CHIEF COMPLAINT: Behavioral Changes

PRESENT ILLNESS: This is a 70 yo female with a medical hisptry significant for
stage IV Left thoracic rhabdomyosarcoma currently receiving
chemotherapy and Left breast cancer. She was transferred from
NWH with a right frontal hemorrhagic brain mass.  Per patient's
husband, she had dramatic behavioral changes 2-3 days prior to
admission. She could not remember when her doctors [**Name5 (PTitle) 4314**]
were despite repeat reminders. She could not figure out how to
use the phone. She had
an extremely poor memory.  She was subsequently brought to the
ER
at NWH where head CT showed a right frontal brain lesion and she
was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: stage IV L thoracic rhabdomyosarcoma currently receiving
chemotherapy, L breast ca - DCIS s/p lumpectomy.

MEDICATION ON ADMISSION: Lovenox (prophylaxis - has never had a clot), chemotherapy -
last [**1-2**] next on [**1-11**].

ALLERGIES: Codeine

PHYSICAL EXAM: On Admission:
Vitals: T 98.4; BP 121/71 ; P 114; RR 20; O2 sat 100%

FAMILY HISTORY: parents deceased from heart disease.  Brother - colon cancer.

SOCIAL HISTORY: Lives with husband.  Worked as a bookeeper in husband's law
practice.  Never smoked.  Occasionally drinks champagne.
Secondary malignant neoplasm of brain and spinal cord,Intracerebral hemorrhage,Cerebral edema,Malignant neoplasm of connective and other soft tissue of thorax,Personal history of malignant neoplasm of breast
Sec mal neo brain/spine,Intracerebral hemorrhage,Cerebral edema,Mal neo soft tis thorax,Hx of breast malignancy
Admission Date:  [**2176-1-10**]              Discharge Date:   [**2176-1-17**]

Date of Birth:  [**2105-12-31**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Codeine

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Behavioral Changes

Major Surgical or Invasive Procedure:
[**2176-1-12**] Right Frontal Craniotomy for Mass resection


History of Present Illness:
This is a 70 yo female with a medical hisptry significant for
stage IV Left thoracic rhabdomyosarcoma currently receiving
chemotherapy and Left breast cancer. She was transferred from
NWH with a right frontal hemorrhagic brain mass.  Per patient's
husband, she had dramatic behavioral changes 2-3 days prior to
admission. She could not remember when her doctors [**Name5 (PTitle) 4314**]
were despite repeat reminders. She could not figure out how to
use the phone. She had
an extremely poor memory.  She was subsequently brought to the
ER
at NWH where head CT showed a right frontal brain lesion and she
was
transferred to [**Hospital1 18**] for further management.


Past Medical History:
stage IV L thoracic rhabdomyosarcoma currently receiving
chemotherapy, L breast ca - DCIS s/p lumpectomy.


Social History:
Lives with husband.  Worked as a bookeeper in husband's law
practice.  Never smoked.  Occasionally drinks champagne.


Family History:
parents deceased from heart disease.  Brother - colon cancer.


Physical Exam:
On Admission:
Vitals: T 98.4; BP 121/71 ; P 114; RR 20; O2 sat 100%

General: lying in bed NAD
HEENT: NCAT, dry mucous membranes
Neck: supple
Pulmonary: decrease lung sounds on L.
Cardiac: tachycardic, with no m/r/g
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: no c/c/e.

Neurological Exam:
Mental status: A & O x3, unable to say MOYB.  Fluent speech with
no paraphasic or phonemic errors.  Adequate comprehension.
Follows simple and multi-step commands.  Registers [**2-28**], recalls
[**12-31**] at 5 min.  Repetition intact (no ifs, ands or buts).  Able
to
name low and high frequency objects.  Some L/R confusion.  No
apraxia/neglect.  [**Location (un) **]/Writing intact.   Clock drawing shows
poor planning with numbers collected on R side of clock face.
Misses a line on L during line bisection.

Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-1**]
XII: Tongue midline without fasciculations.

