CHIEF COMPLAINT: nausea, emesis, lethargy

PRESENT ILLNESS: 53RH woman with stage IV non-small cell lung cancer with brain
mets s/p steroid therapy and whole brain radiation completed on
[**2188-6-18**] presented [**2188-7-9**] with sudden onset nausea/vomiting and
lethargy. CT head showed increased size of her left occipital
mass with significant vasogenic edema. Prior to [**2188-7-9**], her
family reports that she had trouble seeing things in her right
visual field but had no other neurological symptoms.

MEDICAL HISTORY: ONCOLOGIC HISTORY:
- Stage IV non-small cell lung cancer (adenocarcinoma; EGFR
wild-type, EML-ALK non-rearranged, KRAS mutated (p.G12C).
Current treatment - Cisplatin 75mg/m2 + pemetrexed 500 mg/m2
with concurrent radiation therapy.
- MRI [**5-/2188**] head revealed new brain lesions after new
neurological symptoms of headaches, visual deficit of the right
field, and right lower extremity weakness. She was initiated on
steroids and then underwent whole brain radiation from [**2099-6-5**]
to [**2188-6-18**].

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PharmacywebOMR.
1. Dexamethasone 2 mg PO DAILY
taper per Dr [**Last Name (STitle) **]
Tapered dose - DOWN
2. Nystatin Oral Suspension 5 mL PO QID
3. Omeprazole 20 mg PO DAILY
4. Zolpidem Tartrate 10 mg PO HS insomnia
5. LeVETiracetam 500 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
Vitals: T:98.9 P:70s  R:20  BP:140s/70s  SaO2:98% RA
General: eyes closed, no acute distress
HEENT: NC/AT, shaved head, no scleral icterus, MMM
Neck: No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Father, deceased, with lung cancer
Mother, alive, h/o breast cancer, colon cancer
Brother, [**Name (NI) 94917**] 2 weeks ago from small cell lung cancer,smoker,
rx at [**Company 2860**]
Gfather, deceased, colon cancer
Gmother, deceased, lung cancer

SOCIAL HISTORY: The patient is single/lives alone in [**Location (un) 1411**], never married, no
children.
Occupation: previously worked fulltime as a waitress at Legals
restaurant
Mobility: unaided
Smoking: Ex-smoker quir 10 years ago previously 30 per day for
close to 30 years
Alcohol: occasionally
Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Malignant neoplasm of bronchus and lung, unspecified,Obstructive hydrocephalus,Personal history of tobacco use
Sec mal neo brain/spine,Cerebral edema,Mal neo bronch/lung NOS,Obstructiv hydrocephalus,History of tobacco use
Admission Date:  [**2188-7-9**]              Discharge Date:   [**2188-7-15**]

Date of Birth:  [**2134-7-28**]             Sex:   F

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
nausea, emesis, lethargy

Major Surgical or Invasive Procedure:
[**2188-7-11**]:  Left craniotomy with metastasis resection
[**2188-7-11**]:  Right frontal EVD placement
[**2188-7-14**]:  Removal of Right EVD and placement of right frontal
VP Shunt


History of Present Illness:
53RH woman with stage IV non-small cell lung cancer with brain
mets s/p steroid therapy and whole brain radiation completed on
[**2188-6-18**] presented [**2188-7-9**] with sudden onset nausea/vomiting and
lethargy. CT head showed increased size of her left occipital
mass with significant vasogenic edema. Prior to [**2188-7-9**], her
family reports that she had trouble seeing things in her right
visual field but had no other neurological symptoms.

In the ED she was noted to be lethargic but otherwise moving all
extremities. She received 10mg IV dexamethasone and has been
continued on 4mg IV q 6 hours. She was started on levetiracetam
this morning for seizure prophylaxis. There has been no clinical
activity concerning for seizure.

Past Medical History:
ONCOLOGIC HISTORY:
- Stage IV non-small cell lung cancer (adenocarcinoma; EGFR
wild-type, EML-ALK non-rearranged, KRAS mutated (p.G12C).
Current treatment - Cisplatin 75mg/m2 + pemetrexed 500 mg/m2
with concurrent radiation therapy.
- MRI [**5-/2188**] head revealed new brain lesions after new
neurological symptoms of headaches, visual deficit of the right
field, and right lower extremity weakness. She was initiated on
steroids and then underwent whole brain radiation from [**2099-6-5**]
to [**2188-6-18**].

