CHIEF COMPLAINT: Confusion

PRESENT ILLNESS: HPI: The pt is a 54 year-old right-handed man who presents with
confusion and new left parietal mass. This morning, he was found
in the lobby of his building by a neighbor confused and oriented
to person only.  He was taken to [**Location (un) **] [**Location (un) 1459**] for further
evaluation.  Head CT was done which shows left parietal mass
with
surrounding edema and intratumoral hemorrhage.  He was loaded
with 1 g of fosphenytoin.  He was transferred to [**Hospital1 18**] ED for
further management.  Initially, neurosurgery was consulted, and
it was determined that no emergent neurosurgical intervention
was
indicated at this time.  Therefore, neurology was consulted.

MEDICAL HISTORY: Patient unable to discuss past medical history.
Per the records, he has history of alcohol abuse, HTN, COPD, and
aortic regurgitation

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Awake,  NAD, a bit unkempt.
HEENT: NC/AT, no scleral icterus noted, MMM, poor dentition
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Feet very dirty in appearance.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Patient unable to discuss

SOCIAL HISTORY: lives alone. He does not currently work.  He does not
interact with his family as he does not get along with them.  He
quit smoking 1 year ago.  He has history of alcohol abuse. Last
drink was on [**2132-1-26**].
Intracerebral hemorrhage,Cerebral edema,Hyposmolality and/or hyponatremia,Alcohol-induced persisting dementia,Personal history of tobacco use,Other convulsions,Unspecified essential hypertension,Aortic valve disorders,Polydipsia,Malignant neoplasm of thyroid gland,Other and unspecified alcohol dependence, unspecified
Intracerebral hemorrhage,Cerebral edema,Hyposmolality,Alcohol persist dementia,History of tobacco use,Convulsions NEC,Hypertension NOS,Aortic valve disorder,Polydipsia,Malign neopl thyroid,Alcoh dep NEC/NOS-unspec
Admission Date:  [**2132-2-15**]              Discharge Date:   [**2132-5-1**]

Date of Birth:  [**2077-10-6**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 4583**]
Chief Complaint:
Confusion

Major Surgical or Invasive Procedure:
CT scan.  MRI scans.


History of Present Illness:
HPI: The pt is a 54 year-old right-handed man who presents with
confusion and new left parietal mass. This morning, he was found
in the lobby of his building by a neighbor confused and oriented
to person only.  He was taken to [**Location (un) **] [**Location (un) 1459**] for further
evaluation.  Head CT was done which shows left parietal mass
with
surrounding edema and intratumoral hemorrhage.  He was loaded
with 1 g of fosphenytoin.  He was transferred to [**Hospital1 18**] ED for
further management.  Initially, neurosurgery was consulted, and
it was determined that no emergent neurosurgical intervention
was
indicated at this time.  Therefore, neurology was consulted.

Of note, the patient has felt that there was "something wrong
with his head" this past month.  He has had poor sleep for the
past month as well.

On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech.  Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.

On general review of systems, the pt denies recent fever or
chills.  No night sweats or recent weight loss or gain. He has
had cough for a few days.  Denies chest pain or tightness,
palpitations.  Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain.  No recent change in bowel or bladder habits.
No
dysuria.  Denies arthralgias or myalgias. Denies rash.


Past Medical History:
Patient unable to discuss past medical history.
Per the records, he has history of alcohol abuse, HTN, COPD, and
aortic regurgitation


Social History:
 lives alone. He does not currently work.  He does not
interact with his family as he does not get along with them.  He
quit smoking 1 year ago.  He has history of alcohol abuse. Last
drink was on [**2132-1-26**].


Family History:
Patient unable to discuss


Physical Exam:
General: Awake,  NAD, a bit unkempt.
HEENT: NC/AT, no scleral icterus noted, MMM, poor dentition
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Feet very dirty in appearance.
Skin: no rashes or lesions noted.

Neurologic:
-Mental Status: Awake, alert, oriented to self and "hospital."
He cannot state month.  He thinks it is [**2120**].  Speech is fluent.
Unable to spell WORLD forward or backward.  Poor calcualtion.
Difficulty naming low frequency objects.  Able to name high
frequency objects.  Able to follow both midline and appendicular
commands. Difficulty with repitition.  Pt. was able to register
3
objects and recall 0/3 at 5 minutes.  There was no evidence of
apraxia or neglect.

-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.  VFF to confrontation.
III, IV, VI: EOMI without nystagmus.  Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
[**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.

-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
  Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB
L  5    5   5   5   5  5  5  5   5    5  5     5     5   5
R  5    5   5   5   5  5  5  5   5    5  5     5     5   5

-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.

-DTRs:
  [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach
L  2  2    2    2   1
R  2  2    2    2   1
Plantar response was flexor bilaterally.

-Coordination: No dysmetria on FNF bilaterally.

