CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 55-year-old male with DMII, CAD status post inferior MI,
hypertension, hyperlipidemia, and depression who presented to
the ED with altered mental status and was found to be in DKA and
with head imaging concerning for new metastatic lesions. Today,
neighbors called EMS as patient was lying on his floor naked and
screaming.  Wife was at work at the time.  At ED, initial vital
signs were 98.4 106 180/77 20 100% 6L.  Labs showed glucose 544,
anion gap 33, K 6.0, Cr 1.5 (baseline 1.1), WBC 16.2.  Pt states
that he did not take his insulin this morning. He was given
10units insulin and started on an insulin gtt at 8units/hr.  He
received a total of 3liters of IVFs while in ED.  He was also
given calcium gluconate for his hyperkalemia.  U/A showed few
bacteria; cxr was largely unremarkable

MEDICAL HISTORY: 1.  Coronary artery disease, status post inferior STEMI in [**2158**].
2.  Hypertension.
3.  Hyperlipidemia.
4.  Mitral regurg, mild on stress echo.
5.  Diabetes.
6.  Depression.

MEDICATION ON ADMISSION: BUPROPION HCL - bupropion HCl XL 300 mg 24 hr tablet, extended
release
1 Tablet(s) by mouth daily <i>No Substitution</i>
CHLORTHALIDONE - chlorthalidone 25 mg tablet
1 Tablet(s) by mouth daily <i>No Substitution</i>
FLUOXETINE [PROZAC] - Prozac 20 mg capsule
3 Capsule(s) by mouth DAILY
FLUTICASONE -  (Not Taking as Prescribed) - fluticasone 50
mcg/actuation Nasal Spray, Susp
2 spays(s) nasal q day
INSULIN ASPART [NOVOLOG FLEXPEN] - Novolog Flexpen 100 unit/mL
Sub-Q
20 units before each meal (three times a day).
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL Sub-Q
45 units at bedtime <i>No Substitution</i>
LORAZEPAM - lorazepam 0.5 mg tablet
1 Tablet(s) by mouth at night as needed for anxiety Do not take
while drinking alcohol or operating machinery as medication can
cause sedation
METFORMIN - metformin ER 1,000 mg tablet,extended release 24hr
1 Tablet(s) by mouth daily <i>No Substitution</i>
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr
2 Tablet(s) by mouth DAILY (Daily)
MODAFINIL [PROVIGIL] - Provigil 200 mg tablet
1 Tablet(s) by mouth q a.m. and q 3 hrs later take 1st tab upon
awakening and 2nd 3 hrs later
NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet
1 Tablet(s) sublingually every 5 minutes up to 3 tablets total
as
needed for chest pain
ROSUVASTATIN [CRESTOR] - Crestor 40 mg tablet
1 (One) Tablet(s) by mouth daily
SILDENAFIL [VIAGRA] - Viagra 100 mg tablet
[**1-27**] Tablet(s) by mouth daily several times a month. Use one hour
prior to activity.
TIZANIDINE - tizanidine 4 mg tablet
1 tablet(s) by mouth twice a day as needed for back pain
ZOLPIDEM - zolpidem 5 mg tablet
1 Tablet(s) by mouth at bedtime for use with CPAP only
ASPIRIN -  (OTC; Dose adjustment - no new Rx) - aspirin 81 mg
tablet,delayed release
One Tablet by mouth once a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - One Touch Ultra
Test Strips
use to monitor blood suagr four times a day or as directed
INSULIN NEEDLES (DISPOSABLE) [BD INSULIN PEN NEEDLE UF ORIG] -
BD
Insulin Pen Needle UF Orig 29 x [**1-25**]"
to be used with insulin pen three times a day

ALLERGIES: lisinopril

PHYSICAL EXAM: T afebrile HR 78 BP 159/96 Spo2 95% on RA
General: Alert, oriented x 3, complaining of pain
HEENT: Sclera anicteric, dry MM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: uncooperative with neuro exam, moving all extremities,
following commands, intact rectal tone, pain on LE strength exam

FAMILY HISTORY: Mother with brain tumor.  No other malignancies.

