CHIEF COMPLAINT: 

PRESENT ILLNESS: This is a 49-year-old man with
a history of systemic and CNS lymphoma, who was transferred
from [**Hospital1 41211**] Hospital after he experienced a prolonged
seizure tonic-clonic lasting approximately one hour.

MEDICAL HISTORY: 1. EBV positive B-cell lymphoma.
2. CNS lymphoma status post XRT and intrathecal chemotherapy
complicated by meningitis requiring shunt removal.
3. Seizure disorder status post left frontal craniotomy with
residual left frontal lymphoma.
4. Hypertension.
5. Clostridium difficile infection.
6. Recent Port-A-Cath infection.

MEDICATION ON ADMISSION: 

ALLERGIES: 1. ACE inhibitors.
2. Bactrim.
3. Question Dilantin caused transaminitis.

PHYSICAL EXAM: Temperature was 96.4 F.  Pulse was 58.  Blood
pressure was 120/60.  Respiration was 18.  Saturation was at 98%
on room air.  Generally, he was not responding to voice.  But he
opened his eyes to sternal rub.  He moved his left arm and leg
spontaneously, but no verbal output.  He had moist mucous
membranes.  His head was normocephalic, atraumatic.  Oropharynx
was clear.  Neck was supple without carotid bruits.  Lungs were
clear.  Heart was regular, rate, and rhythm.  Abdomen was benign.
Extremities were without edema.

FAMILY HISTORY: 

SOCIAL HISTORY: He is married and lives with his wife.  [**Name (NI) **]
alcohol or tobacco.  Worked in finance prior to his medical
problems.
Other convulsions,Other pulmonary embolism and infarction,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Unspecified essential hypertension,Rash and other nonspecific skin eruption
Convulsions NEC,Pulm embol/infarct NEC,Oth lymp unsp xtrndl org,Int inf clstrdium dfcile,Hyposmolality,Hypertension NOS,Nonspecif skin erupt NEC
Admission Date:  [**2196-8-15**]     Discharge Date:  [**2196-8-24**]

Date of Birth:   [**2146-12-16**]     Sex:  M

Service:  Oncology Medicine

HISTORY OF PRESENT ILLNESS:  This is a 49-year-old man with
a history of systemic and CNS lymphoma, who was transferred
from [**Hospital1 41211**] Hospital after he experienced a prolonged
seizure tonic-clonic lasting approximately one hour.

According to his family, patient was doing well at home until
yesterday despite a recent Clostridium difficile and Port-A-Cath
infection.  One day prior to admission, he had seemed more tired
than usual, although he had no specific complaints.  His wife
heard him moan the evening before admission, which he typically
does at the onset of seizure.  She went to check on him.  He was
shaking all 4 extremities.  His head was deviated to the right.
This lasted about 3 minutes and then stopped.  She asked some
questions but he was unable to respond.  She asked him to raise
his arm if he understood, and he was able to do that.  She says
this seizure was typical with seizures.  They start with eyes and
head turning to the right followed by generalized tonic-clonic
activity.  His last seizure prior to this was in [**2196-4-24**].

About one minute after his seizure stopped, his seizure recurred.
His eyes again deviated to the right.  He was shaking all 4
extremities.  After this continued for approximately 4 minutes,
she called EMS.  The next hour during the ambulance ride and
arrival at the outside hospital, the patient continued to have
seizure on and off.  In the ambulance, he was given 4 mg of IV
Ativan and received another 4 mg at the outside hospital and his
seizures ceased.  He did not require intubation.  He is normally
on Depakote and Keppra.  His family denies any recent doses or
any change in his doses.  His valproic acid level was 95. Unknown
if this was a trough and he was given another 500 mg of Depakote
IV.

PAST MEDICAL HISTORY:
1. EBV positive B-cell lymphoma.
2. CNS lymphoma status post XRT and intrathecal chemotherapy
complicated by meningitis requiring shunt removal.
3. Seizure disorder status post left frontal craniotomy with
residual left frontal lymphoma.
4. Hypertension.
5. Clostridium difficile infection.
6. Recent Port-A-Cath infection.