-Gait: not tested


Pertinent Results:
[**2132-2-15**] 05:55PM URINE  HOURS-RANDOM
[**2132-2-15**] 05:55PM URINE  GR HOLD-HOLD
[**2132-2-15**] 05:55PM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.022
[**2132-2-15**] 05:55PM URINE  BLOOD-SM NITRITE-NEG PROTEIN-25
GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-8* PH-6.5 LEUK-NEG
[**2132-2-15**] 05:55PM URINE  MUCOUS-MOD
[**2132-2-15**] 01:20PM   GLUCOSE-112* UREA N-8 CREAT-0.9 SODIUM-133
POTASSIUM-3.6 CHLORIDE-96 TOTAL CO2-29 ANION GAP-12
[**2132-2-15**] 01:20PM   estGFR-Using this
[**2132-2-15**] 01:20PM   ALT(SGPT)-23 AST(SGOT)-22 LD(LDH)-174 ALK
PHOS-36* TOT BILI-0.5
[**2132-2-15**] 01:20PM   ALBUMIN-4.1
[**2132-2-15**] 01:20PM   WBC-5.3 RBC-4.68 HGB-14.2 HCT-39.3* MCV-84
MCH-30.3 MCHC-36.1* RDW-12.7
[**2132-2-15**] 01:20PM   PLT COUNT-133*
[**2132-2-15**] 01:20PM   PT-12.4 PTT-25.6 INR(PT)-1.0

MRI [**2132-4-25**]
IMPRESSION:
1. Near-complete resorption of large left parietal hemorrhage,
with residual cystic cavity and no evidence of underlying
masses. The presumed etiology is either hypertensive bleed or a
ruptured vascular malformation which has involuted, and is no
longer visualized.
2. Chronic opacification of right frontal sinus, with
T1-hyperintense
material suggesting inspissated secretions or fungal infection.

MRI [**2132-3-14**]
IMPRESSION: Interval partial resorption of the left parietal
hematoma and
stable ventricular dimension without evidence of new hemorrhage
or infarction. No evidence of a mass lesion.

MRI [**2132-2-16**]
1. 6.4x6.0cm area of mixed signal intensity in the left parietal
lobe
representing acute-subacute hematoma with mild-to-moderate
surrounding edema noted. While there are no large areas of
abnormal enhancement, underlying causes include small
mass/vascular lesion within or hemorrhagic infarct or amyloid
angiopathy(less likely given the patient's age and lack of
micorhemorrhages elsewhere). Consider close follow up to assess
interval change and further workup to be based on INR consult.

2. Decreased signal in the distal vertebral and the Basilar
artery as
described above. A few tiny vessels in proximity to the superior
part of the hematoma, liekly veins. CTA and CTV can be
considered for better assessment of the above findings.




Brief Hospital Course:
Neurology: Mr. [**Known lastname 4643**] has been an inpatient since [**2132-2-15**].

He was admitted with a large left parietal hemorrhage requiring
Metoprolol and agressive blood pressure control. He also had
seizures and was started on Keppra.
He only is oriented to person only, and was not clinically
competent to make medical decisions for himself. Guardianship
though the court system was thus pursued.

Upon admission to [**Hospital Ward Name **] 11 the patient has appeared clinically
stable.  Patient has continued to have cognitive dysfunction
regarding his overall orientation.  He has remained oriented to
self, but place and time has varied, but continued to improve.
The patient was originally started on Dexamethasone due to
concern for mass underlying bleed.  Dexamethasone was tapered.

Metoprolol was started twice daily for blood pressure control.
HCTZ was also started, however was switched to Lisinopril due to
hyponatremia.

Keppra was given for seizure prophylaxis. Mr. [**Name13 (STitle) 1356**] had a period
in the middle of [**Month (only) **] when he had started to refuse
medications, and he had a generalized tonic-clonic seizure along
with a hypertensive episode into the 200's.  He was transferred
to the NeuroICU for 2 days where he was soon extubated and sent
back to the floor.  He soon recovered on the floor, and
continued to take his PO medications, without further seizures
or hypertension greater than 150's.

There was no evidence of mass on initial and repeat MRI.
Subsequent brain MRI [**4-25**] showed near-complete resorption of
large left parietal hemorrhage, with residual
cystic cavity and no evidence of underlying masses.

Mr. [**Known lastname 4643**] had transient hyponatremia thought to be due to
primary polydipsia and HCTZ.  His HCTZ was changed to
Lisinopril.  Fluid restriction was attempted, but logistically
impossible.  Therefore, Mr. [**Known lastname 4643**] was treated briefly with salt
tabs.  Hyponatremia resolved.

Mr. [**Known lastname 4643**] was found to have thyroid nodules on chest CT scan.
A thyroid ultrasound showed calcification of one left thyroid
nodule.  This was biopsied (FNA) under anesthesia.  The
pathology was pending at discharge and will need to be followed
outpatient.

