CHIEF COMPLAINT: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
IVC filter placement

PRESENT ILLNESS: This is a 60 year old man with lung cancer with brain metastases
previously on anticoagulation for [**Hospital **] transferred to the MICU
from the SICU in the setting of arrythmias, most prominently
tachyarrythmias, who originally presented to medical care on
[**8-17**] late morning after being found by his family, lying down on
the sidewalk outside of his home, minimally responsive. He awoke
at the scene complaining of headache and left shoulder pain. He
was taken to [**Hospital 6136**] Hospital; and then taken by [**Location (un) **] to
[**Hospital1 18**] after a CT showed extensive acute ICH. An EKG there showed
sinus rhythm, with an S in I and a Q in III, with prominent
upright T waves in precordial leads and no indication of
ischemia. He reportedly started the flight being AOx3 and
following commands and then deteriorated into lethargy and
minimal responsiveness. He was intubated for airway protection.
Of note, his INR was 3.7 on arrival to [**Hospital1 18**] consistent with
coumadin taken regularly at home for known PE in [**2179-12-30**].
He received 2 units of FFP and vitamin K.
.
At [**Hospital1 18**] he was admitted to the SICU on the neurosurgical
service. Ultimately, neurosurgery decided to observe the
patient, start seizure prophylaxis, normalize INR (with a
recommendation to avoid anticoagulation for one month) with no
indication for neurosurgical intervention. He was diagnosed with
a left humeral fracture for which orthopedics recommended
splint. He was extubated on [**8-19**]. An IVC filter was placed on
[**8-21**].
.
Of note in terms of his functional status prior to the event, he
had not had recent falls prior to this. However, prior to his
diagnosis with brain mets, he had a persistent cough and had
some prior episodes, unwitnessed by family and only uncovered in
retrospect, in which he coughed violently and then fell down,
perhaps similar to this presentation. He was until this
admission able to perform basic ADLs, ambulating, toileting,
eating, etc; though with low energy and slow mobility.

MEDICAL HISTORY: Stage IV lung cancer with brain metastases diagnosed [**9-5**] after
episode of seizures, s/p R craniectomy [**9-5**] for tumor resection,
s/p chemo/radiation; oncologist [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] ([**Hospital1 6136**]), rad
onc [**Location (un) **] ([**First Name8 (NamePattern2) **] [**Doctor First Name **]); per daughter, little effect of chemo/rads,
oncologist said emphasis should be on quality of life at this
point
PE diagnosed in [**1-7**] (on coumadin), diagnosed by routine CT
scan, was evidently asymptomatic at that time
Hyperlipidemia
NIDDM
GERD
Bipolar disorder diagnosed in [**2174**] after a psych hospitalization
for mania, has been on several meds; stopped meds and was
rehospitalized; since then has been on seroquel alone
Seizure disorder secondary to brain mets only
.

MEDICATION ON ADMISSION: Medications prior to admission:
1. Omeprazole 20mg
2. Tramadol 50mg [**12-31**] q 6h
3. Simvastatin 20mg daily
4. Seroquel 100mg HS
5. Glipizide ER 10mg daily
6. Coumadin 4mg daily
7. Keppra 500mg [**Hospital1 **]
8. IBU 800mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM on admission:
O: T:97.0  BP:129/6/   HR:102   RR:16  O2Sats 96%
Gen: WD/WN, comfortable, NAD.
HEENT:normocephalic, small superficial abrasion to left head.
Pupils:PERRLA
EOMs: UTA due to inattention/lethargy
Neuro:Mental status: Lethargic, arousable to loud voice. No
commands.
Face appears to be symmetric. Spont mvmt observed in the RUE.
Brisk w/drawl of LE(R>L). minimal mvmt of LUE observed, though
also withdraws to nox. 5/5 strength throughout. [**12-31**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Ran an auto detailing and used car sales business until his
cancer diagnosis; was on disability thereafter. Two adult
children who live ~half hour away from his home. Lives with
wife. Portuguese-speaking only. 60 pack year cigarette history.
No EtOH or drugs by report.
Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Pulmonary collapse,Unspecified pleural effusion,Malignant neoplasm of lower lobe, bronchus or lung,Secondary malignant neoplasm of brain and spinal cord,Ventilator associated pneumonia,Closed fracture of unspecified part of upper end of humerus,Fall from other slipping, tripping, or stumbling,Epilepsy, unspecified, without mention of intractable epilepsy,Esophageal reflux,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Bipolar disorder, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Foreign body in larynx,Foreign body accidentally entering other orifice,Atrial fibrillation
Subarach hem-brief coma,Pulmonary collapse,Pleural effusion NOS,Mal neo lower lobe lung,Sec mal neo brain/spine,Ventltr assoc pneumonia,Fx up end humerus NOS-cl,Fall from slipping NEC,Epilep NOS w/o intr epil,Esophageal reflux,Hyperlipidemia NEC/NOS,DMII wo cmp nt st uncntr,Bipolar disorder NOS,Hx-ven thrombosis/embols,Long-term use anticoagul,Foreign body in larynx,FB entering oth orifice,Atrial fibrillation
Admission Date:  [**2180-8-17**]              Discharge Date:   [**2180-8-26**]

