CHIEF COMPLAINT: Lung mass.

PRESENT ILLNESS: 88 year old male with a history of prostate cancer, CVA, DM2,
CEA and [**Hospital 2182**] transferred to the medicine service for further
evaluation of a lung mass. The patient was in his usual state of
health until one month prior to admission when he developed
upper extremity weakness, right more than left as well as
bilateral shoulder pain and a cough. He was admitted to an OSH
and was found to have a LLL infiltrate and was treated for
pneumonia and COPD flare.  He also had a spine MRI which
demonstrated a T1 compression fracture.  The patient was
transitioned to rehabilitation.  At the rehab facility he
continued to have upper extremity weakness and bilateral
shoulder pain refractory to conservative measures.  MRI of his
brain showing no significant change from his post-stroke MRI per
report.  His R hand weakness progressed and he was sent from
rehab back to the OSH where he again had a MRI of his C-spine
which showed interval progression of the compression fracture
with retropulsion of the posterior fragment into the upper
thoracic cord.  Additionally, a soft tissue mass anterior to the
vertebral body brought up the possibility of metastatic disease.
 His PSA remained flat at this time and a CT chest showed 2 LLL
masses along with renal and thyroid cysts.  He was started on
steroids and  sent to [**Hospital1 18**] for further managment.
Incidentally, he was restarted on CTX/gentamycin at the OSH per
family report because he developed fevers but they denied any
other infectious symptoms at this time including SOB, cough,
dysuria, or abdominal pain.  He did have mild diarrhea.
.
At [**Hospital1 18**], his films were reviewed by neurosurgery and no cord
compression was noted.  His thoracic vertebral fracture was
thought to be stable and he was fitted for a brace.  IP was
consulted to perform a percutaneous biopsy of the mass and CT of
the chest, abdomen and pelvis were performed.  A bone scan and
CT head were ordered along with a MRI of C5-T4.  The patient was
transfered to medicine for further work-up of his lung mass once
acute neurosurgical issues were excluded.
.
On interview today, the patient feels generally well.  He denies
any CP, SOB, abdominal pain, nausea, vomiting or headache.  He
does have some LE paresthesias and notes weakness in his R hand
that is worse than baseline.  His family notes chronically loose
bowels but states this has been worse of late and feels that his
cognition has slipped over the past month.

MEDICAL HISTORY: 1. HTN
2. Prostate CA s/p XRT and since treated w/ lupron and zoladex
3. CVA '[**92**] w/ residual R sided weakness
4. DM2
5. s/p Nephrectomy ~'[**82**]
6. GIB
7. carotid endarterectomy
8. COPD
9. Shoulder OA
10. Glaucoma

MEDICATION ON ADMISSION: (on transfer):
HSQ
ISS
Allopurinol 300mg
Latanoprost 1 drop qhs
CTX 1g
Gentamycin 80mg [**Hospital1 **]
Protonix 40mg
Iron 325mg [**Hospital1 **]
Propoxyphene-APAP prn
FA
Glipizide 5mg
.
Meds (at rehab):
Lisinopril 20mg
Glipizide 5mg
Allopurinol 300mg
Lasix 40mg
ASA 325mg
Metformin 500mg
Lactulose prn
Xalatan eye drop qhs
Naprosyn prn
Zantac 150mg [**Hospital1 **]
FA 1mg
Lidocaine patch to back
Darvocet prn
Prednisone taper
Zoladex 10.8mg q3mo (due this mo)

ALLERGIES: Demerol / Aspirin / Dilaudid

PHYSICAL EXAM: (on admission)
99.3, 126/69, 88, 20, 98%RA
Gen: WNWD Elderly [**Male First Name (un) 4746**] sitting up in chair w/ neck brace in place
HEENT: MMM, O/P clear, EOMI, PERRLA
CV: RRR, 3/6 SEM at the apex
Lungs: Decreased breath sounds on the L
Abd: S/NT/ND, +BS, -HSM
Ext: No peripheral edema
Neuro: Decreased strength on R side w/ worst strength in grip,
intact sensation to light touch bilaterally, AAO to person and
year but not date or location, 0/3 recall immediately and w/
prompting, thought 5 quarters in $1.75, intact heel-to-shin on L
but impaired on R, able to name watch/pen and describe what they
are used for
Skin: No rashes

