CHIEF COMPLAINT: Confusion, dizziness

PRESENT ILLNESS: 51 year-old male with history of newly diagnosed metastatic lung
cancer to liver, bones, and brain via PET imaging, stigmata of
chronic liver disease probably from alcoholism based on history,
presenting with one day history of confusion and dizziness in
addition to worsening LFTs. Patient has not established with
oncology given lack of tissue diagnosis. Patient's labs drawn by
Thoracic Surgery [**2166-4-3**] were as follows: Tbili 10.8, ALP 283,
AST 220, ALT 81, so he was called by primary care NP and asked
to present to the ED.

MEDICAL HISTORY: Lung cancer
Hypertension
Back pain

MEDICATION ON ADMISSION: Acetaminophen-Codeine 300-30 mg 1 tab q4h PRN pain
Hydrochlorothiazide 25 mg PO daily
Cyclobenzaprine 10 mg PO daily PRN muscle spasm
Lisinopril 10 mg PO daily
Naproxen 500 mg PO BID PRN pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission
T: 98.5  BP: 151/78 P: 109 R: 14  O2: 94% 2L NC
General: easily arousable, no acute distress, jaundiced
HEENT: Sclera icteric, very dry mucus membranes
Neck: supple, visble carotid pulsations
Lungs: Limited air movement bilaterally, no
rhonchi/wheezes/crackles appreciated
CV: Regular rhythm, rapid rhythm, very hyperdynamic heart
Abdomen: Hypoactive bowel sounds, soft, non-tender, mild to
moderately distended, no rebound tenderness or guarding
GU: Foley with icteric urine
Ext: Warm, well perfused, 1+ DP pulses, no peripheral edema
Skin: Spider angiomata
Neuro: oriented to name, but not year or place; PERRLA;
symmetric DTR's globally; no clonus

FAMILY HISTORY: Father with CAD/PVD, diabetes, HTN, mother with stroke. Brother
with diabetes mellitus.

SOCIAL HISTORY: Tobacco: Reports [**12-8**] ppd for many years.
ETOH: Former heavy drinker, now drinks daily. Per brother [**Name (NI) **],
with whom he lives, last drink was about a week prior to
admission
Illicits: denies, but per brother [**Name (NI) **] last used cocaine night
prior to admission
Lives with brother [**Name (NI) **], but also has another brother [**Doctor Last Name **]
and sister involved in her care.
Malignant neoplasm of liver, secondary,Pneumonia, organism unspecified,Hepatic encephalopathy,Acute kidney failure, unspecified,Secondary malignant neoplasm of brain and spinal cord,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Malignant neoplasm of lower lobe, bronchus or lung,Hyposmolality and/or hyponatremia,Other ascites,Alcoholic cirrhosis of liver,Other and unspecified coagulation defects,Hypercalcemia,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous,Neoplasm related pain (acute) (chronic),Edema,Backache, unspecified
Second malig neo liver,Pneumonia, organism NOS,Hepatic encephalopathy,Acute kidney failure NOS,Sec mal neo brain/spine,Mal neo lymph intra-abd,Mal neo lower lobe lung,Hyposmolality,Ascites NEC,Alcohol cirrhosis liver,Coagulat defect NEC/NOS,Hypercalcemia,Hypertension NOS,Alcoh dep NEC/NOS-contin,Neoplasm related pain,Edema,Backache NOS
Admission Date:  [**2166-4-12**]              Discharge Date:   [**2166-4-23**]

Date of Birth:  [**2114-8-20**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2290**]
Chief Complaint:
Confusion, dizziness

Major Surgical or Invasive Procedure:
Liver biopsy [**2166-4-18**]

History of Present Illness:
51 year-old male with history of newly diagnosed metastatic lung
cancer to liver, bones, and brain via PET imaging, stigmata of
chronic liver disease probably from alcoholism based on history,
presenting with one day history of confusion and dizziness in
addition to worsening LFTs. Patient has not established with
oncology given lack of tissue diagnosis. Patient's labs drawn by
Thoracic Surgery [**2166-4-3**] were as follows: Tbili 10.8, ALP 283,
AST 220, ALT 81, so he was called by primary care NP and asked
to present to the ED.