Date of Birth:  [**2120-4-26**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Doctor First Name 2080**]
Chief Complaint:
CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
IVC filter placement


History of Present Illness:
This is a 60 year old man with lung cancer with brain metastases
previously on anticoagulation for [**Hospital **] transferred to the MICU
from the SICU in the setting of arrythmias, most prominently
tachyarrythmias, who originally presented to medical care on
[**8-17**] late morning after being found by his family, lying down on
the sidewalk outside of his home, minimally responsive. He awoke
at the scene complaining of headache and left shoulder pain. He
was taken to [**Hospital 6136**] Hospital; and then taken by [**Location (un) **] to
[**Hospital1 18**] after a CT showed extensive acute ICH. An EKG there showed
sinus rhythm, with an S in I and a Q in III, with prominent
upright T waves in precordial leads and no indication of
ischemia. He reportedly started the flight being AOx3 and
following commands and then deteriorated into lethargy and
minimal responsiveness. He was intubated for airway protection.
Of note, his INR was 3.7 on arrival to [**Hospital1 18**] consistent with
coumadin taken regularly at home for known PE in [**2179-12-30**].
He received 2 units of FFP and vitamin K.
.
At [**Hospital1 18**] he was admitted to the SICU on the neurosurgical
service. Ultimately, neurosurgery decided to observe the
patient, start seizure prophylaxis, normalize INR (with a
recommendation to avoid anticoagulation for one month) with no
indication for neurosurgical intervention. He was diagnosed with
a left humeral fracture for which orthopedics recommended
splint. He was extubated on [**8-19**]. An IVC filter was placed on
[**8-21**].
.
Of note in terms of his functional status prior to the event, he
had not had recent falls prior to this. However, prior to his
diagnosis with brain mets, he had a persistent cough and had
some prior episodes, unwitnessed by family and only uncovered in
retrospect, in which he coughed violently and then fell down,
perhaps similar to this presentation. He was until this
admission able to perform basic ADLs, ambulating, toileting,
eating, etc; though with low energy and slow mobility.


Past Medical History:
Stage IV lung cancer with brain metastases diagnosed [**9-5**] after
episode of seizures, s/p R craniectomy [**9-5**] for tumor resection,
s/p chemo/radiation; oncologist [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] ([**Hospital1 6136**]), rad
onc [**Location (un) **] ([**First Name8 (NamePattern2) **] [**Doctor First Name **]); per daughter, little effect of chemo/rads,
oncologist said emphasis should be on quality of life at this
point
PE diagnosed in [**1-7**] (on coumadin), diagnosed by routine CT
scan, was evidently asymptomatic at that time
Hyperlipidemia
NIDDM
GERD
Bipolar disorder diagnosed in [**2174**] after a psych hospitalization
for mania, has been on several meds; stopped meds and was
rehospitalized; since then has been on seroquel alone
Seizure disorder secondary to brain mets only
.


Social History:
Ran an auto detailing and used car sales business until his
cancer diagnosis; was on disability thereafter. Two adult
children who live ~half hour away from his home. Lives with
wife. Portuguese-speaking only. 60 pack year cigarette history.
No EtOH or drugs by report.