[**2188-2-24**] - CT of the chest for refractory cough reveals a large
right upper lobe mass extending into the chest wall with
probable/possible chest wall invasion, with mediastinal
lymphadenopathy.
[**2188-3-10**] - Bronchoscopy - Transbronchial biopsy of the mass, 4L,

4R and 11R nodes, and bronchial wash positive for non-small cell

lung cancer (adenocarcinoma)
[**2188-3-17**] - PET/CT - FDG avid right upper lobe mass with surrouding

ground-glass opacities suggestive of lymphangitic spread and FDG

avid extensive mediastinal lymphadenopathy, but no other FDG
avid lesions at other sites.
MRI head - Concern of a single 4 mm left occipital mass,
questionable metastases.
[**2188-3-26**] - Initiated radiation therapy
[**2188-3-27**] - Cycle 1 Cisplatin (75 mg/m2) + Pemetrexed (500 mg/m2)

[**2188-4-17**] - Cycle 2 Cisplatin/Pemetrexed
[**2188-5-8**] - Cycle 3 Cisplatin/Pemetrexed
[**2188-5-13**] - Completed thoracic radiation therapy
[**2188-6-2**]- MRI head - New brain mets
[**2188-6-2**] - PET/CT Partial remission
[**2188-6-6**] - [**2188-6-18**] - Whole brain radiation

Social History:
The patient is single/lives alone in [**Location (un) 1411**], never married, no
children.
Occupation: previously worked fulltime as a waitress at Legals
restaurant
Mobility: unaided
Smoking: Ex-smoker quir 10 years ago previously 30 per day for
close to 30 years
Alcohol: occasionally


Family History:
Father, deceased, with lung cancer
Mother, alive, h/o breast cancer, colon cancer
Brother, [**Name (NI) 94917**] 2 weeks ago from small cell lung cancer,smoker,
rx at [**Company 2860**]
Gfather, deceased, colon cancer
Gmother, deceased, lung cancer

Physical Exam:
On Admission:
Vitals: T:98.9 P:70s  R:20  BP:140s/70s  SaO2:98% RA
General: eyes closed, no acute distress
HEENT: NC/AT, shaved head, no scleral icterus, MMM
Neck: No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.


Neurological examination:
- Mental Status: Eyes closed spontaneously, opens briefly to
loud
voice/noxious. Resists eye opening. Says "yes" to questions
inappropriately. No other verbal output. Does not follow
commands. Very inattentive.

- Cranial Nerves:
PERRL 3mm -->2.5mm and brisk. Resists eye opening. Corneals
intact bilaterally. OCR intact. No blink to threat bilaterally.
When eyelids held open, eyes dysconjugate, bilaterally deviated
laterally. At brief times when patient arouses and eyes are
open,
they start to converge closer to conjugate.
Face symmetric.

- Motor: Normal bulk, tone throughout. No adventitious
movements.
All 4 limbs move at least antigravity to stimulus and
occasionally spontaneously.

- Sensory: Grimaces to noxious throughout with localization.

- DTRs:
   [**Name2 (NI) **] Br Tt  Pa  AJ
L  2  2  2   2   1
R  2  2  2   2   1

Plantar response was extensor bilaterally although patient also
have brisk voluntary withdrawal.

On discharge:
AOx3, following commands, alert and interactive.
Right hemianopsia
Motor: Full strength throughout

Pertinent Results:
CT head [**2188-7-9**]:
Increased size of the metastatic lesion within the left
occipital
lobe with increasing surrounding vasogenic edema.  New mild
hydrocephalus of unclear etiology.

CT head [**2188-7-10**]:
1.  Stable appearance of the three known metastases in
comparison to the prior exam performed 10 hours prior.  There is
no evidence of new hemorrhage, mass effect, or infarction.
2.  Stable mass effect on the left lateral ventricle with
persistent  ventriculomegaly, unchanged from the prior exam
performed 10 hours earlier, but increased from the prior MRI in
[**2188-5-13**].

