CHIEF COMPLAINT: Confusion, Headache

PRESENT ILLNESS: 66M hx of CLL with subsequent evidence of Hodgkin's Lymphoma
that p/w low grade fever, headache and mild confusion. Per
patients wife and confirmed with the patient, the pt started
experiencing decreased appetitie, headaches, mild confusion and
lightheadedness on Sunday night [**2119-11-5**]. On Monday, [**11-6**], the pt
underwent removal of his PEG tube without complication. That
night the pt became more disoriented with 3-5 episodes of
yellowish emesis. He also experienced (+) chills, with
temperatures ranging from 98.1 to 100.0. The pt described his HA
as on top of his head [**2-6**]. In addition the patient states he
has been forgetful over the last few days. He admits to
occasional chills. No neck stiffness. No recent travel or sick
contacts.
.
Review of symptoms was positive for occasional blood on his
stool without frank melena or without gross hematochezia. Also
the pt complained of mild burning with urination. Otherwise no
abdominal pain, constipation, melena, chest pain, shortness of
breath, orthopnea, PND, lower extremity edema, cough, urinary,
dysuria, lightheadedness, no focal weakness, no vision changes,
no skin changes.

MEDICAL HISTORY: - CLL: diagnosed in [**2090**], but treatment started in [**2115**].
Treated
with FCR X 3 and is without evidence of recurrence since [**2116**].
-Hodgkin lymphoma: diagnosed in [**4-6**] after presenting in [**2-4**]
with high fever and syncope. Complicated by paraneoplasic
neuropathy manifested as dysphagia requiring G-tube placement

MEDICATION ON ADMISSION: Oxycodone 5mg PO 1-2 Tabs Q8PRN
Quetiapine 25mg TID:PRN
Bactrim SS Po Daily
MVI
Acyclovir 400mg PO Daily
Buproprion SR 100mg PO Daily
Lactulose PRN
Lorazepam 0.5mg PO PRN Anxiety

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.6 BP: 114/72 HR: 85 RR: 16 O2Sat: 98%
GEN: Thin appearing, speaking slightly slowly but fluently, no
acute distress
HEENT: NCAT, PERRL, EOMI, Oropharynx Clear for erythema or
lesions. Sclera anicteric, no epistaxis or rhinorrhea, MMM.
NECK: Neck Veins flat, No cervical, submental or submandibular
appreciable lymphadenopathy, trachea midline
COR: S1S2 No MRG
PULM: R basilar crackles. Lungs otherwise CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, slightly erythematous and tenderness at
site of prior PEG. No HSM, No masses. Negative Murphys
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: Right upper back 1cm fluctuant, mobile nodule without
erythema. No jaundice, cyanosis, or gross dermatitis. No
ecchymoses.
RECTAL: Positive Perianal Warts without frank erythema or
tenderness, no DRE was performed.

FAMILY HISTORY: Non-Contributory

SOCIAL HISTORY: Former Sea-man. Married, not working, Denies Tobacco/Etoh
Other malignant lymphomas, lymph nodes of head, face, and neck,Eosinophilic meningitis,Toxic encephalopathy,Communicating hydrocephalus,Hyposmolality and/or hyponatremia,Acute respiratory failure,Other specified cardiac dysrhythmias
Lymphomas NEC head,Eosinophilic meningitis,Toxic encephalopathy,Communicat hydrocephalus,Hyposmolality,Acute respiratry failure,Cardiac dysrhythmias NEC
Admission Date:  [**2119-11-8**]              Discharge Date:   [**2119-11-16**]

Date of Birth:  [**2052-12-16**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3326**]
Chief Complaint:
Confusion, Headache

Major Surgical or Invasive Procedure:
Brain Biopsy
VP shunt

History of Present Illness:
66M hx of CLL with subsequent evidence of Hodgkin's Lymphoma
that p/w low grade fever, headache and mild confusion. Per
patients wife and confirmed with the patient, the pt started
experiencing decreased appetitie, headaches, mild confusion and
lightheadedness on Sunday night [**2119-11-5**]. On Monday, [**11-6**], the pt
underwent removal of his PEG tube without complication. That
night the pt became more disoriented with 3-5 episodes of
yellowish emesis. He also experienced (+) chills, with
temperatures ranging from 98.1 to 100.0. The pt described his HA
as on top of his head [**2-6**]. In addition the patient states he
has been forgetful over the last few days. He admits to
occasional chills. No neck stiffness. No recent travel or sick
contacts.
.
Review of symptoms was positive for occasional blood on his
stool without frank melena or without gross hematochezia. Also
the pt complained of mild burning with urination. Otherwise no
abdominal pain, constipation, melena, chest pain, shortness of
breath, orthopnea, PND, lower extremity edema, cough, urinary,
dysuria, lightheadedness, no focal weakness, no vision changes,
no skin changes.


