CHIEF COMPLAINT: L sided weakness

PRESENT ILLNESS: 65yo man with PMH significant for small cell lung cancer
metastatic to the liver and bone, HTN, hyperlipidemia, OCPD,
presents as a transfer from an OSH with new onset headache, L
hemiparesis, and alteration of consciousness. He presented to
the OSH on [**2158-1-26**] with acute on chronic diffuse abdominal
pain. The day of transfer, his RN found him at 9am with his legs
over the side of the bed, lethargic, incontinent of urine, and
complaining of a new frontal headache. He had a left facial
droop and left hemiparesis. He was taken to the head CT, where
he was found to have a right frontal hemorrhage, reported to be
3.5cm x 2cm. He also had plts of 38 and was transfused one pack
of platelets. He was transferred to [**Hospital1 18**].

MEDICAL HISTORY: small cell lung cancer, mets to liver and bone
hypertension
COPD
hyperlipidemia
BPH
ex-lap for gunshot wound
s/p sinus surgery [**2153**]

MEDICATION ON ADMISSION: percocet, ambien, prilosec, belladonna, lasix 20 daily,
buproprion 150mg daily, lipitor 40mg daily, terazosin 2mg daily,
lisinopril 10mg daily, serevent diskus, nitro prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T98, HR 79sr, BP 115/73, RR 17, SaO2 93/2L
Genl: NAD, sleeping
HEENT: NCAT, MMM, OP Clear
CV: RRR, nl S1, S2, several PVC/PACs appreciated
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm & dry, not edematous

FAMILY HISTORY: unremarkable

SOCIAL HISTORY: 50py tobacco, h/o EtOH
Intracerebral hemorrhage,Malignant neoplasm of other parts of bronchus or lung,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Hypopotassemia,Other specified cardiac dysrhythmias,Unspecified essential hypertension
Intracerebral hemorrhage,Mal neo bronch/lung NEC,Second malig neo liver,Secondary malig neo bone,Thrombocytopenia NOS,Chr airway obstruct NEC,Hypopotassemia,Cardiac dysrhythmias NEC,Hypertension NOS
Admission Date:  [**2158-1-28**]              Discharge Date:   [**2158-2-10**]

Date of Birth:  [**2092-11-16**]             Sex:   M

Service: NEUROLOGY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8747**]
Chief Complaint:
L sided weakness

Major Surgical or Invasive Procedure:
none

History of Present Illness:
65yo man with PMH significant for small cell lung cancer
metastatic to the liver and bone, HTN, hyperlipidemia, OCPD,
presents as a transfer from an OSH with new onset headache, L
hemiparesis, and alteration of consciousness. He presented to
the OSH on [**2158-1-26**] with acute on chronic diffuse abdominal
pain. The day of transfer, his RN found him at 9am with his legs
over the side of the bed, lethargic, incontinent of urine, and
complaining of a new frontal headache. He had a left facial
droop and left hemiparesis. He was taken to the head CT, where
he was found to have a right frontal hemorrhage, reported to be
3.5cm x 2cm. He also had plts of 38 and was transfused one pack
of platelets. He was transferred to [**Hospital1 18**].

On arrival, he endorsed headache and abdominal pain but no other
complaints. His brother noted that he had not been doing as well
recently, but was still looking to fight through his illness. He
has been treated with chemotherapy with fair stability of the
lesions (last CT showing LAD, hepatic mets with no significant
change, but an increased size of the lung lesion), but has had a
60lb weight loss, decreased appetite and po intake, and 4 months
of abdominal pain. He was started on topotecan one week prior to
admission.

Past Medical History:
small cell lung cancer, mets to liver and bone
hypertension
COPD
hyperlipidemia
BPH
ex-lap for gunshot wound
s/p sinus surgery [**2153**]


Social History:
50py tobacco, h/o EtOH

Family History:
unremarkable

Physical Exam:
T98, HR 79sr, BP 115/73, RR 17, SaO2 93/2L
Genl: NAD, sleeping
HEENT: NCAT, MMM, OP Clear
CV: RRR, nl S1, S2, several PVC/PACs appreciated
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm & dry, not edematous

Neurologic examination:
Mental status: somnolent, able to open eyes and follow simple
commands but will not stay awake. Oriented to name, year, month,
and "hospital," but not which hospital. Will say one or two
words at a time, not complete sentences.
Cranial nerves: pupils equal and symmetric, R gaze preference,
?left hemianopia or hemineglect. Left facial droop. No gag.
Tongue midline.
Motor: R arm full strength, L arm flaccid; R leg full strength,
L leg 1-2/5, able to see contraction of hamstrings and motion of
toes.
Sensory: grimaces to pain throughout
Coord: unable to test

On discharge:
MS: Frequently sleeping (sometimes with eyes open) but arousable
and will follow commands and answer questions appropriately.
Cranial nerves: as above, but gaze at midline.
Motor: R arm and leg full strength; L arm can lift slightly off
bed and can move well at elbow; L leg can lift and hold off bed.