MEDICATIONS:
1. Decadron 2 mg p.o. q.d.
2. Keppra 1,000 mg p.o. b.i.d.
3. Depakote 750 mg p.o. q.i.d.
4. Protonix 40 mg p.o. q.d.
5. Actonel 30 mg p.o. q week.
6. KCl 20 mEq p.o. q.d.
7. Flagyl 500 mg p.o. t.i.d.
8. Thiamine 100 mg p.o. q.d.
9. Rituxan.

ALLERGIES:
1. ACE inhibitors.
2. Bactrim.
3. Question Dilantin caused transaminitis.

SOCIAL HISTORY:  He is married and lives with his wife.  [**Name (NI) **]
alcohol or tobacco.  Worked in finance prior to his medical
problems.

PHYSICAL EXAM:  Temperature was 96.4 F.  Pulse was 58.  Blood
pressure was 120/60.  Respiration was 18.  Saturation was at 98%
on room air.  Generally, he was not responding to voice.  But he
opened his eyes to sternal rub.  He moved his left arm and leg
spontaneously, but no verbal output.  He had moist mucous
membranes.  His head was normocephalic, atraumatic.  Oropharynx
was clear.  Neck was supple without carotid bruits.  Lungs were
clear.  Heart was regular, rate, and rhythm.  Abdomen was benign.
Extremities were without edema.

NEUROLOGICAL EXAMINATION:  He opened his eyes to sternal rub,
BUT not following commands at all.  He did not have verbal output
at all.  Cranial nerves II through XII:  Discs were not well
visualized, with difficulty dolling eyes to the left.  He had
pendular nystagmus and a right facial droop.  He would not
protrude his tongue.  Motor:  When his left arm was lifted, he
was able to hold it up by himself for at least 5 seconds.
Spontaneously raises his left arm, right arm with decreased tone,
falls right to the bed when released, withdrew with both legs to
nail bed pressure and winced.  His right leg was externally
rotated, withdrew less to plantar stimulation with right leg
compared to the left.  He withdrew from pain sensation at all 4
extremities and winces.  Deep tendon reflexes were decreased
throughout and flexor plantar responses bilaterally. Coordination
was not able to assess and gait was deferred.

LABORATORIES FROM THE OUTSIDE HOSPITAL:  White count of 2.8,
65 neutrophils, 7 bands, 2 lymphocytes, 5 atypical
lymphocytes, 2 metamyelocytes, and 9 eosinophils.  Hematocrit
29.5, platelets 70.  Sodium 139, potassium 4.3, chloride 100,
bicarb 29, BUN 19, creatinine 1.3, glucose 86, calcium 8,
magnesium 1.4, albumin 2.9, AST 29, ALT 28, alkaline
phosphatase 55, and total bilirubin less than 0.5.  Valproic acid
was 94.5 at midnight on [**2196-8-14**].  Blood cultures x 2 were
negative growth to date.

A head CT showed small areas of hyperintensity in the left
frontal lobe, which is likely consistent with residual lymphoma.
No evidence of a new hemorrhage or mass effect.

Patient was admitted and his hospital course was significant for
the following issues:  Patient was admitted initially to the
Neuro ICU.

(1) Seizures:  A Neurology consult was obtained in the Emergency
Department.  An EEG was obtained, which showed nearly persistent
polymorphic theta frequency slowing seen over the left frontal
and temporal lobes.  The entire record was of low amplitude.
There was no epileptiform features and no electrocardiographic
seizures are recorded, thought to be consistent with a post-ictal
state after prolonged seizure.

A repeat EEG was obtained the following day.  It was consistent
with encephalopathy.  Multifocal isolated sharp waves seen on the
right parasagittal, central, and posterior regions.  A MRI of the
head was obtained, which was abnormal on FLAIR.  There was
extensive white matter disease in the left frontal greater than
the right frontal, but study showed no evidence of a brain
abscess and abnormalities did not change significantly since the
prior examination.

Lumbar puncture was obtained.  CSF was remarkable for a white
count of 1, no red blood cells, protein of 91, glucose of 41, and
LDH of 30.  CSF cytology was pending at the time of dictation
as was beta-2 microglobulin.  Gram stain was negative.  The
patient's Keppra level was increased to 1500 mg b.i.d. and was
continued on the valproic acid 750 mg q 6 hours.  Sepsis workup
was undertaken with the LP negative for acute infectious process.
The Flagyl, which the patient had been started on for Clostridium
difficile was changed to vancomycin given the concern for a
decrease seizure threshold with the metronidazole.