Family History:
non-contributory

Physical Exam:
PHYSICAL EXAM on admission:
O: T:97.0  BP:129/6/   HR:102   RR:16  O2Sats 96%
Gen: WD/WN, comfortable, NAD.
HEENT:normocephalic, small superficial abrasion to left head.
Pupils:PERRLA
EOMs: UTA due to inattention/lethargy
Neuro:Mental status: Lethargic, arousable to loud voice. No
commands.
Face appears to be symmetric. Spont mvmt observed in the RUE.
Brisk w/drawl of LE(R>L). minimal mvmt of LUE observed, though
also withdraws to nox. 5/5 strength throughout. [**12-31**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred

Discharge:
O: T:97 BP:132/60   HR:84   RR:18 O2Sats 97%RA
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA. MMM. OP clear. Neck Supple, No LAD, No
thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or gallops.
LUNGS: high whistle-like wheeze heard throughout bilat lung
fields
ABDOMEN: NABS. Soft, NT, ND.
EXTREMITIES: No edema or calf pain or cords, 2+ dorsalis
pedis/posterior tibial pulses.
SKIN: No rashes/lesions, ecchymoses. No ulcers.
NEURO:  Awake with eyes open, follows simple commands. A&O to
name, [**Hospital 86**] hospital, [**Last Name (un) 2753**] president. Responds appropriately
to questions (eg "how are you today?" "I'm OK." PERRL, EOMI,
face symmetric. Able to squeeze hand with L and R hand,
decreased strength on L. Unable to assess left arm due to
orthopedic injury and L arm in sling. Moves RUE and RLE
spontaneously. No spontaneous movement of LLE but withdraws from
pain.
Lines: bilateral SCDs, R PIV without erythema, cords, purulence,
TTP.



Pertinent Results:
LEFT SHOULDER, THREE VIEWS [**2180-8-17**]: There is a fracture
involving the proximal shaft of the left femur. There is
displacement by approximately one shaft width with apex lateral
angulation of the fracture site.

CT OSH(1227 [**8-17**]): "extensive acute ICH identified which all
appears to be extra-xial and is most prominent superficial to
the
anterior left frontal lobe, but there is less extensive acute
ICH
along the right anterolateral aspect of the suprasellar cistern,
right side of the anterior cranial fossa, left ambient cistern,
along the adjacent left tentorium cerebelli, and along the
sulcus
posterior right frontal lobe".

CT/CTA([**Hospital1 18**]): Left frontal subarachnoid hemorrhage and subdural
blood measuring up to 6mm and layering along the falx. No
signficant mass effect. No intraventricular hemorrhage. 5 x 9 mm
focus of hemorrhage in the right parietal lobe. No e/o aneurysm
or vascular abnl.
   CTA: 1. Left frontal subarachnoid hemorrhage and subdural
hematoma without evidence of significant mass effect. 2. Small
focus of subarachnoid hemorrhage or intraparenchymal hemorrhage
in
the right parietal lobe. 3. Small amount of intraventricular
hemorrhage in the left perimesencephalic cistern. 4.
Unremarkable CTA of the head.

Repeat CTA [**2180-8-19**]: IMPRESSION: 1. Previously noted left
frontal hypodensity and subarachnoid hemorrhages as well as
intraventricular hemorrhage are again seen. 2. Mild vasospasm is
identified more predominantly in the left middle cerebral artery
and the main divisions of middle cerebral artery. No vascular
occlusion is seen.

Echo ([**2180-8-25**]): Left ventricular wall thicknesses are normal.
The left ventricular cavity size is normal. Overall left
ventricular systolic function is mildly depressed (LVEF= 40-50
%) secondary to inferior posterior hypokinesis Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. Trace aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. There is a small pericardial effusion. There are
no echocardiographic signs of tamponade.

Video Oropharyngeal Swallow ([**2180-8-25**]): No gross aspiration or
penetration.

Labs:
[**2180-8-17**] 05:51PM   GLUCOSE-176* UREA N-10 CREAT-0.7 SODIUM-143
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-29 ANION GAP-15
[**2180-8-17**] 05:51PM   CALCIUM-9.3 PHOSPHATE-3.4 MAGNESIUM-1.9
[**2180-8-17**] 05:51PM   WBC-9.7 RBC-3.67* HGB-9.4* HCT-30.7* MCV-84
MCH-25.7* MCHC-30.6* RDW-14.8
[**2180-8-17**] 05:51PM   PLT COUNT-252
[**2180-8-17**] 05:51PM   PT-16.5* PTT-20.4* INR(PT)-1.5*

