CHIEF COMPLAINT: word-finding difficulties

PRESENT ILLNESS: HPI: Patient is a 47 year old right handed man with past medical
history of metastatic malignant melanoma who presented to [**Hospital1 18**]
ED on [**2177-9-18**] for evaluation acute onset word finding
difficulties x 3.5 hours.

MEDICAL HISTORY: 1. Malignant melanoma. His oncologic history began in [**2169**] when
he had a 0.32-mm thick, [**Doctor Last Name 10834**] level III melanoma resected from
his posterior neck. He was well until [**2174-10-7**] when he
noted
right neck swelling. He underwent fine needle aspiration
revealing melanoma versus carcinoma. He underwent right modified
radical neck dissection in [**2174-11-6**] with pathology
revealing
melanoma. He underwent radiation therapy to the neck in [**2175-1-7**] secondary to extracapsular extension. He began interferon
in
[**2175-2-4**], discontinued [**2175-11-6**] when biopsy of a sacral
lesion noted on CT revealed melanoma. He was followed with
serial
CTs with progressive L2 bony metastases noted on [**2176-11-6**]. He received radiation to this region, completed in
[**2177-1-7**]. Follow-up CTs revealed questionable right
inguinal mass, questionable splenic lesion and an enlarging
bony metastasis and L2 coupled with worsening back pain. He
began [**First Name9 (NamePattern2) **] [**2177-5-31**] with usual side effects
as well as grade 4 thrombocytopenia after cycle #2 and grade
III thrombocytopenia after cycle #3, requiring a 50% dose
reduction in DTIC and vinblastine. Follow-up CTs after cycle
#2 revealed stable disease. Follow-up CTs after cycle #4
revealed stable disease and 5 x 4-mm right lower lobe nodule
of unclear significance. Started interleukin biologic therapy
last month. Head CT in [**5-11**] with no evidence of metastatic
disease.

MEDICATION ON ADMISSION: 1. Interleukin maintenance regimen; was to be admitted next week
for cycle #2
2. GMCSF as part of interleukin protocol
3. Ranitidine
4. Benadryl
5. Tylenol
No ASA or anticoagulants.

ALLERGIES: Keflex

PHYSICAL EXAM: PHYSICAL EXAM:
Tc: 98.2          BP: 117/74        HR: 88
RR: 16            O2Sat.: 100%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: no melanoma

SOCIAL HISTORY: Married, lives with wife. 12 year old daughter.
[**Name (NI) 1403**] as a graphic designer. No tobacco, alcohol, drug use
Secondary malignant neoplasm of brain and spinal cord,Intracerebral hemorrhage,Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck,Personal history of malignant melanoma of skin
Sec mal neo brain/spine,Intracerebral hemorrhage,Mal neo lymph-head/neck,Hx-malig skin melanoma
Admission Date:  [**2177-9-19**]              Discharge Date:   [**2177-9-22**]

Date of Birth:  [**2130-3-2**]             Sex:   M

Service: NEUROLOGY

Allergies:
Keflex

Attending:[**First Name3 (LF) 6075**]
Chief Complaint:
word-finding difficulties

Major Surgical or Invasive Procedure:
none

History of Present Illness:
HPI: Patient is a 47 year old right handed man with past medical
history of metastatic malignant melanoma who presented to [**Hospital1 18**]
ED on [**2177-9-18**] for evaluation acute onset word finding
difficulties x 3.5 hours.

Initially, a Code Stroke was called but was later cancelled. Per
his wife, patient was in his usual state of health earlier
today. Around 7:30pm, they were in their kitchen putting away
groceries when she noted him to have word finding difficulties
and naming problems. For example, he kept referring to the
broccoli as pepper. He seemed to be talking around things in
order to get his point across. Seemed to have some difficulty
understanding directions and following what she was saying as
well. She did not note any facial droop or weakness.

Even so, he was able to actually prepare their dinner meal and
ate dinner. Throughout, she still noticed word substitutions and
some difficulty following conversation on his part. After
dinner, she called her friend, who is a nurse. Friend told her
to call patient's oncologist, who them referred them to ED.

Patient denies any headaches, visual changes, numbness,
weakness, incoordination, vertigo, lightheadedness. No recent
fevers, chills, chest pain, palpitations, shortness of breath,
cough, sputum, abdominal pain, nausea, vomiting. Per his wife,
he has been confused at times since starting interleukin therapy
for melanoma, but they attributed this to the chemo. She
actually thought that mentally, he was better this weekend than
he had been in terms of thinking clearly than since starting
chemo.