In the ED, initial vs were: T 97.6 P 104 BP 142/70 R 18 Sat 96%
RA. Patient was noted to be jaundiced. Labs were notable for Na
131, Ca [**69**], Cr 1.6 from baseline of 0.8. LFTs were remarkable
for AST 352, ALT 76, TBili 15.8, Direct Bili 12, Alk Phos 229.
Ammonia was 105. INR was noted to be 1.5. Blood and urine
cultures were sent, with urinalysis unremarkable. 2 liters IVF
were given in ED for hypercalcemia with some improvement in
mental status. Head CT was performed and showed no acute process
with known cerebellar lesion on MRI not visualized. Right upper
quadrant U/S showed CBD with 2 mm diameter and no intrahepatic
biliary dilation, with no evidence of cholecystitis or focal
liver lesions seen on limited images obtained. Vitals in ED
prior to transfer were as follows: T98.4 HR 103 166/79 93% RA.

On the floor, patient is in no acute distress, but unable to
answer questions appropriately.

Review of systems:
(+) Per HPI.  Patient has had some weight loss but difficult to
cooperate in answering questions at this time. Endorses
constipation.
(-) Denies headache, sinus tenderness. Denied shortness of
breath. Denied chest pain. Denied abdominal pain. Denied
arthralgias or myalgias.

Past Medical History:
Lung cancer
Hypertension
Back pain

Social History:
Tobacco: Reports [**12-8**] ppd for many years.
ETOH: Former heavy drinker, now drinks daily. Per brother [**Name (NI) **],
with whom he lives, last drink was about a week prior to
admission
Illicits: denies, but per brother [**Name (NI) **] last used cocaine night
prior to admission
Lives with brother [**Name (NI) **], but also has another brother [**Doctor Last Name **]
and sister involved in her care.

Family History:
Father with CAD/PVD, diabetes, HTN, mother with stroke. Brother
with diabetes mellitus.

Physical Exam:
Admission
T: 98.5  BP: 151/78 P: 109 R: 14  O2: 94% 2L NC
General: easily arousable, no acute distress, jaundiced
HEENT: Sclera icteric, very dry mucus membranes
Neck: supple, visble carotid pulsations
Lungs: Limited air movement bilaterally, no
rhonchi/wheezes/crackles appreciated
CV: Regular rhythm, rapid rhythm, very hyperdynamic heart
Abdomen: Hypoactive bowel sounds, soft, non-tender, mild to
moderately distended, no rebound tenderness or guarding
GU: Foley with icteric urine
Ext: Warm, well perfused, 1+ DP pulses, no peripheral edema
Skin: Spider angiomata
Neuro: oriented to name, but not year or place; PERRLA;
symmetric DTR's globally; no clonus

Pertinent Results:
ADMISSION LABS:
ALT-76* AST-352* CK-330* ALK PHOS-229* TOT BILI-15.8* DIR
BILI-12* INDIR BIL-3.8
ALBUMIN-3.8 CALCIUM-15* PHOSPHATE-3.9 MAGNESIUM-2.4
ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
WBC-10.3 RBC-4.47* HGB-14.6 HCT-41.4 MCV-93 MCH-32.6* MCHC-35.2*
RDW-17.3*

URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-POS
amphetmn-NEG mthdone-NEG
URINE  COLOR-AMBER APPEAR-Cloudy SP [**Last Name (un) 155**]-1.017 URINE  BLOOD-NEG
NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD
UROBILNGN-8* PH-5.0 LEUK-NEG

CK-MB-2 cTropnT-<0.01 CK(CPK)-315
PTH-9*

LAST SET OF LABS: [**2166-4-20**]
WBC-8.7 Hgb-11.0* Hct-32.5* MCV-95 Plt-88*
PT-30.6* PTT-43.3* INR(PT)-3.0*
Glucose-70 UreaN-71* Creat-1.6* Na-140 K-3.9 Cl-104 HCO3-15*
Calcium-7.3* Phos-4.9*# Mg-1.6
ALT-126* AST-871* LD(LDH)-4180* AlkPhos-212* TotBili-18.1*

MICROBIOLOGY:
BLOOD CULTURES: NEGATIVE
URINE CULTURE: NEGATIVE
MRSA SCREEN: NEGATIVE
HCV VIRAL LOAD: 800,000

PATHOLOGY:
LIVER CORE BX  [**2166-4-18**]:  Metastatic carcinoma with
neuroendocrine features. The morphologic and immunophenotypic
features are consistent with a lung primary.

