CHIEF COMPLAINT: Recurrent GBM

PRESENT ILLNESS: 51 y.o. who initially presented on [**2121-12-8**] with GTC.  MRI
reveald a contrast enhancing lesion in the right parietal
region.
Biopsy revealed GBM.  The patient underwent standard
chemo-radiation therapy.  While on therapy, the patient suffered
neurologic decline (unsteady gait and headache).  MRI revealed
significant radiographic progression, necessitating a craniotomy
for tumor resection in [**12-26**].  The post-operative course was
uneventful and the patient was ultimatley discharged home. He
subsequently completed his chemo-radiation therapy.

MEDICAL HISTORY: 1. Recurrent left spontaneous pneumothoraces with left apical
blebs, s/p left upper lobe bleb resection, pleurodesis, and
sclerosis in [**2105**]; had post operative air leak requiring
exploratory thoracotomy
2. Right tension pneumothorax, s/p bullectomy with mechanical
pleurodesis in [**2108**]
3. Childhood strabismus, s/p multiple corrective procedures,
last
at age 14
4. Benign connective tissue nevus
5. GBM

MEDICATION ON ADMISSION: 

ALLERGIES: Dilantin

PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-20**] bilaterally          EOM intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Son had a febrile seizure at age eight.  Has a niece with
generalized seizures, now ~age 27.   No stroke, hemorrhage, or
aneurysm.

SOCIAL HISTORY: Lives with wife and two children. Former smoker, 1-2 packs daily
for 10 years but quit years ago. He denies a history of illicit
drug use. He drinks "an occasional beer."
Malignant neoplasm of parietal lobe,Hemiplegia, unspecified, affecting unspecified side,Epilepsy, unspecified, without mention of intractable epilepsy
Mal neo parietal lobe,Unsp hemiplga unspf side,Epilep NOS w/o intr epil
Admission Date:  [**2122-5-1**]              Discharge Date:   [**2122-5-4**]

Date of Birth:  [**2071-3-22**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Dilantin

Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Recurrent GBM

Major Surgical or Invasive Procedure:
Rt craniotomy with rescetion, biopsy, and debulking of tumor

History of Present Illness:
51 y.o. who initially presented on [**2121-12-8**] with GTC.  MRI
reveald a contrast enhancing lesion in the right parietal
region.
Biopsy revealed GBM.  The patient underwent standard
chemo-radiation therapy.  While on therapy, the patient suffered
neurologic decline (unsteady gait and headache).  MRI revealed
significant radiographic progression, necessitating a craniotomy
for tumor resection in [**12-26**].  The post-operative course was
uneventful and the patient was ultimatley discharged home. He
subsequently completed his chemo-radiation therapy.

On [**2-23**], the patient again suffered decline with left neglect
and
hemiparesis.  CT and MRI of the head revealed expansion of a
cystic structure in the resection site.  A Rickam reservoir was
placed by Dr. [**Last Name (STitle) **] and aspriation yielded approximately 15
cc's
of fluid.  As the patient was symptomatically improved, the
patient was discharged [**Last Name (un) **].  The patient presented again in [**3-26**]
with worsening left hemiparesis and neglect.  Aspiration of the
Rickam reservoir failed, prompting Dr. [**Last Name (STitle) **] to insert a second
catheter. With this fresh catheter, only a few cc's of fluid was
obtained.  In this context, I am concerned that the previously
thought "cyst" actually represented non-enhancing tumor and that
the symptoms are the result of tumor progression.  The patient
presents today for discussion of re-do craniotomy for cyst
decompression by open resection.


Past Medical History:
1. Recurrent left spontaneous pneumothoraces with left apical
blebs, s/p left upper lobe bleb resection, pleurodesis, and
sclerosis in [**2105**]; had post operative air leak requiring
exploratory thoracotomy
2. Right tension pneumothorax, s/p bullectomy with mechanical
pleurodesis in [**2108**]
3. Childhood strabismus, s/p multiple corrective procedures,
last
at age 14
4. Benign connective tissue nevus
5. GBM


Social History:
Lives with wife and two children. Former smoker, 1-2 packs daily
for 10 years but quit years ago. He denies a history of illicit
drug use. He drinks "an occasional beer."

