spine ) Has lesions in brain which
are not consistant with metastasis, consistant with glioma.
Currrently on Xeloda and Zometa. Also uses large amount of pain
medication: MS Contin 100 QAM and 60 QHS, oxycodone 5mg prn.
2. pulmonary embolism on coumadin since [**9-17**].
3. recently treated with valtrex for HSV on positive anal
swab([**7-18**]) found due to diarrhea after radiation treatment
4. left femur rod

MEDICATION ON ADMISSION: coumadin 4mg
oxycontin 80 QAM and QHS
oxycodone 5mg Q4-6prn
Zometa Q 3 months
Xeloda

ALLERGIES: Morphine

PHYSICAL EXAM: T99.2 P95 BP133/65 R18
PS 5/5 FiO2 0.3
propofol 80mcg/kg/min
Gen- intubated, sedated, patient sit upright and tries to remove
tubes/lines when sedation switched off
HEENT- PERRLA, no facial/head trauma, moist mucus membrane, neck
supple, JVD not appreciable
CV- regular, no rubs/murmurs/gallop
RESP- CTAB
ABDOMEN- soft, does not appear tender, no bowel sounds
NEURO- PERRLA, minimally withdraw to painful stimuli, stiff,
upgoing toes bilaterally, no tremor, cannot elicit knee jerks

FAMILY HISTORY: Father died from MI at age 79
Mother died from Breast cancer in age 70's.

SOCIAL HISTORY: She is a real estate [**Doctor Last Name 360**]. Has an adopted daughter from [**Name (NI) **].
No tobacco, no etoh. Independent. 

### Response:
{'Drug-induced delirium,Malignant neoplasm of brain, unspecified,Other opiates and related narcotics causing adverse effects in therapeutic use,Long-term (current) use of anticoagulants,Personal history of malignant neoplasm of breast'}