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Lives with sons but most recently in rehab.  Social EtOH.  Quit
smoking ~20yrs ago (30-45pk/yrs prior).  No drug use.  Worked
for [**Company 2676**] but also spent time in a [**Doctor Last Name **] quarry.  No work in
construction, demolition, or shipyard.  No exposure to
chemicals.
Malignant neoplasm of other parts of bronchus or lung,Chronic airway obstruction, not elsewhere classified,Pneumonia, organism unspecified,Pathologic fracture of vertebrae,Atrial fibrillation,Hypoxemia,Ulcer of heel and midfoot,Secondary malignant neoplasm of bone and bone marrow,Acute kidney failure, unspecified,Systolic heart failure, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Personal history of malignant neoplasm of prostate,Other chronic pulmonary heart diseases,Anemia of other chronic disease,Unspecified glaucoma,Gout, unspecified,Nontoxic uninodular goiter
Mal neo bronch/lung NEC,Chr airway obstruct NEC,Pneumonia, organism NOS,Path fx vertebrae,Atrial fibrillation,Hypoxemia,Ulcer of heel & midfoot,Secondary malig neo bone,Acute kidney failure NOS,Systolic hrt failure NOS,DMII unspf uncntrld,Hx-prostatic malignancy,Chr pulmon heart dis NEC,Anemia-other chronic dis,Glaucoma NOS,Gout NOS,Nontox uninodular goiter
Admission Date:  [**2193-2-22**]              Discharge Date:   [**2193-3-21**]


Service: MEDICINE

Allergies:
Demerol / Aspirin / Dilaudid

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
Lung mass.

Major Surgical or Invasive Procedure:
Lung biopsy on [**2193-2-28**].
Vertebroplasty


History of Present Illness:
88 year old male with a history of prostate cancer, CVA, DM2,
CEA and [**Hospital 2182**] transferred to the medicine service for further
evaluation of a lung mass. The patient was in his usual state of
health until one month prior to admission when he developed
upper extremity weakness, right more than left as well as
bilateral shoulder pain and a cough. He was admitted to an OSH
and was found to have a LLL infiltrate and was treated for
pneumonia and COPD flare.  He also had a spine MRI which
demonstrated a T1 compression fracture.  The patient was
transitioned to rehabilitation.  At the rehab facility he
continued to have upper extremity weakness and bilateral
shoulder pain refractory to conservative measures.  MRI of his
brain showing no significant change from his post-stroke MRI per
report.  His R hand weakness progressed and he was sent from
rehab back to the OSH where he again had a MRI of his C-spine
which showed interval progression of the compression fracture
with retropulsion of the posterior fragment into the upper
thoracic cord.  Additionally, a soft tissue mass anterior to the
vertebral body brought up the possibility of metastatic disease.
 His PSA remained flat at this time and a CT chest showed 2 LLL
masses along with renal and thyroid cysts.  He was started on
steroids and  sent to [**Hospital1 18**] for further managment.
Incidentally, he was restarted on CTX/gentamycin at the OSH per
family report because he developed fevers but they denied any
other infectious symptoms at this time including SOB, cough,
dysuria, or abdominal pain.  He did have mild diarrhea.
.
At [**Hospital1 18**], his films were reviewed by neurosurgery and no cord
compression was noted.  His thoracic vertebral fracture was
thought to be stable and he was fitted for a brace.  IP was
consulted to perform a percutaneous biopsy of the mass and CT of
the chest, abdomen and pelvis were performed.  A bone scan and
CT head were ordered along with a MRI of C5-T4.  The patient was
transfered to medicine for further work-up of his lung mass once
acute neurosurgical issues were excluded.
.
On interview today, the patient feels generally well.  He denies
any CP, SOB, abdominal pain, nausea, vomiting or headache.  He
does have some LE paresthesias and notes weakness in his R hand
that is worse than baseline.  His family notes chronically loose
bowels but states this has been worse of late and feels that his
cognition has slipped over the past month.