Psychiatry was consulted and it was determined that the patient
lacked capacity to make his own decisions. Guardianship was
pursued and assigned to Attorney [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 72186**].

Medications on Admission:
None

Discharge Medications:
1. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
4. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
8. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for SBP >160.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 2857**] - Twin Oaks - [**Location (un) 4047**]

Discharge Diagnosis:
Intracranial Bleed.
Hypertension.
Thyroid nodules
Presumed history of alcohol abuse.


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:

You were admitted to the hospital due to altered mental status
and found to have a left sided parietal hemmorhage though to be
secondary to hypertension.  You had several brain MRIs which did
not show evidence of an underlying tumor.

You had high blood pressure which was treated initially with
metoprolol and hydrochlorothiazide.  However, you developed low
sodium.  Therefore, your blood pressure medication was switched
to metoprolol and lisinopril. Your sodium levels improved.

Psychiatry was consulted and it was determined that you require
a guardian, which has been assigned - Attorney [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **]
[**Telephone/Fax (1) 72186**], who will make medical decisions.

You were found to have thyroid nodules.  You had a biopsy of
your thyroid on [**4-25**] under sedation and results were pending at
discharge.

You were started on Keppra to prevent seizures.  You should
continue Keppra until instructed otherwise.

Followup Instructions:
Please follow up with a local neurologist outpatient in [**2-28**]
months.  Please also follow up with your primary care physician
in the next 1-2 weeks for follow up of the thyroid biopsy
results.





Name:  [**Known lastname **],[**Known firstname **]                    Unit No:   [**Numeric Identifier 14261**]

Admission Date:  [**2132-2-15**]              Discharge Date:   [**2132-5-1**]

Date of Birth:  [**2077-10-6**]             Sex:   M

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 542**]
Addendum:
Mr. [**Known lastname 14262**] pathology on his thyroid biopsy showed likely
papillary carcinoma.  He remained in the hospital for several
additional days and was evaluated by endocrinology and endocrine
surgery.  Both felts that he need a thyroidectomy for treatment.
 After extensive discussions with the surgical team, Mr.
[**Known lastname 14262**] legal guardian ([**Name (NI) 582**] [**Last Name (NamePattern1) 1478**]) and Mr. [**Known lastname **], it was
determined that this could safely be completed outpatient within
the next 8 weeks.  Mr. [**Known lastname 14262**] guardian will call the surgeon
Dr.[**Name (NI) 14263**] office at [**Telephone/Fax (1) 14264**] to schedule an
appointment or will find a local thyroid surgeon to perform the
procedure.  He was discharged to rehab on [**2132-5-1**].


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7340**] - Twin Oaks - [**Location (un) 4186**]

                             [**First Name11 (Name Pattern1) 194**] [**Last Name (NamePattern4) 544**] MD [**MD Number(1) 545**]

Completed by:[**2132-5-1**]
{'Intracerebral hemorrhage,Cerebral edema,Hyposmolality and/or hyponatremia,Alcohol-induced persisting dementia,Personal history of tobacco use,Other convulsions,Unspecified essential hypertension,Aortic valve disorders,Polydipsia,Malignant neoplasm of thyroid gland,Other and unspecified alcohol dependence, unspecified'}


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

PRESENT ILLNESS: HPI: The pt is a 54 year-old right-handed man who presents with
confusion and new left parietal mass. This morning, he was found
in the lobby of his building by a neighbor confused and oriented
to person only.  He was taken to [**Location (un) **] [**Location (un) 1459**] for further
evaluation.  Head CT was done which shows left parietal mass
with
surrounding edema and intratumoral hemorrhage.  He was loaded
with 1 g of fosphenytoin.  He was transferred to [**Hospital1 18**] ED for
further management.  Initially, neurosurgery was consulted, and
it was determined that no emergent neurosurgical intervention
was
indicated at this time.  Therefore, neurology was consulted.

MEDICAL HISTORY: Patient unable to discuss past medical history.
Per the records, he has history of alcohol abuse, HTN, COPD, and
aortic regurgitation

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: General: Awake,  NAD, a bit unkempt.
HEENT: NC/AT, no scleral icterus noted, MMM, poor dentition
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally. Feet very dirty in appearance.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Patient unable to discuss

SOCIAL HISTORY: lives alone. He does not currently work.  He does not
interact with his family as he does not get along with them.  He
quit smoking 1 year ago.  He has history of alcohol abuse. Last
drink was on [**2132-1-26**]. 

### Response:
{'Intracerebral hemorrhage,Cerebral edema,Hyposmolality and/or hyponatremia,Alcohol-induced persisting dementia,Personal history of tobacco use,Other convulsions,Unspecified essential hypertension,Aortic valve disorders,Polydipsia,Malignant neoplasm of thyroid gland,Other and unspecified alcohol dependence, unspecified'}