Family History:
Son had a febrile seizure at age eight.  Has a niece with
generalized seizures, now ~age 27.   No stroke, hemorrhage, or
aneurysm.


Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-20**] bilaterally          EOM intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to
2mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. Positive jerking
motions
seen intermittently to LLE > LUE.
Motor RUE [**Hospital1 **] 5, Tri 5, grip 5. RLE full throughout.
      LUE [**Hospital1 **] [**3-22**], tri4/5, grip [**3-22**], LLE [**3-22**] DF/PF [**3-22**]
No clonus present

Exam upon discharge:
Alert, oriented to person, place and date. Pupils are equally
round and reactive to light. Full motor strength throughout
upper and lower extremities, however with some deconditioning to

the left side.  Left parietal pronator drift.


Pertinent Results:
[**2122-5-1**] 11:44AM   GLUCOSE-160* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
[**2122-5-1**] 11:44AM   estGFR-Using this
[**2122-5-1**] 11:44AM   CALCIUM-8.4 PHOSPHATE-3.0 MAGNESIUM-2.1
[**2122-5-1**] 11:44AM   WBC-9.7 RBC-4.46* HGB-14.2 HCT-41.0 MCV-92
MCH-31.9 MCHC-34.8 RDW-14.2
[**2122-5-1**] 11:44AM   PLT COUNT-311

MRI OF THE BRAIN AFTER GADOLINIUM USING CYBERKNIFE PROTOCOL

HISTORY: GBM status post resection, evaluate for pre-surgical
mapping.

Comparison is made with [**2122-4-20**].

Again noted is a postoperative cavity in the right parietal lobe
with nodular
extensive enhancement along its margins concerning for
residual/recurrent
neoplasm. Findings could also reflect some component of
radiation necrosis.

There is stable surrounding edema and mass effect. There is
subependymal
enhancement of the ventricular surface. The ventricles are
unchanged in size
and configuration.


Impression:

Nodular enhancement surrounding the right parietal lobe cavity
may represent
some combination of neoplasm and post radiation change.

INDICATION: 51-year-old man with right parietal GBM status post
reexploration
and debulking.

COMPARISON: [**2122-4-23**].

TECHNIQUE: Non-contrast head CT.

FINDINGS: There has been a repeat right parietal craniotomy,
with air seen
within the cystic cavity status post debulking. Perilesional
edema appears
similar, with leftward midline shift unchanged at 4 mm. There is
bilateral
frontal pneumocephalus. Hyperdense material overlying the right
parietal
surgical site likely represents blood products. There is no new
intraparenchymal hemorrhage. Ventricles and cisterns are
unchanged. The
mastoid air cells are clear. Visualized paranasal sinuses are
unremarkable.

IMPRESSION: Expected postoperative changes with no new midline
shift or
intraparenchymal hemorrhage.

The study and the report were reviewed by the staff radiologist.


DR. [**First Name8 (NamePattern2) 5206**] [**Name (STitle) **]
DR. [**First Name (STitle) 3905**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3906**]
Approved: [**Last Name (NamePattern4) **] [**2122-5-1**] 6:37 PM

[**5-2**] MRI

CLINICAL INFORMATION: Patient with right parietal GBM status
post surgery.

TECHNIQUE: T1 sagittal and axial and FLAIR T2 susceptibility and
diffusion
axial images of the brain were obtained before gadolinium. T1
axial and MP-
RAGE sagittal images were acquired following gadolinium.
Correlation was made
with the MRI of [**2122-5-1**].

FINDINGS: Since the previous study, the patient has undergone
debulking of
the right parietal tumor. Surgical defect is seen in the right
parietal lobe
with marginal enhancement indicating residual lesion. The
enhancement extends
to the periatrial region. Surrounding edema is identified which
is not
changed. There are expected post-surgical changes seen. There is
no acute
infarct identified. Small bilateral extra-axial collections and
pneumocephalus are seen as postoperative finding.