Brief Hospital Course:
60 year old Portugese speaking gentleman found down and taken to
outside hospital where CT scan revealed left frontal tentorial
cistern acute subarachnoid and subdural hemorrhage. He was
transported by [**Location (un) **] to [**Hospital1 18**] when his mental status
deteriorated in flight. He was intubated for a GCS of 7  at
arrival and recieved profiline and FFP in ED. He also sustained
a left humeral fracture that was splinted by ortho trauma. On
[**8-18**] he was found to have a left lower lobe mass. He remained
intubated becuase he did not tolerate CPAP. On [**8-19**], the patient
was extubated and placed on nimodipine for subarachnoid
hemorrhage. On physical exam, patient was awake, following
commands, giving thumbs up and moving R>L. Pupils were equal and
reactive. On [**8-20**], cardiology was consulted for arrthymias seen
on telemetry and nimoedipine was discontinued, as no vasospasm
was seen on CTA. On [**8-21**], a repeat head CT scan showed a stable
intra-cranial bleed. Patient did not sustain any further
injuries to the body per trauma. Family meeting was conducted to
discuss goals of care and patient was made DNR/DNI. Patient was
transferred out of the ICU to the medicine floor to coordinate
recommendations of consult services and to initiate discharge
planning.

1. Intracranial hemorrhage: The patient's intracranial bleed was
stable on head CTs on [**8-21**] and [**8-23**]. Patient's mental status
improved over the course of the admission, becoming more
interactive, A&Ox2, able to state his address and birthday,
following commands and moving all four extremities to command.
It's still unclear why the patient fell initially--the
differential includes seizure, arrythmia, hypoxia secondary to
cigarette smoking/lung CA. The patient had cardiac enzymes
negative x3. He had an echo with above results. Neurosurgery
followed the patient while admitted, with recommendations to
hold the patient's Coumadin for (at least) 1 month as well as to
continue seizure prophylaxis with Keppra 1000 mg [**Hospital1 **].  Neurology
and neurosurgery both felt the patient's prognosis was somewhat
guarded, but may improve in time. As his coumadin had to be
discontinued, the patient had an IVC filter placed while
admitted.
.
2. Arrhthymias: The patient had several episodes of atrial
tachycardia while on telemetry, as well as one episode of
bradycardia. This was likely atrial fibrillation secondary to
the stress of acute event. Cardiology was consulted and
recommended a low-dose beta blocker for rate control (metoprolol
12.5mg three times daily). TSH was normal. The patient remained
hemodynamically stable throughout his admission, with normal
blood pressure. Cardiology was also concerned that additional
anti-arrythmic intervention would increase his risk for
bradycardia, of which the patient had only one concerning
episode but which would ultimately likely be more problem[**Name (NI) 115**]
than his well-perfusing tachycardia. If the patient
decompensates in the future, a pacemaker could be considered as
a palliative measure if life expectancy sufficient.
.
3. Lung cancer: Per report of family, the patient and his
oncologist had decided to emphasize on quality of life for the
last few months given failure to respond to chemo/rads.  The
patient had a chest CT, showing 8 cm mass of the left lower lobe
growing into the left main stem bronchus and associated with
complete collapse of the left lower lobe. This mass may
contribute to future respiratory compromise via obstruction or
subsequent pneumonia--however, the patient remained stable from
a respiratory stand-point throughout his hospitalization, with
02 saturations >95% on room air and without respiratory
distress. In the future, if the patient develops respiratory
distress, intervention on the bronchial mass could be considered
by interventional pulmonology with stenting or phototherapy.
These procedures would require intubation with bronchoscopy.
The patient with follow up with IP as an out-patient.
.
4. Fever: the patient became febrile on the floor, spiking
fevers of up to 101.3 (PO) on multiple occasions.  Although he
had no obvious source, with a negative UA and indeterminate CXR
showing extensive left lung collapse and effusion, the patient
was begun on coverage for ventilator associated pneumonia with
IV Cefepime, Vanc, and Flagyl, given his increased risk from
recent intubation. He will continue this regimen at rehab. Blood
and urine cultures were pending at discharge.  The patient had
been afebrile for 24 hours at discharge after 3 days of
antibiotics.
.
5. Diabetes: While in the hospital, the patient had elevate CBGs
into the 300s. He was started on a PM dose of Lantus (14 units)
prior to discharge.  His blood sugar control can be further
titrated at rehab.  However, intensive glucose control may
create sharp swings in glucose, could precipitate arrythmias so
aggressive glucose control should be avoided.
.
6. Hypertension: The patient's systolic blood pressure should be
kept <180 per neurosurgery recommedation. This was achieved with
Metoprolol 12.5mg TID, with the patient's blood pressure ranging
from 114-132/60-80 on day of discharge.
.
7. Left humerus fracture: The patient is being discharged with
his arm in a sling after splinting by ortho. He will need to
follow up with ortho as an outpatient.
.
8. Nutrition: The patient was evaluated by the speech and
swallow with the recommendation to feed the patient thin
liquids/soft solids with 1:1 supervision. He had a video swallow
which showed no aspiration.