Past Medical History:
1. HTN
2. Prostate CA s/p XRT and since treated w/ lupron and zoladex
3. CVA '[**92**] w/ residual R sided weakness
4. DM2
5. s/p Nephrectomy ~'[**82**]
6. GIB
7. carotid endarterectomy
8. COPD
9. Shoulder OA
10. Glaucoma


Social History:
Lives with sons but most recently in rehab.  Social EtOH.  Quit
smoking ~20yrs ago (30-45pk/yrs prior).  No drug use.  Worked
for [**Company 2676**] but also spent time in a [**Doctor Last Name **] quarry.  No work in
construction, demolition, or shipyard.  No exposure to
chemicals.

Family History:
Noncontributory.

Physical Exam:
(on admission)
99.3, 126/69, 88, 20, 98%RA
Gen: WNWD Elderly [**Male First Name (un) 4746**] sitting up in chair w/ neck brace in place
HEENT: MMM, O/P clear, EOMI, PERRLA
CV: RRR, 3/6 SEM at the apex
Lungs: Decreased breath sounds on the L
Abd: S/NT/ND, +BS, -HSM
Ext: No peripheral edema
Neuro: Decreased strength on R side w/ worst strength in grip,
intact sensation to light touch bilaterally, AAO to person and
year but not date or location, 0/3 recall immediately and w/
prompting, thought 5 quarters in $1.75, intact heel-to-shin on L
but impaired on R, able to name watch/pen and describe what they
are used for
Skin: No rashes

(on discharge)
99.1, 130/70, 74, 18, 95% on 2L NC
Gen: chronically ill appearing male in soft neck collar in place
HEENT: OP clear, EOMI, MMM
CV: RRR, 3/6 SEM apex radiating to axilla, heard across
precordium
Resp: sporadic ronchi, decreased breath sounds left
Abd: soft, nontender, nondistended, normal bowel sounds
Ext: No edema, able to move UE/LE bilaterally