On the next day, the patient's mental status improved but had
residual right sided weakness.  A swallowing study was obtained.
The patient had a video swallow study.  Recommendations were
initiated p.o. diet consistency of thin liquids and soft solids,
crushing pills in puree.  Maintaining aspiration precautions with
one-to-one supervision at meals to provide q's, to make sure that
the patient cleared his throat and swallowed after every [**2-27**]
bites or sips.

Patient remained alert and oriented to name, occasionally to
place.  He continued to experience difficulty with word finding.
No further seizure activity was observed, and he was transferred
to the Oncology Medicine floor on [**2196-8-18**].  At that time, the
patient seemed comfortable with no signs of seizure activity.  He
was continued on Keppra and Depakote.  Over the next few days,
the patient continued to improve.

On the [**2196-8-21**], the patient was noted to have some global
seizure activity in the right upper extremity and left upper
extremity.  On that day, he was started on Lamictal 25 mg b.i.d.
and received that dose for one day afterwards the dose was
reduced to 12.5 mg p.o. q.d. given the concern for increased
half-life of the drug with concurrent valproic acid.  He remained
seizure free throughout the rest of the hospital course, and his
mental status continued to improve.  His right sided weakness
also resolved.  Patient was discharged on valproic acid, Keppra,
and Lamictal with plans to titrate up the Lamictal within the
next several weeks.

Patient had a tremor, which was thought to be secondary to high
levels of valproic acid.  Tremor was not present at the time of
discharge.

(2) Metastatic CNS lymphoma:  Due to the MRI and CSF profile
provided evidence for disease progression, a staging CT of the
torso was done, which showed the patient had a right sided
pulmonary embolism.

(3) Pulmonary embolism:  Patient had a pulmonary embolism
diagnosed on [**8-19**] on a staging CT.  He was started on a heparin
drip without a bolus.  PTT was maintained in the 80 to 100 range.
He also started on Coumadin.  A Pulmonary consult was obtained
given the concern that this might be tumor invasion.  However,
this was thought to be a pulmonary embolism and the patient was
recommended to be on life-long anticoagulation.  He was
discharged on Coumadin.  Heparin drip was discontinued 24 hours
prior to discharge after the patient's INR was therapeutic.

(4) Hyponatremia:  Patient experienced hyponatremia in the Neuro
ICU, question of whether this was related to fluid depletion
versus CNS hyponatremia.  However, the patient seemed to resolve
over the next few days with IV fluids.  A sodium was stable for
several days prior to discharge.

(5) Oncology/systemic lymphoma:  CT of the torso did not show
significant progression of the disease.  Patient was on
filgrastim for several days during the hospital course, but it
was discontinued on [**2196-7-20**].  His white count decreased over the
next few days.  This will be monitored as an outpatient.

The patient has cutaneous manifestations of his lymphoma with
red blotchy areas on his back, right pelvis, and arm, which seem
to come and go.  The rash was watched closely given the concern
for Lamictal toxicity.  The patient showed no signs of this
toxicity while in the hospital.

(6) Infectious Disease/C. difficile Diarrhea:  Patient was
continued on p.o. vancomycin and discharged on p.o. vancomycin
for a 14 day course.

(7) FEN:  The patient's electrolytes were monitored and repleted
as necessary.  The patient was maintained on H2 blocker and
pneumoboots for DVT prophylaxis.  Communication with his wife was
maintained throughout the hospital course.

Patient was also seen by Physical Therapy, who deemed that
the patient was initially not safe to go home by himself.
However, a discussion with the family was undertaken and the
decision was made that the patient would go home with home
physical therapy and 24 hour care.  Nutrition consult was also
obtained.  Patient improved throughout his hospital course and
was eating and drinking with supervision, diet of soft solids and
thin liquids with one-to-one supervision prior to discharge.

DISPOSITION:  The patient was sent home with VNA services and
physical therapy, and will be maintained on his seizure
medications which will be titrated as an outpatient as well as
Coumadin for anticoagulation.