MRI Head [**2188-7-11**]:
1. Increase in size of left occipital lobe lesion with increased
mass effect on the occipital [**Doctor Last Name 534**] of the left lateral ventricle,
similar degree of subependymal spread along the occipital [**Doctor Last Name 534**]
of the left lateral ventricle and mild adjacent mass effect and
rightward deviation of the posterior falx.
2. Second lesion just adjacent to the vermis within the left
occiput and right frontal lesion have decreased in size compared
to the prior examination.
3. Mildly increased size of the ventricles compared to the prior
exam.

MRI Head [**2188-7-12**]:
1. Status post left occipital craniotomy, expected post-surgical
changes are seen, consistent with edema in the surgical bed and
residual blood products. There is persistent residual mass
effect in the left ventricular trigone and associated vasogenic
edema.
2. The area with enhancement in the left occipital lobe has been
removed, the possibility of residual mass cannot be completely
excluded, followup is advised.  Unchanged right frontal
enhancing lesion.  Ventricular shunt is in place, terminating at
the foramen of [**Last Name (un) 2044**] via right frontal burr hole with no
evidence of hydrocephalus.

NONCONTRAST HEAD CT ([**2188-7-14**], post-VP shunt):
1. The right frontal approach intraventricular catheter
terminates in the
region of the foramen of [**Last Name (un) 2044**]. The ventricles have decreased in
size since [**2188-7-11**]. Small amount of intraventricular hemorrhage.

2. S/p left occipital mass resection. Related findings are
better assessed on the [**2188-7-12**] MRI.

Brief Hospital Course:
53 yo RH woman with stage IV NSCLC with brain mets s/p steroid
therapy and whole-brain radiation completed on [**2188-6-18**] presenting
with sudden-onset N/V and lethargy, found to have increased size
of left occipital mass with significant vasogenic edema
.
# OCCIPITAL MASS: Patient was admitted to medicine on after CT
head showed large left occipital mass. In the ED she was started
on dexamethasone and keppra. On HD#2 she became more lethargic
so neurosurgery consult was obtained. She was transferred to ICU
and started seizure prophylaxis. Dr. [**Last Name (STitle) **] met with the family
to discuss the option of surgery, and family met with palliative
care to discuss comfort options.On HD#3 her neurological status
significantly improved, and the decision was made to pursue
operative care. That evening, she underwent right EVD drain
placement, followed by a left craniotomy with metastasis
excision. The operation was without complications. Following the
procedure, the patient was extubated and transported back to the
ICU.  Her steroid dose was escalated with accompanying
percautions. On HD#4 (POD #1), she was AAOx3 with fluid speech
and intact repetition/comprehension, but reported NEW right
hemianopia likely secondary to mass resection. She was
transferred to stepdown unit. On HD#4 (POD #2), her neuro exam
remained stable. Dressings were removed, wound C/D/I. Her EVD
remained open at 10 mmHg. On HD#5, patient returned to OR for VP
shunt placement. Her EVD was clamped prior to procedure. Right
VP shunt was placed and EVD removed during procedure. Follow-up
CT showed good shunt placement and small intraventricular
hemorrhage. On HD#6 she was tolerating PO diet and meds.  She
was seen and evaluated by physical therapy who recommended acute
rehab. Steroids to taper to Dexamethsaone 2mg [**Hospital1 **] and continute
until follow up in brain tumor clinic.
.
# GOALS OF CARE: Patient's family initially requested palliative
care consult, and plan was for CMO until her neurologic status
improved on HD#3 and patient requested surgery. On HD#6 she and
family expressed interest in discharge to hospice. Hospice
consult was obtained and will follow her through her rehab
period

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PharmacywebOMR.
1. Dexamethasone 2 mg PO DAILY
taper per Dr [**Last Name (STitle) **]
Tapered dose - DOWN
2. Nystatin Oral Suspension 5 mL PO QID
3. Omeprazole 20 mg PO DAILY
4. Zolpidem Tartrate 10 mg PO HS insomnia
5. LeVETiracetam 500 mg PO BID