Pertinent Results:
At the time of callout from the MICU ([**2193-3-2**]):
.
Labs: Remarkable for WBC 18.3 trending downward, Hct 27.9
baseline 32, INR 1.3.
.
MR thoracic and cervical spine without contrast ([**2193-2-25**]): 1.
Again seen is compression deformity involving the T1 vertebral
body. There
is no evidence of cord signal abnormality. Degenerative changes
within the cervical spine result in areas of spinal canal
stenosis, as described above. 2. There is left pleural effusion
and ill-defined mass in left lower lobe, which is better
evaluated on prior CT scans.
.
Bone Scan ([**2193-2-26**]): No evidence of osseous metastatic disease.
Focal uptake in the lower neck likely correlates with T1
compression fracture on CT scan.
.
CT chest/abd/pelvis ([**2193-2-24**]):
1. Multiple heterogeneously enhancing soft tissue masses within
the posterior left lung likely centering within the pleura
extending into the lateral chest wall and causing mild bony
erosion. A small linear calcification is noted adjacent to the
pleura within the dominant mass suggesting possible
mesothelioma. Additional diagnoses within the differential
include primary lung cancer or metastatic lesion from thyroid or
renal cell carcinoma. The lesion appears to be amenable to
percutaneous biopsy. 2. Heterogeneously enhancing middle
mediastinal left thyroid lesion. This likely represents a simple
goiter but can be further evaluated with ultrasound if
clinically indicated. 3. Cholelithiasis without evidence of
acute cholecystitis. 4. Multiple right renal hypoattenuating
lesions, some of which are clearly cystic and others which are
too small to characterize. 5. Diffuse atherosclerotic
calcifications. 6. T1 compression fracture with multilevel
degenerative changes throughout the spine, including grade 1
anterolisthesis of L5 on S1 and mild posterior disc protrusion
of L3-4 intervertebral disc.
.
Bronchial brushings and washings ([**2193-2-28**]): Negative for
malignant cells.
.
Lymph node biopsy ([**2193-2-28**]): Non-diagnostic, lymph node not
sampled, likely reactive lymphocytes.
.
Echo ([**2193-3-1**]): The left atrium is elongated. The left
ventricular cavity size is normal. Left ventricular systolic
function is grossly preserved although views are technically
suboptimal (EF probably >45%). Regional wall motion could not be
fully assessed. Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The ascending aorta is mildly dilated. The aortic
valve leaflets are severely thickened/deformed. There is mild
aortic valve stenosis (area 1.2-1.9cm2). Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The
tricuspid valve leaflets are mildly thickened. There is mild
pulmonary artery systolic hypertension. There is no pericardial
effusion.
.
CXR ([**2193-3-1**]): Large lower lobe consolidation.  This may be due
to aspiration, hemorrhage, or pneumonia.
.
CXR ([**2193-3-2**]): Increased airspace opacity involving both lungs
is new when compared to the previous chest radiograph and CT.
The finding represents mild pulmonary edema. Previously
identified bilateral lower lobe opacities are much less
conspicuous on the current exam. Deviation of the trachea from
the midline to the right attributable to the previously seen
enlarged thyroid.
.
CTA ([**2193-3-1**]): 1.  No pulmonary embolism. 2.  New bilateral
pleural effusions, moderate on the left and small on the right.
3. Consolidation of the majority of the right lower lobe.
Increased
consolidation surrounding the left lower lobe masses.  This may
be infectious or due to aspiration. 4.  No short interval change
in the left lower lobe masses previously detailed on the study
from five days ago.
.
TTE [**2193-3-3**]: The left atrium is elongated. The left ventricular
cavity size is normal. Left ventricular systolic function is
grossly preserved although views are technically suboptimal (EF
probably >45%). Regional wall motion could not be fully
assessed. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic root is
mildly dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets are severely
thickened/deformed. There is mild aortic valve stenosis (area
1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. [Due to
acoustic shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
.
Thyroid Ultrasound:  1) Very limited study due to overlying
brace and patient immobility. Thyroid parenchyma not visualized.
2) 4.1-cm mass centered in the expected position of the upper
lobe of the left thyroid/supraclavicular region. It is
impossible to tell on the current study whether this lesion is
exophytic from the left lobe thyroid or represents
supraclavicular adenopathy, though the former appears more
likely in correlation with the recent CTA chest.
.
Noncontrast CT Chest:
1. No change in large soft tissue mass in the left lower lobe
with extension/invasion into adjacent chest wall, pleural
effusion, and infrahilar and mediastinal lymphadenopathy.

2. Decreased right pleural effusion and improved right basilar
atelectasis/consolidation.
.
CT Head ([**3-13**]) for mental status changes:
1. No hemorrhage or mass effect.