RADIOLOGY:
PET SCAN [**2166-4-9**]:
1. Large left lower lobe FDG avid mass with multiple osseous and

hepatic metastases as well as large metastatic lymph nodes in
the aortocaval and portocaval regions.
2. Asymmetric FDG avidity in the left vocal chord which may be
due to tumor involvement of the right recurrent laryngeal nerve.


MRI HEAD [**2166-4-9**]:
3-mm lesion within the left cerebellar hemisphere with
enhancement seen on
only axial post-gadolinium images are not clearly visualized on
the
post-gadolinium MP-RAGE images as described above. The presence
of the lesion on the FLAIR and T2 images is suggestive of
metastatic lesion. However, given the small size of this
solitary if further confirmation is clinically required (for
therapeutic purposes), repeat T1 post-gadolinium axial and
coronal images of the posterior fossa with 3-mm section
thickness would help.

CT HEAD [**2166-4-11**]:
1. No acute intracranial process. Known left cerebellar lesion
is not
apparent on unenhanced CT.
2. Aerosolized secretions and mucosal thickening in the left
maxillary sinus.

RUQ U/S [**2166-4-12**]:
1. No intrahepatic biliary ductal dilation. The common bile duct
measures 2 mm.
2. The gallbladder is decompressed, likely accounting for wall
thickening,
with no evidence of cholecystitis.
3. Limited images demonstrating no focal liver lesion, though
correlation
with recent PET-CT (reportedly showing focal liver lesions
concerning for
metastases) is advised.

CXR [**2166-4-12**]:
There is again seen an area of consolidation projecting over the
left base
compatible with known infiltrate in the left lower lobe abutting
the major
fissure. The cardiac silhouette is within normal limits. There
is no
pneumothoraces or pleural effusions identified.

Brief Hospital Course:
51 year-old male with h/o newly diagnosed metastatic cancer with
lung, liver, brain, and bone lesions via PET imaging, presented
with altered mental status, liver failure, and hypercalcemia.
Patient was treated for hypercalcemia and hepatic encephalopathy
in the ICU; IV fluids, calcitonin, and pamidronate for
hypercalcemia and lactulose and rifaximin for hepatic
encephalopathy.  CXR revealed PNA for which the patient was
treated initially with levofloxacin and metronidazole and later
broadened to cefepime and metronidazole.  His mental status
improved and patient was transferred to the floor on hospital
day 2.

Diagnostic paracentesis and liver biopsy were performed.  Liver
biopsy pathology revealed findings consistent with lung cancer.
The patient's liver failure progressively worsened with MELD
score reaching 34 when labs stopped being drawn. Because of the
extremely grave prognosis of widely metastatic lung cancer (mets
to the brain, liver nad bones) and hepatic failure, the patient
opted to transition to hospice care.  His chief request was that
he be made comfortable and that any pain related to cancer will
be treated promptly and adequately.  He designated his brother,
[**Name (NI) **] [**Name (NI) 102482**], to be his healthcare proxy.

On [**2166-4-23**], he was noted to have worsening in his mental
status and to be more labored in his breathing.  He appeared to
be near death.  His family was notified of his change in status.
 However, soon after notifying the family, this writer was
notified that he had died.  He was reassessed and was noted to
have unreactive pupils and no evidence of cardiopulmonary
activity.  The family was notified of his death.  Time of death
was 8:34 AM.  The patient's brother declined post-mortem exam.


Medications on Admission:
Acetaminophen-Codeine 300-30 mg 1 tab q4h PRN pain
Hydrochlorothiazide 25 mg PO daily
Cyclobenzaprine 10 mg PO daily PRN muscle spasm
Lisinopril 10 mg PO daily
Naproxen 500 mg PO BID PRN pain

Discharge Medications:
1. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO every
eight (8) hours: titrate to 3 bowel movements daily.
2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).