Past Medical History:
1. Malignant melanoma. His oncologic history began in [**2169**] when
he had a 0.32-mm thick, [**Doctor Last Name 10834**] level III melanoma resected from
his posterior neck. He was well until [**2174-10-7**] when he
noted
right neck swelling. He underwent fine needle aspiration
revealing melanoma versus carcinoma. He underwent right modified
radical neck dissection in [**2174-11-6**] with pathology
revealing
melanoma. He underwent radiation therapy to the neck in [**2175-1-7**] secondary to extracapsular extension. He began interferon
in
[**2175-2-4**], discontinued [**2175-11-6**] when biopsy of a sacral
lesion noted on CT revealed melanoma. He was followed with
serial
CTs with progressive L2 bony metastases noted on [**2176-11-6**]. He received radiation to this region, completed in
[**2177-1-7**]. Follow-up CTs revealed questionable right
inguinal mass, questionable splenic lesion and an enlarging
bony metastasis and L2 coupled with worsening back pain. He
began [**First Name9 (NamePattern2) **] [**2177-5-31**] with usual side effects
as well as grade 4 thrombocytopenia after cycle #2 and grade
III thrombocytopenia after cycle #3, requiring a 50% dose
reduction in DTIC and vinblastine. Follow-up CTs after cycle
#2 revealed stable disease. Follow-up CTs after cycle #4
revealed stable disease and 5 x 4-mm right lower lobe nodule
of unclear significance. Started interleukin biologic therapy
last month. Head CT in [**5-11**] with no evidence of metastatic
disease.

Social History:
Married, lives with wife. 12 year old daughter.
[**Name (NI) 1403**] as a graphic designer. No tobacco, alcohol, drug use


Family History:
no melanoma

Physical Exam:
PHYSICAL EXAM:
Tc: 98.2          BP: 117/74        HR: 88
RR: 16            O2Sat.: 100%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Awake and alert, cooperative with exam,
disaffected
affect.
Orientation: Oriented to person, place, and date.
Attention: Able to recite [**Doctor Last Name 1841**] forwards and backwards.
Registration intact.
Recall: [**2-6**] objects at 5 minutes.
Language: Speech fluent with intact repetition. However, has
anomia for low frequency items, makes frequent semantic
paraphasic errors, is perserverative (named cactus off naming
card then named next several items as cactus), and has some
subtle problems with comprehension on complex and multistep
commadns. No dysarthria. No apraxia, no neglect. [**Location (un) **] intact.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally. Visual fields are full to confrontation. Optic disc
margins sharp.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Flattening of right nasolabial fold. Facial sensation
symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**4-10**] throughout. No pronator drift.

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right     2 2 2   2  2
Left      2 2 2   2  2
Toes upgoing on right, downgoing on left.

Coordination: Normal on finger-nose-finger, rapid alternating
movements, heel to shin.

Gait: narrow-based gait with negative Romberg.


Pertinent Results:
wbc 11.0/hct 30.3/plt 197
Na 138/K 4.0/CL 102/Bicarb 26/BUN 24/Cr 1.1/Gluc 97
Ca 9.4/Mg 1.9/P 3.6
PT 13.1/PTT 24.9/INR 1.1

CT BRAIN AT ADMISSION:
1. Large left frontal intraparenchymal hemorrhage with left to
right subfalcine shift.
2. Numerous additional metastatic foci throughout the brain
parenchyma may be further evaluated with MR of the brain without
and with gadolinium.

Brief Hospital Course:
Patient is a 47 year old man with history of malignant melanoma
with acute onset word finding difficulties at 7:30pm on the
night of admission, found to have word finding aphasia with
anomia for low frequency words and frequent semantic paraphasic
errors as well as some subtle comprension difficulties, as well
as a right facial droop and upgoing right toe.  Initial CT of
the head revealed a large left frontal hemorrhage and multiple
foci of metastatic disease.  He was admitted to the neuro ICU
with q1hr neuro checks, systolic blood pressure goal under 140,
and started on IV Decadron 10mg q6hrs, with sliding scale
insulin and proton pump inhibitor for prophylaxis.  For seizure
prophylaxis, although he had not had events suggestive of
seizures, he was started on Dilantin and transitioned to Keppra
during his hospital course.

An MRI was performed, and was read as follows:
"FINDINGS: Multiple enhancing lesions are identified in the
brain with an area of hemorrhage and enhancement in the left
frontal lobe. There is mass effect on the left lateral
ventricle. Enhancing lesions are seen in both cerebral
hemispheres as well as in the left superior cerebellar region.
There is no midline shift noted. No evidence of hydrocephalus or
brain herniation is identified.  IMPRESSION: Left frontal lobe
hemorrhage as seen on the CT of [**2177-9-18**] with an area of
increased signal which could be secondary to enhancement.
Multiple enhancing lesions in both cerebral hemispheres and in
the left superior cerebellar region consistent with clinical
diagnosis of metastatic disease."

For further workup, a chest xray was performed which showed:
"Post-radiation fibrosis in right upper lobe with otherwise
grossly clear lungs."

An EEG was abnormal as follows: "This is an abnormal portable
study obtained in wakefulness progressing to drowsiness due to
the presence of frequent slowing over
the left anterior quadrant broadly, suggesting subcortical
dysfunction
in this region. There were no epileptiform discharges seen."