2. Old bilateral basal ganglia and left cerebellar infarcts.
.


Brief Hospital Course:
1. T1 compression fracture: the patient was initially evaulated
by neurosurgery who did not feel that the patient had new
weakness or evidence of spinal cord compression. He was fitted
for [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] brace which he wore at all times. In an effort to
free the patient from the brace and improve his pain, he
underwent interventional radiology-vertebroplasty. After that,
the patient was able to be changed to a small soft collar, but
had very little palliation from the procedure.  His mobility is
significantly limited and requires significant assistance to get
out of bed. At discharge, he could move all extremities at his
baseline.  Radiation oncology was involved and radiated his T1
lesion in a single fraction, with little palliation.  Tissue
biopsy at the time of vertebroplasty was unrevealing.
.
2. LLL mass: likely primary lung cancer, however, no definitive
tissue pathology was obtained despite several attempts including
transbronchial biopsy.  DDx included thyroid and renal cell
cancers, and the patient does have a large thyroid nodule which
was unable to be biopsied secondary to his neck fracture
constraints. Oncology consulted who thought patient was not a
chemotherapy candidate given his solitary kidney and poor
performance status. Radiation oncology consulted, as above.  He
was not a candidate for radiation to the lung mass.
.
3. Post obstructive pneumonia: The patient was intermittently
febrile throughout the hospitalization and was found to have a
postobstructive pneumonia.  He was treated with broad spectrum
antibiotics for a prolonged course given his inability to clear
secretions effectively. Chest PT was not able to be done given
the constraints of his neck fracture. On the day of discharge,
he was febrile to 102 after a long period of being afebrile with
a resolving leukocytosis.  He was continued on antibiotics at
discharge.
.
4. Atrial fibrillation: the patient developed new onset atrial
fibrillation during the hospitalization around the time of his
transbronchial biopsy.  He was diltiazem refractory and
ultimately responded to IV Metoprolol. He was maintained on
Metoprolol orally during the hospitalization.  He received a
course of Amiodarone and coverted to sinus rhythm.  He was
discharged on 200 mg Amiodarone daily in NSR.
.
5. Hypoxia: the patient was intermittently hypoxic during the
initial period of his hospitalization from the large LLL mass,
post obstructive pneumonia/mucus plugging, paroxysmal atrial
fibrillation and intermittent volume overload.  He would have a
tendency to desaturate overnight, but would respond to increased
oxygen and diuresis if overloaded.  At discharge, the patient
had a much improved requirement  of 2 liters by nasal cannula.
.
6. Left Lobe Thyroid Nodule. Incidentally found on chest CT on
[**2193-2-23**]. Normal thyroid function. Thyroid ultrasound completed,
but limited by the patient's large neck brace and T1 fracture.
The decision was made not to pursue further characterization of
the thyroid nodule.
.
7. Anemia of chronic inflammation: stable at his baseline
hematocrit of 28-30.
.
8. Prostate cancer: prior history, on Zoladex as outpatient. Not
continued as inpatient. PSA flat despite evidence of metastatic
disease.  Stable as inpatient.
.
9. Diabetes: home regimen of metformin and glipizide held in the
hospital, placed on sliding scale.  Uncontrolled sugars in the
setting of steroids for pain control.  Titrating Lantus based on
sliding scale requirement.
.
10. Pain and Palliation: Palliative care consulted given that
the patient's pain was difficult to control.  He was refractory
to Tylenol but very sensitive to narcotics.  He was on several
regimens during the hospitalization, but was ultimately
discharged on Methadone 0.5 mg q8 am and q2 pm.  He was also
maintained on Ritalin for improved mood and energy during the
day.  He was also pulsed with Decadron with improvement in his
mood, but not pain. Decadron was tapered to 4 mg daily with the
plan to taper off as tolerated.
.
11.  Glaucoma: continued home Latanoprost
.
12. Gout: continued home allopurinol. No acute issues.
.
13. Hypertension: well controlled initially on home regimen, but
became difficult to control in the setting of steroids. At
discharge, he was stable in 130s/70s on Lisinopril and
Metoprolol.
.
14. Disposition: the patient had a long and complicated hospital
course, ultimately resulting in vertebroplasy for his T1
compression fracture. He was deconditioned and depressed at the
time of discharge to hospice.  Palliative care followed closely
in the management of this patient and helped the family cope
with the new diagnosis and complications.  Ultimately it was
decided not to pursue aggressive diagnostic and therapeutic
measures and the patient was discharged to hospice care.
.