SOCIAL HISTORY: Lives with his wife and 8-year-old daughter.  [**Name (NI) **] drinks two
glasses of wine at night, not recently. Smokes roughly three
cigarettes a day.  No drug use.
Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Septicemia due to pseudomonas,Toxic encephalopathy,Acute kidney failure, unspecified,Sepsis,Secondary malignant neoplasm of brain and spinal cord,Hyperpotassemia,Pathologic fracture of other specified part of femur,Malignant neoplasm of kidney, except pelvis,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Cerebral edema,Hemiplegia, unspecified, affecting dominant side,Long-term (current) use of insulin,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric),Hypercalcemia,Physical restraints status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
DMII ketoacd uncontrold,Pseudomonas septicemia,Toxic encephalopathy,Acute kidney failure NOS,Sepsis,Sec mal neo brain/spine,Hyperpotassemia,Path fx oth spcf prt fmr,Malig neopl kidney,Urin tract infection NOS,Ac posthemorrhag anemia,Cerebral edema,Unsp hemiplga domnt side,Long-term use of insulin,Old myocardial infarct,Status-post ptca,Hypertension NOS,Hyperlipidemia NEC/NOS,Tobacco use disorder,Obstructive sleep apnea,Hypercalcemia,Physical restrain status,Abn react-procedure NEC
Admission Date:  [**2162-10-14**]              Discharge Date:   [**2162-11-12**]

Date of Birth:  [**2106-11-25**]             Sex:   M

Service: MEDICINE

Allergies:
lisinopril

Attending:[**First Name3 (LF) 12131**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Fixation of right femoral neck/intertrochanteric fracture with
intramedullary device and prophylactic fixation of several
distal femur metastatic lesions prophylactically with
intramedullary device on [**2162-10-22**]

Open reduction internal fixation left radius fracture, curettage
left radius bone lesions on [**2162-11-3**]

History of Present Illness:
55-year-old male with DMII, CAD status post inferior MI,
hypertension, hyperlipidemia, and depression who presented to
the ED with altered mental status and was found to be in DKA and
with head imaging concerning for new metastatic lesions. Today,
neighbors called EMS as patient was lying on his floor naked and
screaming.  Wife was at work at the time.  At ED, initial vital
signs were 98.4 106 180/77 20 100% 6L.  Labs showed glucose 544,
anion gap 33, K 6.0, Cr 1.5 (baseline 1.1), WBC 16.2.  Pt states
that he did not take his insulin this morning. He was given
10units insulin and started on an insulin gtt at 8units/hr.  He
received a total of 3liters of IVFs while in ED.  He was also
given calcium gluconate for his hyperkalemia.  U/A showed few
bacteria; cxr was largely unremarkable

Patient endorsed headache and neck pain and stated that he fell
at home.  CT head was done which showed vasogenic edema most
likely [**2-25**] underlying mass or multiple metastases.  CT C-spine
showed destruction of the left C2/C3 pedicle associated with a
soft tissue lesion extending into adjacent epidural space,
concerning for metastatic lesion.

Of note, he has been seen at [**Company 191**] and at ED for lower back pain.
Wife states that he has been debilitated from back pain for the
last two weeks.  Initially, back pain was felt to be
musculoskeletal and he was referred to PT who noted decreased
reflexes and pt complained of urinary incontinence. On [**2162-10-12**]
he presented to ED where MRI L-spine was performed showing
acute/subacute compression fracture at L2; no cord compression
or cauda equina.  Final read MRI also noted large heterogeneous
mass involving the interpolar region of the left kidney.
Attempt was made to contact PCP with the final results but this
was never communicated to PCP or to patient.  He was discharged
from ED with valium and oxycodone. Wife reports that he has not
taken valium, may have taken oxycodone.

On arrival to the MICU, pt is A & O x 3, complaining of back
pain.

Review of systems:
Unable to obtain from patient; per wife, no fevers/chills,
diarrhea, abdominal pain, cough, URI-like systems.