Pertinent Results:
Admission labs:
GLUCOSE-131* UREA N-19 CREAT-1.2 SODIUM-134 POTASSIUM-4.1
CHLORIDE-98 TOTAL CO2-25 ANION GAP-15

freeCa-1.23 CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-2.0

WBC-10.8 RBC-3.28* HGB-10.2* HCT-30.0* MCV-91 MCH-31.1 MCHC-34.1
RDW-19.4* PLT COUNT-65*

PT-12.5 PTT-26.4 INR(PT)-1.1

ALT(SGPT)-19 ALK PHOS-358* AMYLASE-46 TOT BILI-0.5 OSMOLAL-283
LIPASE-29

Discharge labs:
WBC-7.9 RBC-3.44* Hgb-10.8* Hct-32.7* MCV-95 MCH-31.3 MCHC-32.9
RDW-19.3* Plt Ct-333
Glucose-103 UreaN-52* Creat-1.3* Na-142 K-4.1 Cl-106 HCO3-22

Pending labs:
FREE KAPPA AND LAMBDA, WITH K/L RATIO-PND

IMAGING:
Head CT noncontrast: Examination is limited secondary to patient
motion. There is a large hemorrhage in the right fronto-temporal
lobe extending to basal ganglia measuring approximately 6.3 x
2.0 cm with surrounding hypodensity consistent with edema. Just
superior to this large hemorrhage are multiple smaller punctate
foci of hemorrhage. There is mass effect on the right lateral
ventricle with 2 mm of midline shift to the left. There is
probable mild subfalcine herniation. The remaining ventricles
are not dilated. The basal cisterns are patent. The [**Doctor Last Name 352**]-white
matter differentiation is grossly preserved. The surrounding
osseous and soft tissue structures are unremarkable. The imaged
paranasal sinuses are well aerated.
IMPRESSION: Right fronto-temporal intraparenchymal hemorrhage
extending to basal ganglia with surrounding edema with slight
degree of midline shift.

Head MRI w/o & w/contrast: FINDINGS: Today's exam is correlated
with head CT from [**2158-1-28**]. As noted on the
examination, there is a large right frontal temporal
intraparenchymal hemorrhage extending into the basal ganglia.
There is surrounding edema and mass effect upon the ipsilateral
lateral ventricle. There is no evidence of herniation. The
ambient cisterns are present and not effaced. There is no slow
diffusion to indicate an acute infarct.
On series 12, image 388, there is a subtle enhancing lesion in
the right centrum semiovale. This could represent a small
vascular anomaly as opposed to metastatic lesion, given the
absence of adjacent edema. This is separate from the region of
hemorrhage. There is no enhancement in the region of the
intraparenchymal hemorrhage.
IMPRESSION: There is no enhancement in the region of hemorrhage
to indicate that this is from a metastasis.
Small lesion in the right centrum semiovale could be consistent
with a small vascular anomaly versus (less likely) a small
metastasis.
No acute infarcts.

Repeat Head CT [**2158-2-2**]:
Increasing edema since [**2158-1-28**]. Otherwise similar appearance of
large right cerebral hemisphere intraparenchymal hemorrhage.

Repeat Head CT [**2158-2-4**]:
Overall no significant interval change in size of right large
cerebral hemisphere intraparenchymal hemorrhage and associated
mass effect since [**2158-2-2**].