Discharge Medications:
1. Zolpidem Tartrate 10 mg PO HS insomnia
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 Capsule(s) by mouth Daily Disp #*30
Capsule Refills:*3
3. Nystatin Oral Suspension 5 mL PO QID
4. LeVETiracetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 Tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
5. Dexamethasone 1 mg PO SEE TAPER BELOW
Starting on [**2188-7-16**], take 4 pills 3 times per day. On [**2188-7-18**],
decrease dose to 3 pills 3 times per day. On [**2188-7-20**], decrease
dose to 2 pills 3 times per day. on [**2188-7-22**], decrease dose to 2
pills 2 times per day. Continue this dose until neuro-oncology
follow-up.
Tapered dose - DOWN
RX *dexamethasone 1 mg 1 Tablet(s) by mouth see taper below Disp
#*80 Tablet Refills:*0
6. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-14**] Tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. Acetaminophen 325-650 mg PO Q6H:PRN pain
8. Docusate Sodium 100 mg PO BID
9. Senna 1 TAB PO BID:PRN Constipation


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Stage 4 non-small cell lung cancer metastasis to brain with mass
effect and hydrocephalus

Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).

Discharge Instructions:
??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Dressing may be removed on Day 2 after surgery.
??????	**You have dissolvable sutures you may wash your hair and get
your incision wet day 3 after surgery.  You may shower before
this time using a shower cap to cover your head.
??????	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) &
Senna 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.
??????	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.
??????	Make sure to continue to use your incentive spirometer while
at home.


Followup Instructions:
??????	You have an appointment in the Brain [**Hospital 341**] Clinic on [**2188-7-28**] at 12pm.  The Brain [**Hospital 341**] Clinic is located on the [**Hospital Ward Name 5074**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building, [**Location (un) **]. Their phone
number is [**Telephone/Fax (1) 1844**]. Please call if you need to change your
appointment, or require additional directions.
??????	You will not need an MRI of the brain.


Completed by:[**2188-7-15**]
{'Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Malignant neoplasm of bronchus and lung, unspecified,Obstructive hydrocephalus,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: nausea, emesis, lethargy

PRESENT ILLNESS: 53RH woman with stage IV non-small cell lung cancer with brain
mets s/p steroid therapy and whole brain radiation completed on
[**2188-6-18**] presented [**2188-7-9**] with sudden onset nausea/vomiting and
lethargy. CT head showed increased size of her left occipital
mass with significant vasogenic edema. Prior to [**2188-7-9**], her
family reports that she had trouble seeing things in her right
visual field but had no other neurological symptoms.

MEDICAL HISTORY: ONCOLOGIC HISTORY:
- Stage IV non-small cell lung cancer (adenocarcinoma; EGFR
wild-type, EML-ALK non-rearranged, KRAS mutated (p.G12C).
Current treatment - Cisplatin 75mg/m2 + pemetrexed 500 mg/m2
with concurrent radiation therapy.
- MRI [**5-/2188**] head revealed new brain lesions after new
neurological symptoms of headaches, visual deficit of the right
field, and right lower extremity weakness. She was initiated on
steroids and then underwent whole brain radiation from [**2099-6-5**]
to [**2188-6-18**].

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PharmacywebOMR.
1. Dexamethasone 2 mg PO DAILY
taper per Dr [**Last Name (STitle) **]
Tapered dose - DOWN
2. Nystatin Oral Suspension 5 mL PO QID
3. Omeprazole 20 mg PO DAILY
4. Zolpidem Tartrate 10 mg PO HS insomnia
5. LeVETiracetam 500 mg PO BID

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On Admission:
Vitals: T:98.9 P:70s  R:20  BP:140s/70s  SaO2:98% RA
General: eyes closed, no acute distress
HEENT: NC/AT, shaved head, no scleral icterus, MMM
Neck: No nuchal rigidity.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.

FAMILY HISTORY: Father, deceased, with lung cancer
Mother, alive, h/o breast cancer, colon cancer
Brother, [**Name (NI) 94917**] 2 weeks ago from small cell lung cancer,smoker,
rx at [**Company 2860**]
Gfather, deceased, colon cancer
Gmother, deceased, lung cancer

SOCIAL HISTORY: The patient is single/lives alone in [**Location (un) 1411**], never married, no
children.
Occupation: previously worked fulltime as a waitress at Legals
restaurant
Mobility: unaided
Smoking: Ex-smoker quir 10 years ago previously 30 per day for
close to 30 years
Alcohol: occasionally 

### Response:
{'Secondary malignant neoplasm of brain and spinal cord,Cerebral edema,Malignant neoplasm of bronchus and lung, unspecified,Obstructive hydrocephalus,Personal history of tobacco use'}