Past Medical History:
- CLL: diagnosed in [**2090**], but treatment started in [**2115**].
Treated
with FCR X 3 and is without evidence of recurrence since [**2116**].
-Hodgkin lymphoma: diagnosed in [**4-6**] after presenting in [**2-4**]
with high fever and syncope. Complicated by paraneoplasic
neuropathy manifested as dysphagia requiring G-tube placement

-s/p 6 cycles of ABVD
- most recent scans ([**8-7**]) no significant evidence of
adenopathy, small bilateral pulmonary nodules that were tiny,
and ill-defined etiology and modest splenomegaly.
- ([**8-7**]) Bone Marrow BX: No evidence of CLL or Hodgkin's
disease.
- Hx of anal fissure,(followed by surgery)
- Basal cell carcinoma of the skin
- Perianal Warts (Anal Brushing confirming HPV)
- Followed by Dr. [**Last Name (STitle) **] (I.D.) and Dr. [**Last Name (STitle) **] (Surgery)
- chronic complaint of his G-tube bothering him,
- Held bleomycin setting of decrease DLCO.


Social History:
Former Sea-man. Married, not working, Denies Tobacco/Etoh

Family History:
Non-Contributory

Physical Exam:
Vitals: T: 98.6 BP: 114/72 HR: 85 RR: 16 O2Sat: 98%
GEN: Thin appearing, speaking slightly slowly but fluently, no
acute distress
HEENT: NCAT, PERRL, EOMI, Oropharynx Clear for erythema or
lesions. Sclera anicteric, no epistaxis or rhinorrhea, MMM.
NECK: Neck Veins flat, No cervical, submental or submandibular
appreciable lymphadenopathy, trachea midline
COR: S1S2 No MRG
PULM: R basilar crackles. Lungs otherwise CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, slightly erythematous and tenderness at
site of prior PEG. No HSM, No masses. Negative Murphys
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: Right upper back 1cm fluctuant, mobile nodule without
erythema. No jaundice, cyanosis, or gross dermatitis. No
ecchymoses.
RECTAL: Positive Perianal Warts without frank erythema or
tenderness, no DRE was performed.