EEG [**2158-2-7**]:
ABNORMALITY #1: A [**3-16**] Hz slow and disorganized background rhythm
was
noted in the waking state, which increased by [**12-13**] Hz with
external
stimulation.
ABNORMALITY #2: The right hemisphere background activity was 1
Hz slower
and of decreased amplitude compared to the left hemisphere
activity.
ABNORMALITY #3: Bursts of generalized moderate amplitude delta
slowing
was noted in the waking state.
BACKGROUND: As above.
HYPERVENTILATION: Contraindicated due to patient's mental
status.
INTERMITTENT PHOTIC STIMULATION: Produced no activation of the
record.
SLEEP: No normal sleep/wake transitions were seen.
CARDIAC MONITOR: An irregularly irregular rhythm was noted, with
an
average rate of 96 beats per minute.
IMPRESSION: This is an abnormal EEG due to the slow,
disorganized
background rhythm, decreased voltage over the right hemisphere
and
bursts of generalized slowing. The slow and disorganized
background
rhythm and bursts of generalized slowing suggest a moderate
encephalopathy. The decreased voltage and slightly slower
background
over the right hemisphere suggests right hemisphere subcortical
dysfunction.

Brief Hospital Course:
65yo man with metastatic cancer presenting as a transfer from an
OSH with new left hemiparesis, decreased alertness, plts <100k,
and a right frontal hemorrhage. Most
likely etiology is hemorrhage from a metastasis in the setting
of thrombocytopenia, though he has no known metastasis there.
Other etiologies include hypertension (though he has not been
terribly hypertensive, his BP does not have to be that high,
especially with the thrombocytopenia, to bleed), hemorrhagic
conversion of stroke; unlikely to be amyloid, trauma, or
vascular malformation. He had an MRI for further evaluation; it
did not clearly demonstrate an underlying metastasis, though it
did show a small lesion in the right centrum semiovale that
might be a metastasis. He was started on decadron and mannitol
and transfused two more packs of platelets to reach goal
plts>100k. Neuro-oncology was consulted. As his repeat head CT
showed significant edema, the decadron was tapered only to 4mg
q12hrs and he was discharged on this dose, to remain stable
until his follow up appointment with neuro-oncology. The
mannitol was weaned off. Given the edema, brain radiation was
determined to be contraindicated at this time by discussions
between Dr. [**Last Name (STitle) 724**] (neuro-oncology) and Dr. [**Last Name (STitle) **] (primary
oncologist), though this may be possible in the future. He will
follow up in the brain tumor clinic with Dr. [**Last Name (STitle) 724**] in 3 weeks
from discharge. Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 27580**]) will need to be
contact[**Name (NI) **] by the extended care facility to assist with
chemotherapy treatment, which will likely be an oral mediation
regimen dosed daily.

Hospital course was also notable for:
1. hypertension - treated with metoprolol and captopril for goal
SBP<140
2. atrial tachycardia - also treated with metoprolol
3. NSVT - improving with treatment of hypokalemia (see below)
4. hypokalemia - On transfer to the floor from the ICU, the
patient was noted to have a drop in potassium over one day from
3.6 to 2.6. He was given 80mEq KCl with rise to 3.6, then an
additional 40mEq, but the next day the K was 3.1. He had no
diarrhea or vomiting. The renal service was consulted. They felt
that the hypokalemia was likely due to urine losses from
polyuria due to administration of mannitol and decadron. He was
started on standing repletion of K (40meq po bid), prn repletion
of Mg (to >2), and the mannitol was discontinued. The K improved
and the daily KCl was gradually tapered.
5. r/o mult myeloma - SPEP and UPEP were sent for concerns about
the quality of the urine. SPEP was negatve; UPEP showed
"MULTIPLE PROTEIN BANDS SEEN, WITH ALBUMIN PREDOMINATING", "TWO
TRACE BANDS ARE SEEN WHICH STAIN WITH KAPPA BUT DO NOT STAIN
WELL WITH FREE KAPPA. IT IS POSSIBLE THAT THESE REPRESENT
BENCE-[**Doctor Last Name **] PROTEIN." As such, serum free light chain assay was
sent and is pending at the time of discharge.
6. pain control - pain was thought to be secondary to multiple
hepatic metastases. It improved with ultram but persisted.
MSContin was started on [**2-8**] and may need to be titrated upward
for pain control.
7. FEN - swallow evaluation was performed and he was able to
tolerate pureed foods and thin liquids. He had poor po intake
when left to himself; he needs feeding supervision to encourage
po intake and has done well with the nurses and aides assisting.