CONDITION ON DISCHARGE:  The patient was discharged in good
condition to home.

DISCHARGE DIAGNOSES:
1. Pulmonary embolism.
2. Seizure
3. Central nervous system and systemic lymphoma.

DISCHARGE MEDICATIONS:
1. Keppra 1500 mg p.o. b.i.d.
2. Lamotrigine 12.5 mg p.o. q.d.
3. Dexamethasone 2 mg p.o. q.d.
4. Famotidine 20 mg p.o. b.i.d.
5. Vancomycin 125 mg q 6 hours x 8 days.
6. Thiamine 100 mg p.o. q.d.
7. Coumadin:  The dose was still to be determined at the time
of this dictation pending INR.

FOLLOW-UP PLANS:  Patient will follow up with Dr. [**Last Name (STitle) 724**] as an
outpatient.

                          [**Doctor Last Name 640**] [**Doctor First Name 747**] [**Name8 (MD) **], M.D.  [**MD Number(1) 748**]

Dictated By:[**Last Name (NamePattern1) 10195**]
MEDQUIST36

D:  [**2196-8-24**]  10:34
T:  [**2196-8-26**]  11:52
JOB#:  [**Job Number 41212**]




Name:  [**Known lastname 7430**], [**Known firstname **]                      Unit No:  [**Numeric Identifier 7431**]

Admission Date:  [**2196-8-15**]     Discharge Date:  [**2196-8-24**]

Date of Birth:   [**2146-12-16**]     Sex:  M

Service:  Oncology Medicine

ADDENDUM:
1. Anticoagulation:  Patient's INR on the day of discharge
was 4.3.  The patient was discharged with instructions to
hold the Coumadin for the day of discharge and the following
day, and to restart 0.5 mg starting on Friday x3.  Patient
has nursing for INR checks at home, which will be reported to
Dr. [**Last Name (STitle) 25**].



                          [**Doctor Last Name **] [**Doctor First Name 58**] [**Name8 (MD) **], M.D.  [**MD Number(1) 59**]

Dictated By:[**Last Name (NamePattern1) 2685**]
MEDQUIST36

D:  [**2196-8-24**]  13:53
T:  [**2196-8-26**]  06:02
JOB#:  [**Job Number 7432**]
{'Other convulsions,Other pulmonary embolism and infarction,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Unspecified essential hypertension,Rash and other nonspecific skin eruption'}


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: 

PRESENT ILLNESS: This is a 49-year-old man with
a history of systemic and CNS lymphoma, who was transferred
from [**Hospital1 41211**] Hospital after he experienced a prolonged
seizure tonic-clonic lasting approximately one hour.

MEDICAL HISTORY: 1. EBV positive B-cell lymphoma.
2. CNS lymphoma status post XRT and intrathecal chemotherapy
complicated by meningitis requiring shunt removal.
3. Seizure disorder status post left frontal craniotomy with
residual left frontal lymphoma.
4. Hypertension.
5. Clostridium difficile infection.
6. Recent Port-A-Cath infection.

MEDICATION ON ADMISSION: 

ALLERGIES: 1. ACE inhibitors.
2. Bactrim.
3. Question Dilantin caused transaminitis.

PHYSICAL EXAM: Temperature was 96.4 F.  Pulse was 58.  Blood
pressure was 120/60.  Respiration was 18.  Saturation was at 98%
on room air.  Generally, he was not responding to voice.  But he
opened his eyes to sternal rub.  He moved his left arm and leg
spontaneously, but no verbal output.  He had moist mucous
membranes.  His head was normocephalic, atraumatic.  Oropharynx
was clear.  Neck was supple without carotid bruits.  Lungs were
clear.  Heart was regular, rate, and rhythm.  Abdomen was benign.
Extremities were without edema.

FAMILY HISTORY: 

SOCIAL HISTORY: He is married and lives with his wife.  [**Name (NI) **]
alcohol or tobacco.  Worked in finance prior to his medical
problems. 

### Response:
{'Other convulsions,Other pulmonary embolism and infarction,Other malignant lymphomas, unspecified site, extranodal and solid organ sites,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Unspecified essential hypertension,Rash and other nonspecific skin eruption'}