He was followed by neurosurgery, who did not feel that a
resection was warranted, considering the number of metastatic
lesions.  His clinical exam was monitored and showed improvment
of word-finding and of his facial droop.  He was transferred to
the floor from the ICU on [**9-21**].  A repeat CT of the brain,
performed on [**2177-9-21**] was stable.

Neuro-oncology, oncology, and radiation oncology were consulted
regarding his case, and followed him through his admission.
Because of the number of metastases, radiation oncology felt
that whole brain irradiation was the next step regarding his
management.  This could be done as an outpatient.

As he had continued to improve clinically, and was feeling well,
he was discharged on [**2177-9-22**].  His exam at discharge showed
improvement of naming of both low and high frequency objects,
and an improved but not resolved right hemiparesis of the face,
as well as some very mild pronator drift.  He was discharged
with the plan to switch from Dilantin to the full dose of Keppra
over the coming week.


Medications on Admission:
1. Interleukin maintenance regimen; was to be admitted next week
for cycle #2
2. GMCSF as part of interleukin protocol
3. Ranitidine
4. Benadryl
5. Tylenol
No ASA or anticoagulants.


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Phenytoin 50 mg Tablet, Chewable Sig: see instructions
Tablet, Chewable PO see instructions for 6 days: take one tablet
po tid x 2 days, then one tablet [**Hospital1 **] x 2 days, then one tablet
qday x 2 days, then discontinue.
Disp:*12 Tablet, Chewable(s)* Refills:*0*
3. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
4. Decadron 4 mg Tablet Sig: One (1) Tablet PO every six (6)
hours.
Disp:*120 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Intraparenchymal Hemorrhage
Metastatic Melanoma, Brain metastases

Discharge Condition:
stable, improved exam and symptoms


Discharge Instructions:
return if new symptoms of speech or language problems, or
weakness.

Followup Instructions:
1. Radiation Oncology nurse will call you in AM to set up
radiation
2. Call Dr.[**Name (NI) 29259**] office ([**Telephone/Fax (1) 46581**] for appointment in
1 month
3. Call Dr.[**Name (NI) 46582**] office ([**Telephone/Fax (1) 46583**]) for appointment 2 weeks
following completion of radiation



Completed by:[**2177-9-22**]
{'Secondary malignant neoplasm of brain and spinal cord,Intracerebral hemorrhage,Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck,Personal history of malignant melanoma of skin'}


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: word-finding difficulties

PRESENT ILLNESS: HPI: Patient is a 47 year old right handed man with past medical
history of metastatic malignant melanoma who presented to [**Hospital1 18**]
ED on [**2177-9-18**] for evaluation acute onset word finding
difficulties x 3.5 hours.

MEDICAL HISTORY: 1. Malignant melanoma. His oncologic history began in [**2169**] when
he had a 0.32-mm thick, [**Doctor Last Name 10834**] level III melanoma resected from
his posterior neck. He was well until [**2174-10-7**] when he
noted
right neck swelling. He underwent fine needle aspiration
revealing melanoma versus carcinoma. He underwent right modified
radical neck dissection in [**2174-11-6**] with pathology
revealing
melanoma. He underwent radiation therapy to the neck in [**2175-1-7**] secondary to extracapsular extension. He began interferon
in
[**2175-2-4**], discontinued [**2175-11-6**] when biopsy of a sacral
lesion noted on CT revealed melanoma. He was followed with
serial
CTs with progressive L2 bony metastases noted on [**2176-11-6**]. He received radiation to this region, completed in
[**2177-1-7**]. Follow-up CTs revealed questionable right
inguinal mass, questionable splenic lesion and an enlarging
bony metastasis and L2 coupled with worsening back pain. He
began [**First Name9 (NamePattern2) **] [**2177-5-31**] with usual side effects
as well as grade 4 thrombocytopenia after cycle #2 and grade
III thrombocytopenia after cycle #3, requiring a 50% dose
reduction in DTIC and vinblastine. Follow-up CTs after cycle
#2 revealed stable disease. Follow-up CTs after cycle #4
revealed stable disease and 5 x 4-mm right lower lobe nodule
of unclear significance. Started interleukin biologic therapy
last month. Head CT in [**5-11**] with no evidence of metastatic
disease.

MEDICATION ON ADMISSION: 1. Interleukin maintenance regimen; was to be admitted next week
for cycle #2
2. GMCSF as part of interleukin protocol
3. Ranitidine
4. Benadryl
5. Tylenol
No ASA or anticoagulants.

ALLERGIES: Keflex

PHYSICAL EXAM: PHYSICAL EXAM:
Tc: 98.2          BP: 117/74        HR: 88
RR: 16            O2Sat.: 100%/RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: CTA bilaterally. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: no melanoma

SOCIAL HISTORY: Married, lives with wife. 12 year old daughter.
[**Name (NI) 1403**] as a graphic designer. No tobacco, alcohol, drug use 

### Response:
{'Secondary malignant neoplasm of brain and spinal cord,Intracerebral hemorrhage,Secondary and unspecified malignant neoplasm of lymph nodes of head, face, and neck,Personal history of malignant melanoma of skin'}