Pertinent Results:
=============
Labs
=============

Admission Labs:
[**2119-11-8**] 10:55AM   WBC-4.2 RBC-3.83* HGB-11.9* HCT-33.8* MCV-88
MCH-30.9 MCHC-35.1* RDW-15.0
[**2119-11-8**] 10:55AM   NEUTS-90.6* LYMPHS-4.3* MONOS-4.4 EOS-0.4
BASOS-0.3
[**2119-11-8**] 10:55AM   PLT COUNT-146*
[**2119-11-8**] 10:55AM   GRAN CT-3830
[**2119-11-8**] 10:55AM   VIT B12-491
[**2119-11-8**] 10:55AM   TSH-0.26*
[**2119-11-8**] 10:55AM   ALT(SGPT)-13 AST(SGOT)-11 LD(LDH)-101 ALK
PHOS-67 TOT BILI-0.4 DIR BILI-0.1 INDIR BIL-0.3
[**2119-11-8**] 10:55AM   CALCIUM-8.8 PHOSPHATE-3.4 MAGNESIUM-2.0 URIC
ACID-3.2* CHOLEST-142
[**2119-11-8**] 10:55AM   UREA N-12 CREAT-0.5 SODIUM-137 POTASSIUM-3.9
CHLORIDE-100 TOTAL CO2-29 ANION GAP-12
.
CSF
[**2119-11-14**] 03:10PM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-494*
Polys-7 Lymphs-55 Monos-6 Eos-32
[**2119-11-13**] 03:17PM CEREBROSPINAL FLUID (CSF) WBC-63 RBC-[**Numeric Identifier 1871**]*
Polys-50 Lymphs-39 Monos-4 Eos-7
[**2119-11-10**] 11:51AM CEREBROSPINAL FLUID (CSF) WBC-133 RBC-3*
Polys-0 Lymphs-54 Monos-26 Eos-20
[**2119-11-10**] 11:51AM CEREBROSPINAL FLUID (CSF) WBC-88 RBC-51*
Polys-0 Lymphs-53 Monos-25 Eos-22
[**2119-11-8**] 08:22PM CEREBROSPINAL FLUID (CSF) WBC-86 RBC-2* Polys-0
Lymphs-36 Monos-43 Eos-21
[**2119-11-8**] 08:22PM CEREBROSPINAL FLUID (CSF) WBC-70 RBC-6* Polys-0
Bands-2 Lymphs-8 Monos-4 Eos-32 Basos-25 Atyps-2 Myelos-27
[**2119-11-14**] 03:10PM CEREBROSPINAL FLUID (CSF) TotProt-381*
Glucose-24
[**2119-11-13**] 03:17PM CEREBROSPINAL FLUID (CSF) TotProt-296*
Glucose-20
[**2119-11-10**] 11:51AM CEREBROSPINAL FLUID (CSF) TotProt-259*
Glucose-20 LD(LDH)-51
[**2119-11-8**] 08:22PM CEREBROSPINAL FLUID (CSF) TotProt-297*
Glucose-27

==============
Pathology
==============
Brain biopsy [**11-8**]
Non-diagnostic study to evaluate B-cell clonality.  Clonality
could not be assessed in this case due to insufficient numbers
of B cells.  Cell marker analysis was attempted, but was
non-diagnostic in this case due to insufficient numbers of
B-cells for analysis.  Examination of cytospin preparation
reveals collection of histiocytes, suggestive of granulomata
along with increased eosinophils.  If clinically indicated, we
recommend a repeat specimen be submitted to the flow cytometry
laboratory. Findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on
[**2119-11-9**].
.
Spinal fluid [**11-12**]
NEGATIVE FOR MALIGNANT CELLS.
.
============
Radiology
============
CT Head [**11-8**]
No hemorrhage or fracture. Communicating hydrocephalus, right
greater than left. Concerning for infection (e.g. meningitis) or

leptomeningeal tumor.
.
MR [**Name13 (STitle) 430**] [**11-9**]
1. Bilateral periventricular subependymal enhancing foci with
associated white matter abnormalities. In the setting of
lymphoma, these could reflect lymphomatous involvement.
Additionally, there is also questionable
enhancement along the right internal auditory canal, raising the
possibility of leptomeningeal spread. Evaluation with CSF
cytology is recommended.
2. Communicating hydrocephalus, predominantly involving the
lateral and the third ventricles. This could have resulted in
response to the leptomeningeal involvement. The possibility of
opportunistic infection is unlikely given the the pattern of
white matter abnormality.
.
MR [**Name13 (STitle) 430**] [**11-10**]
1. New areas of enhancement are seen in the right medial
temporal lobe and
along the right sylvian fissure.

2. Multiple periventricular enhancing lesions are again noted.

3. Slight increase in ventricular size is noted.

4. Given the rapid progression of the changes, infection is
favored over
neoplastic lesion.
.
CT Head [**11-12**]
1. Stable postoperative appearance following a right frontal
lobe biopsy,
without evidence for intracranial hemorrhage.
2. Stable hydrocephalus.
.
CT Head [**11-13**]
Status post right frontal lobe biopsy with interval increase in
size of the ventricles and leftward midline shift. Unchanged
hydrocephalus.
.
CT Head [**11-14**]
Interval effacement of the cerebral sulci, which could be
related
to debris deposited in the leptomeninges likely infectious in
nature.
Additional considerations include global ischemia, although
given the clinical history is less likely. Emergent
neurosurgical consult is recommended for possible
ventriculostomy to reduce intracranial pressure.
.
CT Head [**11-14**]
CONCLUSION: Status post ventricular catheter placement with
decompression of hydrocephalus. No immediate surgical
complications detected.
Persistent appearance of loss of sulci and high-density material
in the basal cisterns. This finding is extremely worrisome for
severe progression of meningitis.