Motor: Normal bulk. Normal tone. Subtle R pronator drift.
clumsy
finger tap on L.  Orbits L hand upon spinning.  Subtle L UMN
weakness 4/5 of LUE.

Sensation: intact to light touch

Reflexes: Bic T Br Pa Ac
Right      1  1 1  1  1
Left       2  2 2  1  2
Toes vigorous withdrawal.

On discharge:
[**1-17**]: alert and oriented to person, place, month, and year.
Strength full in all extremities, no pronator drift, sensation
intact, cranial nerves II-XII grossly intact, pupils equal and
reactive to light bilaterally.

Pertinent Results:
CT Head [**2176-1-10**]:
stable hemorrhagic mass in the right frontal convexity with
stable surrounding edema. there is local mass effect, and sucal
effacement, but no midline shift. no new areas of hemorrhage.

Echo [**2176-1-11**]:
Moderate mitral regurgitation with borderline LV systolic
function. Mild aortic regurgitation. Mild pulmonary artery
systolic hypertension. No pericardial effusion seen. There
appears to be a mass that impinges on the right atrium - this is
probably the mass seen on CXR.

MRI Brain [**2176-1-11**]:
3.1 cm enhancing hemorrhagic mass located in the right posterior
frontal lobe with surrounding edema but no midline shift. No
additional enhancing lesions are identified. Given the patient's
history of prior malignancy, this finding is suspicious for a
solitary metastasis.

CT Head [**2176-1-13**]:
Expected post-surgical changes following a right frontoparietal
craniotomy, with blood products in the resection cavity and
pneumocephalus
overlying bilateral frontal lobes.

MRI Head [**2176-1-13**]:
Small area of restricted diffusion identified adjacent to the
surgical bed, measuring 9 x 7 mm in size, possibly representing
a small
ischemic area. With gadolinium contrast, there is a nodular area
of
enhancement at the medial aspect of the surgical cavity,
measuring
approximately 6 x 10.3 mm in size in the transverse dimension x
5.3 x 12.8 in coronal projection, possibly consistent with a
small residual lesion, followup is recommended. There is no
shift of normally midline structures. Expected post-surgical
changes following right frontoparietal craniotomy.

[**2176-1-16**] 06:37AM BLOOD WBC-4.0 RBC-3.09* Hgb-9.6* Hct-28.3*
MCV-92 MCH-31.1 MCHC-34.0 RDW-15.9* Plt Ct-160
[**2176-1-15**] 03:00AM BLOOD PT-13.6* PTT-51.9* INR(PT)-1.2*
[**2176-1-16**] 06:37AM BLOOD Glucose-105* UreaN-17 Creat-0.5 Na-142
K-3.9 Cl-108 HCO3-27 AnGap-11
[**2176-1-16**] 06:37AM BLOOD Calcium-8.5 Phos-1.8* Mg-1.9
[**2176-1-14**] 02:34AM BLOOD Type-ART pO2-261* pCO2-31* pH-7.52*
calTCO2-26 Base XS-3

Brief Hospital Course:
Ms. [**Known lastname 69844**] was admitted to [**Hospital1 18**] for a right frontal hemorrhagic
brain lesion on [**2176-1-10**]. She underwent repeat CT imaging which
was stable and MRI imaging. Cardiac Echo was performed. This
showed a mass that impinges on the right atrium with preserved
cardiac function. She was on Keppra for seizure prophylaxis. She
was on Steroids. She was scheduled for a surgical decompression
and taken to the OR on [**2176-1-12**] for right frontal craniotomy and
resection with Dr. [**Last Name (STitle) **], and remained intubated overnight in
the ICU.  On [**2176-1-3**] she was extubated and on [**2176-1-14**] she was
transferred to the SDU.  At that time she was oriented to self
and had a slight left pronator drift.  On [**2176-1-15**] her foley was
discontinued, however it needed to be reinserted for urinary
retention.Plans to wean at rehab facility. She was seen and
evaluated by speech and swallow and tolerating an appropriate
diet upon discharge. On [**2176-1-16**] she was found to be
neurologically stable. She was given instruction to follow up in
the Brain [**Hospital 341**] Clinic on [**2176-2-5**] at 4PM.She was seen
by PT/OT who felt she would be an appropriate candidate for
rehabilitation, and discharged on [**2176-1-17**].