Medications on Admission:
(on transfer):
HSQ
ISS
Allopurinol 300mg
Latanoprost 1 drop qhs
CTX 1g
Gentamycin 80mg [**Hospital1 **]
Protonix 40mg
Iron 325mg [**Hospital1 **]
Propoxyphene-APAP prn
FA
Glipizide 5mg
.
Meds (at rehab):
Lisinopril 20mg
Glipizide 5mg
Allopurinol 300mg
Lasix 40mg
ASA 325mg
Metformin 500mg
Lactulose prn
Xalatan eye drop qhs
Naprosyn prn
Zantac 150mg [**Hospital1 **]
FA 1mg
Lidocaine patch to back
Darvocet prn
Prednisone taper
Zoladex 10.8mg q3mo (due this mo)


Discharge Medications:
1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
3. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane PRN
(as needed).
4. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed for cough.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO
Q12H (every 12 hours).
7. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily): on for
12 hours, off for 12 hours.
8. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2
times a day): At 10 am daily.
9. Oxycodone 5 mg Tablet Sig: 1/2-1 Tablet PO Q3H (every 3
hours) as needed.
10. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily) for 5 days: Please take 4 mg for five days, then 2 mg
for five days, then stop.
11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed.
12. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
13. Methadone 10 mg/5 mL Solution Sig: 0.5 mg PO PLEASE GIVE AT
8AM, 2PM () as needed for PRN pain.
14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
15. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
16. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One
(1) ML Intravenous DAILY (Daily) as needed.
17. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18)
units Subcutaneous at bedtime.
18. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day.

19. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: 0-12
units Subcutaneous four times a day: per sliding scale.
20. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a
day.
21. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day.
22. Flagyl 500 mg Tablet Sig: One (1) Tablet PO twice a day.
23. Heparin Flush PICC (100 units/ml) 2 ml IV DAILY:PRN
10 ml NS followed by 2 ml of 100 Units/ml heparin (200 units
heparin) each lumen Daily and PRN.  Inspect site every shift.


Discharge Disposition:
Extended Care

Facility:
community hospice

Discharge Diagnosis:
T1 compression fracture
Lung mass, likely NSCLC
Shoulder Pain
Hypertension
Diabetes mellitus
Prostate Cancer
CVA with residual R weakness
s/p Nephrectomy
GIB
Carotid endarterectomy
COPD
Shoulder OA
Glaucoma


Discharge Condition:
Stable. On 3L O2, to Hospice


Discharge Instructions:
Discharge to Hospice. Please return to the ED as needed.

Followup Instructions:
As needed.
{'Malignant neoplasm of other parts of bronchus or lung,Chronic airway obstruction, not elsewhere classified,Pneumonia, organism unspecified,Pathologic fracture of vertebrae,Atrial fibrillation,Hypoxemia,Ulcer of heel and midfoot,Secondary malignant neoplasm of bone and bone marrow,Acute kidney failure, unspecified,Systolic heart failure, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Personal history of malignant neoplasm of prostate,Other chronic pulmonary heart diseases,Anemia of other chronic disease,Unspecified glaucoma,Gout, unspecified,Nontoxic uninodular goiter'}


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: Lung mass.

PRESENT ILLNESS: 88 year old male with a history of prostate cancer, CVA, DM2,
CEA and [**Hospital 2182**] transferred to the medicine service for further
evaluation of a lung mass. The patient was in his usual state of
health until one month prior to admission when he developed
upper extremity weakness, right more than left as well as
bilateral shoulder pain and a cough. He was admitted to an OSH
and was found to have a LLL infiltrate and was treated for
pneumonia and COPD flare.  He also had a spine MRI which
demonstrated a T1 compression fracture.  The patient was
transitioned to rehabilitation.  At the rehab facility he
continued to have upper extremity weakness and bilateral
shoulder pain refractory to conservative measures.  MRI of his
brain showing no significant change from his post-stroke MRI per
report.  His R hand weakness progressed and he was sent from
rehab back to the OSH where he again had a MRI of his C-spine
which showed interval progression of the compression fracture
with retropulsion of the posterior fragment into the upper
thoracic cord.  Additionally, a soft tissue mass anterior to the
vertebral body brought up the possibility of metastatic disease.
 His PSA remained flat at this time and a CT chest showed 2 LLL
masses along with renal and thyroid cysts.  He was started on
steroids and  sent to [**Hospital1 18**] for further managment.
Incidentally, he was restarted on CTX/gentamycin at the OSH per
family report because he developed fevers but they denied any
other infectious symptoms at this time including SOB, cough,
dysuria, or abdominal pain.  He did have mild diarrhea.
.
At [**Hospital1 18**], his films were reviewed by neurosurgery and no cord
compression was noted.  His thoracic vertebral fracture was
thought to be stable and he was fitted for a brace.  IP was
consulted to perform a percutaneous biopsy of the mass and CT of
the chest, abdomen and pelvis were performed.  A bone scan and
CT head were ordered along with a MRI of C5-T4.  The patient was
transfered to medicine for further work-up of his lung mass once
acute neurosurgical issues were excluded.
.
On interview today, the patient feels generally well.  He denies
any CP, SOB, abdominal pain, nausea, vomiting or headache.  He
does have some LE paresthesias and notes weakness in his R hand
that is worse than baseline.  His family notes chronically loose
bowels but states this has been worse of late and feels that his
cognition has slipped over the past month.