============
Neurology
============
EEG [**11-10**]
IMPRESSION: Abnormal routine EEG due to the presence of a slow
background. These findings suggest a widespread encephalopathy
affecting both cortical and subcortical structures. Medications,

metabolic disturbances, and infection are among the most common
causes.
Hypoxia is another possible explanation. Nevertheless, there
were no
areas of prominent focal slowing although encephalopathies can
obscure
focal findings. There were no clearly epileptiform features.


Brief Hospital Course:
66M hx of CLL with subsequent evidence of Hodgkin's Lymphoma
that p/w low grade fever, headache and mild confusion likely
communicating hydrocephalus.
.
Plan:
# Eosinophilic Meningitis: The patient presented subtle mental
status changes. Given his change in mental status a non-contast
CT was performed (details above). Given evidence a
non-communicated hydrocephalus, an LP was performed (details
above) that has an opening pressure of 22cm on H20 and revealed
an eosinophilic meningitis. Neuro-Oncology was subsequently
consulted. The patients mental status slowly [**Month/Year (2) **] and on the
third day of admission the pt underwent a second LP, this time
with an opening pressure of 11. Following the LP and MRI of the
brain was peformed (details above) that described numerous
peri-ventricular lesions. The pt was then transfered from the
East to the [**Hospital Ward Name 517**] where he was intubated for an Urgent
Brain Biopsy (details above). The pt was kept in the TICU
overnight and transferred back to the BMT service on Saturday
[**2119-11-11**]. On Sunday the pt's MS [**First Name (Titles) 7037**] [**Last Name (Titles) **]. The pt
underwent EEG revealing a toxic encephalopathy. Monday the
patient underwent a stat head CT and subsuently a third LP
(Opening Pressure of 17). Tuesday Morning the pt was
unresponsive but withdrawing to pain early in the AM. He was
subsequently evaluated by Dr. [**Last Name (STitle) 724**] (See Note:). He was placed on
telemetry following morning rounds. The pt was found to be in
Sinus Bradycardia, had minimally responsive pupils, and
bilateral upgoing toes. The pt was sent for repeat stat Head CT
and transfered to the [**Hospital Unit Name 153**].

Subsequent CT scan demonsrated interval noncommunicating
hydrocephalus with effacement of the sulci. Neurosurgery placed
a VP shunt and opening pressure was estimated at greater than
40. Neuro exam at that time was concerning for worsening CNS
function. Pupils were fixed and dilated, patient was minimally
responsive to painful stiumuli and corneal reflexes were absent.
CSF was again consistent with eosinophilic meningitis. Brain
pathology was discussed at hem-pathology rounds, and was felt to
be consistent with Hodgkin's of the CNS.

Given the patient's rapid decline, there was also concern for
infectious etiology. The patient was broadly covered with
antibiotics, antifungals, and anti-parasitic agents. In
conjunction with an ID consult, 4 drug TB therapy was also
initiated for empiric treatment of TB meninigitis given the
patient's travel history. Culture data was negative (although
brain biopsy showed GPC, this was reported as a contaminant).
Dexemethasone was started, but the patient's mental status
continued to deteriorate. Given his lack of response to
steroids, Radiation oncology felt that there would be no role
for XRT. Patient failed apnea test on [**11-15**]. Over the course of
2 days in the ICU, that patient's neurologic function did not
recover and family decided to change goals of care to CMO on
[**11-15**], and the patient was pronounced deceaased on the morning
of [**11-16**].
.
# Anemia: Pt around baseline Hct.
.
# Mild Dysuria: No fevers, back pain. UA and culture were
negative
.
# NHL: No current evidence for residual disaese per recent
PET-CT, but given presentation there was some concern for CNS
disease (see above).
.
# hx of CLL: No evidence of residual disaese:
.
# Anal Fissures: No evidence on exam for infection.