IMPRESSION: Status post debulking of the right parietal
glioblastoma
multiforme. Residual marginal enhancement is identified.


Brief Hospital Course:
51 y/o male s/p resectionwho presented with L sided neglect and
hemiparesis. He went to the OR and was kept in the PACU
overnight without signifcant event. His post-operative MRI was
revealed complete evacuation of the previously seen hypo-intense
material. His neurologic exam post-operatively was significantly
improved relative to the pre-operative exam, though his LUE
strength was still not full (5-).  He still has difficulty with
fine motor activities.  However, his LLE paresis and neglect had
improved significantly.  His hospital course was uneventful and
he was discharged after evaluation by PT/OT on POD3.

Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2
times a day).
Disp:*180 Tablet(s)* Refills:*2*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
3. Dexamethasone 2 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours: Will taper as per Dr.[**Name (NI) 6767**] instructions.
Disp:*240 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
6. Propranolol 60 mg Capsule,Sustained Action 24 hr Sig: One (1)
Capsule,Sustained Action 24 hr PO DAILY (Daily).
7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
9. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a
day for 4 days.
Disp:*16 Capsule(s)* Refills:*0*
10. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: One
(1) Tablet PO Q4H (every 4 hours) as needed for headaches: do
not exceed 6 every 24 hours.
Disp:*30 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Recurrent GBM

Discharge Condition:
Stable, still with mild residual L sided weakness

Discharge Instructions:
??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	You may shower before this time using a shower cap to cover
your head.
??????	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, and
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion 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.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Follow-Up Appointment Instructions

??????       Please return to the office in [**9-30**] days for wound
check. Please call ([**Telephone/Fax (1) 88**] to schedule an appointment
with Dr. [**First Name (STitle) **].
??????	Please follow up with Dr. [**Last Name (STitle) 4253**] as scheduled today in the
brain tumor clinic as we discussed, you may go there directly
from discharge. Please call ([**Telephone/Fax (1) 6574**] with any questions.


Completed by:[**2122-5-4**]
{'Malignant neoplasm of parietal lobe,Hemiplegia, unspecified, affecting unspecified side,Epilepsy, unspecified, without mention of intractable epilepsy'}


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: Recurrent GBM

PRESENT ILLNESS: 51 y.o. who initially presented on [**2121-12-8**] with GTC.  MRI
reveald a contrast enhancing lesion in the right parietal
region.
Biopsy revealed GBM.  The patient underwent standard
chemo-radiation therapy.  While on therapy, the patient suffered
neurologic decline (unsteady gait and headache).  MRI revealed
significant radiographic progression, necessitating a craniotomy
for tumor resection in [**12-26**].  The post-operative course was
uneventful and the patient was ultimatley discharged home. He
subsequently completed his chemo-radiation therapy.

MEDICAL HISTORY: 1. Recurrent left spontaneous pneumothoraces with left apical
blebs, s/p left upper lobe bleb resection, pleurodesis, and
sclerosis in [**2105**]; had post operative air leak requiring
exploratory thoracotomy
2. Right tension pneumothorax, s/p bullectomy with mechanical
pleurodesis in [**2108**]
3. Childhood strabismus, s/p multiple corrective procedures,
last
at age 14
4. Benign connective tissue nevus
5. GBM

MEDICATION ON ADMISSION: 

ALLERGIES: Dilantin

PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-20**] bilaterally          EOM intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: Son had a febrile seizure at age eight.  Has a niece with
generalized seizures, now ~age 27.   No stroke, hemorrhage, or
aneurysm.

SOCIAL HISTORY: Lives with wife and two children. Former smoker, 1-2 packs daily
for 10 years but quit years ago. He denies a history of illicit
drug use. He drinks "an occasional beer." 

### Response:
{'Malignant neoplasm of parietal lobe,Hemiplegia, unspecified, affecting unspecified side,Epilepsy, unspecified, without mention of intractable epilepsy'}