MEDICAL HISTORY: 1. HTN
2. Prostate CA s/p XRT and since treated w/ lupron and zoladex
3. CVA '[**92**] w/ residual R sided weakness
4. DM2
5. s/p Nephrectomy ~'[**82**]
6. GIB
7. carotid endarterectomy
8. COPD
9. Shoulder OA
10. Glaucoma

MEDICATION ON ADMISSION: (on transfer):
HSQ
ISS
Allopurinol 300mg
Latanoprost 1 drop qhs
CTX 1g
Gentamycin 80mg [**Hospital1 **]
Protonix 40mg
Iron 325mg [**Hospital1 **]
Propoxyphene-APAP prn
FA
Glipizide 5mg
.
Meds (at rehab):
Lisinopril 20mg
Glipizide 5mg
Allopurinol 300mg
Lasix 40mg
ASA 325mg
Metformin 500mg
Lactulose prn
Xalatan eye drop qhs
Naprosyn prn
Zantac 150mg [**Hospital1 **]
FA 1mg
Lidocaine patch to back
Darvocet prn
Prednisone taper
Zoladex 10.8mg q3mo (due this mo)

ALLERGIES: Demerol / Aspirin / Dilaudid

PHYSICAL EXAM: (on admission)
99.3, 126/69, 88, 20, 98%RA
Gen: WNWD Elderly [**Male First Name (un) 4746**] sitting up in chair w/ neck brace in place
HEENT: MMM, O/P clear, EOMI, PERRLA
CV: RRR, 3/6 SEM at the apex
Lungs: Decreased breath sounds on the L
Abd: S/NT/ND, +BS, -HSM
Ext: No peripheral edema
Neuro: Decreased strength on R side w/ worst strength in grip,
intact sensation to light touch bilaterally, AAO to person and
year but not date or location, 0/3 recall immediately and w/
prompting, thought 5 quarters in $1.75, intact heel-to-shin on L
but impaired on R, able to name watch/pen and describe what they
are used for
Skin: No rashes

FAMILY HISTORY: Noncontributory.

SOCIAL HISTORY: Lives with sons but most recently in rehab.  Social EtOH.  Quit
smoking ~20yrs ago (30-45pk/yrs prior).  No drug use.  Worked
for [**Company 2676**] but also spent time in a [**Doctor Last Name **] quarry.  No work in
construction, demolition, or shipyard.  No exposure to
chemicals. 

### Response:
{'Malignant neoplasm of other parts of bronchus or lung,Chronic airway obstruction, not elsewhere classified,Pneumonia, organism unspecified,Pathologic fracture of vertebrae,Atrial fibrillation,Hypoxemia,Ulcer of heel and midfoot,Secondary malignant neoplasm of bone and bone marrow,Acute kidney failure, unspecified,Systolic heart failure, unspecified,Diabetes with unspecified complication, type II or unspecified type, uncontrolled,Personal history of malignant neoplasm of prostate,Other chronic pulmonary heart diseases,Anemia of other chronic disease,Unspecified glaucoma,Gout, unspecified,Nontoxic uninodular goiter'}