Medications on Admission:
Medications prior to admission:
1. Omeprazole 20mg
2. Tramadol 50mg [**12-31**] q 6h
3. Simvastatin 20mg daily
4. Seroquel 100mg HS
5. Glipizide ER 10mg daily
6. Coumadin 4mg daily
7. Keppra 500mg [**Hospital1 **]
8. IBU 800mg

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
2. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID
(4 times a day) as needed for thrush.
Disp:*1 bottle* Refills:*0*
3. Levetiracetam 500 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*0*
4. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: 0.5 Tablet PO TID (3
times a day).
Disp:*45 Tablet(s)* Refills:*0*
5. Simvastatin 10 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY
(Daily).
Disp:*60 Tablet(s)* Refills:*0*
6. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) doses PO BID
(2 times a day).
Disp:*120 doses* Refills:*0*
7. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*0*
8. Acetaminophen 160 mg/5 mL Solution [**Last Name (STitle) **]: [**5-7**] mL PO Q6H (every
6 hours) as needed for pain/fever.
Disp:*1 bottle* Refills:*0*
9. Ipratropium Bromide 0.02 % Solution [**Month/Year (2) **]: One (1) neb
Inhalation Q6H (every 6 hours) as needed for dyspnea.
10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization [**Month/Year (2) **]: One (1) neb Inhalation Q6H (every 6 hours) as
needed for wheezing.
11. Insulin Regular Human 100 unit/mL Solution [**Month/Year (2) **]: asdir unit
Injection four times a day: See attached insulin sliding scale.

12. Insulin Glargine 100 unit/mL Solution [**Month/Year (2) **]: Fourteen (14)
units Subcutaneous qa breakfast: See attached sliding scale.
13. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback [**Month/Year (2) **]:
One (1)  Intravenous Q8H (every 8 hours) for 5 days.
Disp:*qs * Refills:*0*
14. Cefepime 2 gram Recon Soln [**Month/Year (2) **]: One (1) dose Intravenous
twice a day for 5 days.
Disp:*qs * Refills:*0*
15. Vancomycin in Dextrose 1 gram/250 mL Solution [**Month/Year (2) **]: One (1)
dose Intravenous twice a day for 5 days.
Disp:*10 dose* Refills:*0*


Discharge Disposition:
Extended Care

Facility:
[**Hospital 5503**] Rehab Hospital

Discharge Diagnosis:
Primary:
1. intra-cranial hemorrhage
2. heart arrhythmias
3. left humerus fracture
4. Ventilator associated pneumonia
Secondary:
1. stage 4 lung cancer with brain metastasis
2. pulmonary embolism s/p IVC filter placement
3. Diabetes, type 2
4. HTN


Discharge Condition:
stable.


Discharge Instructions:
General Instructions

??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	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)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
??????	If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel) prior to your injury, you may safely resume
taking this on XXXXXXXXXXX.
??????	If you have been prescribed Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week.  This can be drawn at your
PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**].
If you haven been discharged on Keppra (Levetiracetam), you will
not require blood work monitoring.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion, lethargy or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	New onset of the loss of function, or decrease of function on
one whole side of your body.

Followup Instructions:
Follow-Up Appointment Instructions

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**], to be seen in 4 weeks.
??????You will need a CT scan of the brain without contrast prior to
your appointment. This can be scheduled when you call to make
your office visit appointment.
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Pulmonary collapse,Unspecified pleural effusion,Malignant neoplasm of lower lobe, bronchus or lung,Secondary malignant neoplasm of brain and spinal cord,Ventilator associated pneumonia,Closed fracture of unspecified part of upper end of humerus,Fall from other slipping, tripping, or stumbling,Epilepsy, unspecified, without mention of intractable epilepsy,Esophageal reflux,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Bipolar disorder, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Foreign body in larynx,Foreign body accidentally entering other orifice,Atrial fibrillation'}


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: CC:[**CC Contact Info **]
Major Surgical or Invasive Procedure:
IVC filter placement