Medications on Admission:
percocet, ambien, prilosec, belladonna, lasix 20 daily,
buproprion 150mg daily, lipitor 40mg daily, terazosin 2mg daily,
lisinopril 10mg daily, serevent diskus, nitro prn

Discharge Medications:
1. Dexamethasone 4 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q12H (every
12 hours).
2. Morphine 15 mg Tablet Sustained Release [**Month/Year (2) **]: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
3. Tramadol 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Q4-6H (every 4
to 6 hours) as needed for pain.
4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
5. Metoprolol Tartrate 50 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID
(3 times a day).
6. Captopril 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a
day).
7. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg
PO BID (2 times a day).
8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
10. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet,
Chewable PO TID (3 times a day).
11. Polyvinyl Alcohol 1.4 % Drops [**Last Name (STitle) **]: 1-2 Drops Ophthalmic PRN
(as needed).
12. Artificial Tear with Lanolin 0.1-0.1 % Ointment [**Last Name (STitle) **]: One (1)
Appl Ophthalmic PRN (as needed): apply to left eye at night.


Discharge Disposition:
Extended Care

Facility:
NE [**Hospital1 **]  [**Location (un) **]

Discharge Diagnosis:
Right frontal hemorrhage
Right centrum semiovale lesion
Small cell lung cancer
Hypokalemia
Narrow complex tachycardia


Discharge Condition:
Stable; frequently somnolent but arouses and can follow commands
and answer questions appropriately. Left hemiparesis including
the face, arm, and leg, with dysarthria but preserved swallow,
arm movement from the elbow but not the shoulder or much finger
extension, and spontaneous leg movement with some decreased
strength. Also an element of left neglect.


Discharge Instructions:
Take all medications as prescribed.

Follow up with Dr. [**Last Name (STitle) 724**] and Dr. [**Last Name (STitle) **], as well as Dr. [**First Name (STitle) 807**].

Call your doctor or go to the emergency room for any worsening
weakness or difficulty speaking, or any numbness, decreased
alertness, nausea, vomiting, or other concerning symptoms.

Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 724**]:
Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2158-2-27**]
1:00

Please follow up with Dr. [**Last Name (STitle) **]: Please call 617-63-BRAIN to
schedule an appointment in 3 weeks. Please tell them that you
will need a head CT with and without contrast scheduled as well.

Call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 27580**]) to arrange oncologic treatment.

Call your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 807**] ([**Telephone/Fax (1) 823**]) when you have finished
rehab.
{'Intracerebral hemorrhage,Malignant neoplasm of other parts of bronchus or lung,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Hypopotassemia,Other specified cardiac dysrhythmias,Unspecified essential hypertension'}


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: L sided weakness

PRESENT ILLNESS: 65yo man with PMH significant for small cell lung cancer
metastatic to the liver and bone, HTN, hyperlipidemia, OCPD,
presents as a transfer from an OSH with new onset headache, L
hemiparesis, and alteration of consciousness. He presented to
the OSH on [**2158-1-26**] with acute on chronic diffuse abdominal
pain. The day of transfer, his RN found him at 9am with his legs
over the side of the bed, lethargic, incontinent of urine, and
complaining of a new frontal headache. He had a left facial
droop and left hemiparesis. He was taken to the head CT, where
he was found to have a right frontal hemorrhage, reported to be
3.5cm x 2cm. He also had plts of 38 and was transfused one pack
of platelets. He was transferred to [**Hospital1 18**].

MEDICAL HISTORY: small cell lung cancer, mets to liver and bone
hypertension
COPD
hyperlipidemia
BPH
ex-lap for gunshot wound
s/p sinus surgery [**2153**]

MEDICATION ON ADMISSION: percocet, ambien, prilosec, belladonna, lasix 20 daily,
buproprion 150mg daily, lipitor 40mg daily, terazosin 2mg daily,
lisinopril 10mg daily, serevent diskus, nitro prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T98, HR 79sr, BP 115/73, RR 17, SaO2 93/2L
Genl: NAD, sleeping
HEENT: NCAT, MMM, OP Clear
CV: RRR, nl S1, S2, several PVC/PACs appreciated
Chest: CTAB
Abd: soft, NTND, BS+
Ext: warm & dry, not edematous

FAMILY HISTORY: unremarkable

SOCIAL HISTORY: 50py tobacco, h/o EtOH 

### Response:
{'Intracerebral hemorrhage,Malignant neoplasm of other parts of bronchus or lung,Malignant neoplasm of liver, secondary,Secondary malignant neoplasm of bone and bone marrow,Thrombocytopenia, unspecified,Chronic airway obstruction, not elsewhere classified,Hypopotassemia,Other specified cardiac dysrhythmias,Unspecified essential hypertension'}