Medications on Admission:
Lovenox (prophylaxis - has never had a clot), chemotherapy -
last [**1-2**] next on [**1-11**].


Discharge Medications:
1. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain/T/HA.
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
6. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4-6HOURS
PRN () as needed for Pain.
7. Levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
8. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
10. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO Q8H (every 8 hours) as needed for emesis.
11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection TID (3 times a day).
12. regular Insulin
Regular insulin sliding scale per nursign hand out


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

Discharge Diagnosis:
Right Frontal Brain Lesion


Discharge Condition:
Neurologically Stable


Discharge Instructions:
GENERAL INSTRUCTIONS
WOUND CARE:
??????	You or a family member should inspect your wound every day and
report any of the following problems to your physician.
??????	Keep your incision clean and dry.
??????	You may wash your hair with a mild shampoo 24 hours after your
sutures are removed.
??????	Do NOT apply any lotions, ointments or other products to your
incision.
??????	DO NOT DRIVE until you are seen at the first follow up
appointment.
??????	Do not lift objects over 10 pounds until approved by your
physician.

DIET
Usually no special diet is prescribed after a craniotomy. A
normal well balanced diet is recommended for recovery, and you
should resume any specially prescribed diet you were eating
before your surgery.  Be sure however, to remain well hydrated,
and increase your consumption of fiber, as pain medications may
cause constipation.

MEDICATIONS:
??????	Take all of your medications as ordered.  You do not have to
take pain medication unless it is needed.  It is important that
you are able to cough, breathe deeply, and is comfortable enough
to walk.
??????	Do not use alcohol while taking pain medication.
??????	Medications that may be prescribed include:
-Narcotic pain medication such as Dilaudid (hydromorphone).
	-An over the counter stool softener for constipation (Colace or
Docusate). If you become constipated, try products such as
Dulcolax, Milk of Magnesia, first, and then Magnesium Citrate or
Fleets enema if needed). Often times, pain medication and
anesthesia can cause constipation.
??????       You have been discharged on Keppra (Levetiracetam), you
will not require blood work monitoring.
??????	You were on Lovenox prior to your admission, you may safely
resume taking this in 1 month.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc, as this can increase your chances of bleeding.
??????	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.

ACTIVITY:
The first few weeks after you are discharged you may feel tired
or fatigued. This is normal. You should become a little stronger
every day. Activity is the most important measure you can take
to prevent complications and to begin to feel like yourself
again. In general:
??????	Follow the activity instructions given to you by your doctor
and therapist.
??????	Increase your activity slowly; do not do too much because you
are feeling good.
??????	You may resume sexual activity as your tolerance allows.
??????	If you feel light headed or fatigued after increasing
activity, rest, decrease the amount of activity that you do, and
begin building your tolerance to activity more slowly.
??????	DO NOT DRIVE until you speak with your physician.
??????	Do not lift objects over 10 pounds until approved by your
physician.
??????	Avoid any activity that causes you to hold your breath and
push, for example weight lifting, lifting or moving heavy
objects, or straining at stool.
??????	Do your breathing exercises every two hours.
??????	Use your incentive spirometer 10 times every hour, that you
are awake.

WHEN TO CALL YOUR SURGEON:
With any surgery there are risks of complications. Although your
surgery is over, there is the possibility of some of these
complications developing. These complications include:
infection, blood clots, or neurological changes. Call your
Physician Immediately if you Experience:

??????	Confusion, fainting, blacking out, extreme fatigue, memory
loss, or difficulty speaking.
??????	Double, or blurred vision. Loss of vision, either partial or
total.
??????	Hallucinations
??????	Numbness, tingling, or weakness in your extremities or face.
??????	Stiff neck, and/or a fever of 101.5F or more.
??????	Severe sensitivity to light. (Photophobia)
??????	Severe headache or change in headache.
??????	Seizure
??????	Problems controlling your bowels or bladder.
??????	Productive cough with yellow or green sputum.
??????	Swelling, redness, or tenderness in your calf or thigh.