PRESENT ILLNESS: This is a 60 year old man with lung cancer with brain metastases
previously on anticoagulation for [**Hospital **] transferred to the MICU
from the SICU in the setting of arrythmias, most prominently
tachyarrythmias, who originally presented to medical care on
[**8-17**] late morning after being found by his family, lying down on
the sidewalk outside of his home, minimally responsive. He awoke
at the scene complaining of headache and left shoulder pain. He
was taken to [**Hospital 6136**] Hospital; and then taken by [**Location (un) **] to
[**Hospital1 18**] after a CT showed extensive acute ICH. An EKG there showed
sinus rhythm, with an S in I and a Q in III, with prominent
upright T waves in precordial leads and no indication of
ischemia. He reportedly started the flight being AOx3 and
following commands and then deteriorated into lethargy and
minimal responsiveness. He was intubated for airway protection.
Of note, his INR was 3.7 on arrival to [**Hospital1 18**] consistent with
coumadin taken regularly at home for known PE in [**2179-12-30**].
He received 2 units of FFP and vitamin K.
.
At [**Hospital1 18**] he was admitted to the SICU on the neurosurgical
service. Ultimately, neurosurgery decided to observe the
patient, start seizure prophylaxis, normalize INR (with a
recommendation to avoid anticoagulation for one month) with no
indication for neurosurgical intervention. He was diagnosed with
a left humeral fracture for which orthopedics recommended
splint. He was extubated on [**8-19**]. An IVC filter was placed on
[**8-21**].
.
Of note in terms of his functional status prior to the event, he
had not had recent falls prior to this. However, prior to his
diagnosis with brain mets, he had a persistent cough and had
some prior episodes, unwitnessed by family and only uncovered in
retrospect, in which he coughed violently and then fell down,
perhaps similar to this presentation. He was until this
admission able to perform basic ADLs, ambulating, toileting,
eating, etc; though with low energy and slow mobility.

MEDICAL HISTORY: Stage IV lung cancer with brain metastases diagnosed [**9-5**] after
episode of seizures, s/p R craniectomy [**9-5**] for tumor resection,
s/p chemo/radiation; oncologist [**First Name8 (NamePattern2) 1528**] [**Last Name (NamePattern1) **] ([**Hospital1 6136**]), rad
onc [**Location (un) **] ([**First Name8 (NamePattern2) **] [**Doctor First Name **]); per daughter, little effect of chemo/rads,
oncologist said emphasis should be on quality of life at this
point
PE diagnosed in [**1-7**] (on coumadin), diagnosed by routine CT
scan, was evidently asymptomatic at that time
Hyperlipidemia
NIDDM
GERD
Bipolar disorder diagnosed in [**2174**] after a psych hospitalization
for mania, has been on several meds; stopped meds and was
rehospitalized; since then has been on seroquel alone
Seizure disorder secondary to brain mets only
.

MEDICATION ON ADMISSION: Medications prior to admission:
1. Omeprazole 20mg
2. Tramadol 50mg [**12-31**] q 6h
3. Simvastatin 20mg daily
4. Seroquel 100mg HS
5. Glipizide ER 10mg daily
6. Coumadin 4mg daily
7. Keppra 500mg [**Hospital1 **]
8. IBU 800mg

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM on admission:
O: T:97.0  BP:129/6/   HR:102   RR:16  O2Sats 96%
Gen: WD/WN, comfortable, NAD.
HEENT:normocephalic, small superficial abrasion to left head.
Pupils:PERRLA
EOMs: UTA due to inattention/lethargy
Neuro:Mental status: Lethargic, arousable to loud voice. No
commands.
Face appears to be symmetric. Spont mvmt observed in the RUE.
Brisk w/drawl of LE(R>L). minimal mvmt of LUE observed, though
also withdraws to nox. 5/5 strength throughout. [**12-31**]+ reflexes,
equal BL. Normal coordination. Gait assessment deferred

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Ran an auto detailing and used car sales business until his
cancer diagnosis; was on disability thereafter. Two adult
children who live ~half hour away from his home. Lives with
wife. Portuguese-speaking only. 60 pack year cigarette history.
No EtOH or drugs by report. 

### Response:
{'Subarachnoid hemorrhage following injury without mention of open intracranial wound, with brief [less than one hour] loss of consciousness,Pulmonary collapse,Unspecified pleural effusion,Malignant neoplasm of lower lobe, bronchus or lung,Secondary malignant neoplasm of brain and spinal cord,Ventilator associated pneumonia,Closed fracture of unspecified part of upper end of humerus,Fall from other slipping, tripping, or stumbling,Epilepsy, unspecified, without mention of intractable epilepsy,Esophageal reflux,Other and unspecified hyperlipidemia,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Bipolar disorder, unspecified,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants,Foreign body in larynx,Foreign body accidentally entering other orifice,Atrial fibrillation'}