Medications on Admission:
Oxycodone 5mg PO 1-2 Tabs Q8PRN
Quetiapine 25mg TID:PRN
Bactrim SS Po Daily
MVI
Acyclovir 400mg PO Daily
Buproprion SR 100mg PO Daily
Lactulose PRN
Lorazepam 0.5mg PO PRN Anxiety


Discharge Medications:
none

Discharge Disposition:
Expired

Discharge Diagnosis:
Eosinophilic meningitis

Discharge Condition:
deceased


Completed by:[**2119-11-16**]
{'Other malignant lymphomas, lymph nodes of head, face, and neck,Eosinophilic meningitis,Toxic encephalopathy,Communicating hydrocephalus,Hyposmolality and/or hyponatremia,Acute respiratory failure,Other specified cardiac dysrhythmias'}


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: Confusion, Headache

PRESENT ILLNESS: 66M hx of CLL with subsequent evidence of Hodgkin's Lymphoma
that p/w low grade fever, headache and mild confusion. Per
patients wife and confirmed with the patient, the pt started
experiencing decreased appetitie, headaches, mild confusion and
lightheadedness on Sunday night [**2119-11-5**]. On Monday, [**11-6**], the pt
underwent removal of his PEG tube without complication. That
night the pt became more disoriented with 3-5 episodes of
yellowish emesis. He also experienced (+) chills, with
temperatures ranging from 98.1 to 100.0. The pt described his HA
as on top of his head [**2-6**]. In addition the patient states he
has been forgetful over the last few days. He admits to
occasional chills. No neck stiffness. No recent travel or sick
contacts.
.
Review of symptoms was positive for occasional blood on his
stool without frank melena or without gross hematochezia. Also
the pt complained of mild burning with urination. Otherwise no
abdominal pain, constipation, melena, chest pain, shortness of
breath, orthopnea, PND, lower extremity edema, cough, urinary,
dysuria, lightheadedness, no focal weakness, no vision changes,
no skin changes.

MEDICAL HISTORY: - CLL: diagnosed in [**2090**], but treatment started in [**2115**].
Treated
with FCR X 3 and is without evidence of recurrence since [**2116**].
-Hodgkin lymphoma: diagnosed in [**4-6**] after presenting in [**2-4**]
with high fever and syncope. Complicated by paraneoplasic
neuropathy manifested as dysphagia requiring G-tube placement

MEDICATION ON ADMISSION: Oxycodone 5mg PO 1-2 Tabs Q8PRN
Quetiapine 25mg TID:PRN
Bactrim SS Po Daily
MVI
Acyclovir 400mg PO Daily
Buproprion SR 100mg PO Daily
Lactulose PRN
Lorazepam 0.5mg PO PRN Anxiety

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.6 BP: 114/72 HR: 85 RR: 16 O2Sat: 98%
GEN: Thin appearing, speaking slightly slowly but fluently, no
acute distress
HEENT: NCAT, PERRL, EOMI, Oropharynx Clear for erythema or
lesions. Sclera anicteric, no epistaxis or rhinorrhea, MMM.
NECK: Neck Veins flat, No cervical, submental or submandibular
appreciable lymphadenopathy, trachea midline
COR: S1S2 No MRG
PULM: R basilar crackles. Lungs otherwise CTAB, no W/R/R
ABD: Soft, NT, ND, +BS, slightly erythematous and tenderness at
site of prior PEG. No HSM, No masses. Negative Murphys
EXT: No C/C/E, no palpable cords
NEURO: alert, oriented to person, place, and time. CN II ?????? XII
grossly intact. Moves all 4 extremities. Strength 5/5 in upper
and lower extremities. Patellar DTR +1. Plantar reflex
downgoing. No gait disturbance. No cerebellar dysfunction.
SKIN: Right upper back 1cm fluctuant, mobile nodule without
erythema. No jaundice, cyanosis, or gross dermatitis. No
ecchymoses.
RECTAL: Positive Perianal Warts without frank erythema or
tenderness, no DRE was performed.

FAMILY HISTORY: Non-Contributory

SOCIAL HISTORY: Former Sea-man. Married, not working, Denies Tobacco/Etoh 

### Response:
{'Other malignant lymphomas, lymph nodes of head, face, and neck,Eosinophilic meningitis,Toxic encephalopathy,Communicating hydrocephalus,Hyposmolality and/or hyponatremia,Acute respiratory failure,Other specified cardiac dysrhythmias'}