Discharge Disposition:
Expired

Discharge Diagnosis:
Lung cancer, metastatic to brain, liver, and bones
Hepatic failure with encephalopathy, coagulopathy, anasarca
Coma from hepatic encephalopathy and hypercalcemia
Hepatitis C
Acute kidney injury
Pneumonia, community acquired versus aspiration
Cancer-related pain


Discharge Condition:
Deceased

Discharge Instructions:
Deceased

Followup Instructions:
Deceased
{'Malignant neoplasm of liver, secondary,Pneumonia, organism unspecified,Hepatic encephalopathy,Acute kidney failure, unspecified,Secondary malignant neoplasm of brain and spinal cord,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Malignant neoplasm of lower lobe, bronchus or lung,Hyposmolality and/or hyponatremia,Other ascites,Alcoholic cirrhosis of liver,Other and unspecified coagulation defects,Hypercalcemia,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous,Neoplasm related pain (acute) (chronic),Edema,Backache, unspecified'}


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: Confusion, dizziness

PRESENT ILLNESS: 51 year-old male with history of newly diagnosed metastatic lung
cancer to liver, bones, and brain via PET imaging, stigmata of
chronic liver disease probably from alcoholism based on history,
presenting with one day history of confusion and dizziness in
addition to worsening LFTs. Patient has not established with
oncology given lack of tissue diagnosis. Patient's labs drawn by
Thoracic Surgery [**2166-4-3**] were as follows: Tbili 10.8, ALP 283,
AST 220, ALT 81, so he was called by primary care NP and asked
to present to the ED.

MEDICAL HISTORY: Lung cancer
Hypertension
Back pain

MEDICATION ON ADMISSION: Acetaminophen-Codeine 300-30 mg 1 tab q4h PRN pain
Hydrochlorothiazide 25 mg PO daily
Cyclobenzaprine 10 mg PO daily PRN muscle spasm
Lisinopril 10 mg PO daily
Naproxen 500 mg PO BID PRN pain

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission
T: 98.5  BP: 151/78 P: 109 R: 14  O2: 94% 2L NC
General: easily arousable, no acute distress, jaundiced
HEENT: Sclera icteric, very dry mucus membranes
Neck: supple, visble carotid pulsations
Lungs: Limited air movement bilaterally, no
rhonchi/wheezes/crackles appreciated
CV: Regular rhythm, rapid rhythm, very hyperdynamic heart
Abdomen: Hypoactive bowel sounds, soft, non-tender, mild to
moderately distended, no rebound tenderness or guarding
GU: Foley with icteric urine
Ext: Warm, well perfused, 1+ DP pulses, no peripheral edema
Skin: Spider angiomata
Neuro: oriented to name, but not year or place; PERRLA;
symmetric DTR's globally; no clonus

FAMILY HISTORY: Father with CAD/PVD, diabetes, HTN, mother with stroke. Brother
with diabetes mellitus.

SOCIAL HISTORY: Tobacco: Reports [**12-8**] ppd for many years.
ETOH: Former heavy drinker, now drinks daily. Per brother [**Name (NI) **],
with whom he lives, last drink was about a week prior to
admission
Illicits: denies, but per brother [**Name (NI) **] last used cocaine night
prior to admission
Lives with brother [**Name (NI) **], but also has another brother [**Doctor Last Name **]
and sister involved in her care. 

### Response:
{'Malignant neoplasm of liver, secondary,Pneumonia, organism unspecified,Hepatic encephalopathy,Acute kidney failure, unspecified,Secondary malignant neoplasm of brain and spinal cord,Secondary and unspecified malignant neoplasm of intra-abdominal lymph nodes,Malignant neoplasm of lower lobe, bronchus or lung,Hyposmolality and/or hyponatremia,Other ascites,Alcoholic cirrhosis of liver,Other and unspecified coagulation defects,Hypercalcemia,Unspecified essential hypertension,Other and unspecified alcohol dependence, continuous,Neoplasm related pain (acute) (chronic),Edema,Backache, unspecified'}