Call 911 or go to the Nearest Emergency Room if you Experience:
??????	Sudden difficulty in breathing.
??????	New onset of seizure or change in seizure, or seizure from
which you wake up confused.
??????	A seizure that lasts more than 5 minutes.

Important Instructions Regarding Emergencies and After-Hour
Calls
??????	If you have what you feel is a true emergency at any time,
please present immediately to your local emergency room, where a
doctor there will evaluate you and contact us if needed. Due to
the complexity of neurosurgical procedures and treatment of
neurosurgical problems, effective advice regarding emergency
situations cannot be given over the telephone.
??????	Should you have a situation which is not life-threatening, but
you feel needs addressing before normal office hours or on the
weekend, please present to the local emergency room, where the
physician there will evaluate you and contact us if needed.


Followup Instructions:

FOLLOW UP APPOINTMENT INSTRUCTIONS

??????Please return to the office in [**7-6**] days (from your date of
surgery) for removal of your staples/sutures and a wound check.
This appointment can be made with the Nurse Practitioner.
Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you
live quite a distance from our office, please make arrangements
for the same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**2-5**] at 4pm.  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 with/ or without
gadolinium contrast



Completed by:[**2176-1-17**]

Name:  [**Known lastname 13317**],[**Known firstname **]                      Unit No:   [**Numeric Identifier 13318**]

Admission Date:  [**2176-1-10**]              Discharge Date:   [**2176-1-17**]

Date of Birth:  [**2105-12-31**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Codeine

Attending:[**First Name3 (LF) 599**]
Addendum:
Appointment with Dr. [**Last Name (STitle) 13319**] in [**Hospital **] clinic [**2176-1-24**] at
9:15am for further evaluation of vocal cord impairment found on
speech and swallow exam.  Office phone number is [**Telephone/Fax (1) 1848**]

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 **]

                             [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**]

Completed by:[**2176-1-17**]
{'Secondary malignant neoplasm of brain and spinal cord,Intracerebral hemorrhage,Cerebral edema,Malignant neoplasm of connective and other soft tissue of thorax,Personal history of malignant neoplasm of breast'}


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: Behavioral Changes

PRESENT ILLNESS: This is a 70 yo female with a medical hisptry significant for
stage IV Left thoracic rhabdomyosarcoma currently receiving
chemotherapy and Left breast cancer. She was transferred from
NWH with a right frontal hemorrhagic brain mass.  Per patient's
husband, she had dramatic behavioral changes 2-3 days prior to
admission. She could not remember when her doctors [**Name5 (PTitle) 4314**]
were despite repeat reminders. She could not figure out how to
use the phone. She had
an extremely poor memory.  She was subsequently brought to the
ER
at NWH where head CT showed a right frontal brain lesion and she
was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: stage IV L thoracic rhabdomyosarcoma currently receiving
chemotherapy, L breast ca - DCIS s/p lumpectomy.

MEDICATION ON ADMISSION: Lovenox (prophylaxis - has never had a clot), chemotherapy -
last [**1-2**] next on [**1-11**].

ALLERGIES: Codeine

PHYSICAL EXAM: On Admission:
Vitals: T 98.4; BP 121/71 ; P 114; RR 20; O2 sat 100%

FAMILY HISTORY: parents deceased from heart disease.  Brother - colon cancer.

SOCIAL HISTORY: Lives with husband.  Worked as a bookeeper in husband's law
practice.  Never smoked.  Occasionally drinks champagne. 

### Response:
{'Secondary malignant neoplasm of brain and spinal cord,Intracerebral hemorrhage,Cerebral edema,Malignant neoplasm of connective and other soft tissue of thorax,Personal history of malignant neoplasm of breast'}