Past Medical History:
1.  Coronary artery disease, status post inferior STEMI in [**2158**].
2.  Hypertension.
3.  Hyperlipidemia.
4.  Mitral regurg, mild on stress echo.
5.  Diabetes.
6.  Depression.


Social History:
Lives with his wife and 8-year-old daughter.  [**Name (NI) **] drinks two
glasses of wine at night, not recently. Smokes roughly three
cigarettes a day.  No drug use.


Family History:
Mother with brain tumor.  No other malignancies.


Physical Exam:
T afebrile HR 78 BP 159/96 Spo2 95% on RA
General: Alert, oriented x 3, complaining of pain
HEENT: Sclera anicteric, dry MM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: uncooperative with neuro exam, moving all extremities,
following commands, intact rectal tone, pain on LE strength exam


DISCHARGE PHYSICAL EXAM:
Gen: Alert, oriented to person and place but not time, NAD
HEENT: unchanged
CV: unchanged
Pulm: unchanged
Abd: unchanged
GU: condom catheter
MSK: R arm flexed against chest, able to passively extend with
some mild discomfort; L forearm in splint; healing surgical
wound at R upper lateral thigh
Neuro: CNII-XII intact, uncooperative with neuro exam, moving
left lower leg to try to sit up in bed, movement of right lower
extremity limited secondary to pain, movement of right upper
extremity limited

Pertinent Results:
ADMISSION LABS

[**2162-10-14**] 11:40AM BLOOD WBC-16.2*# RBC-4.21* Hgb-14.1 Hct-43.3
MCV-103* MCH-33.5* MCHC-32.6 RDW-12.1 Plt Ct-487*
[**2162-10-14**] 11:40AM BLOOD Neuts-90.0* Lymphs-7.3* Monos-2.4 Eos-0.1
Baso-0.3
[**2162-10-14**] 11:40AM BLOOD Plt Ct-487*
[**2162-10-14**] 06:45PM BLOOD PT-10.9 INR(PT)-1.0
[**2162-10-14**] 11:40AM BLOOD Glucose-544* UreaN-24* Creat-1.5* Na-135
K-6.0* Cl-91* HCO3-11* AnGap-39*
[**2162-10-14**] 06:45PM BLOOD ALT-13 AST-18
[**2162-10-14**] 02:23PM BLOOD Calcium-10.2 Phos-4.0 Mg-2.1
[**2162-10-14**] 07:11PM BLOOD Type-ART pO2-106* pCO2-25* pH-7.31*
calTCO2-13* Base XS--11
[**2162-10-14**] 11:59AM BLOOD Lactate-3.8*
[**2162-10-14**] 01:00PM URINE Blood-TR Nitrite-NEG Protein-30
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
[**2162-10-14**] 01:00PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE Epi-0
[**2162-10-15**] 05:20PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0
Lymphs-26 Monos-0 Macroph-74
[**2162-10-15**] 05:20PM CEREBROSPINAL FLUID (CSF) TotProt-86*
Glucose-135

__________________________________________________________
[**2162-10-15**] 5:20 pm CSF;SPINAL FLUID      Source: LP #3.

   GRAM STAIN (Final [**2162-10-15**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Preliminary):    NO GROWTH.

   FUNGAL CULTURE (Preliminary):

   VIRAL CULTURE (Preliminary):
__________________________________________________________
[**2162-10-15**] 5:20 pm CSF;SPINAL FLUID      Source: LP.

                            **FINAL REPORT [**2162-10-15**]**

   CRYPTOCOCCAL ANTIGEN (Final [**2162-10-15**]):
      CRYPTOCOCCAL ANTIGEN NOT DETECTED.
           (Reference Range-Negative).
      Performed by latex agglutination.
      Results should be evaluated in light of culture results
and clinical
      presentation.
__________________________________________________________
[**2162-10-14**] 4:21 pm MRSA SCREEN      Source: Nasal swab.

   MRSA SCREEN (Pending):
__________________________________________________________
[**2162-10-14**] 1:00 pm BLOOD CULTURE

   Blood Culture, Routine (Pending):
__________________________________________________________
[**2162-10-14**] 1:00 pm URINE

                            **FINAL REPORT [**2162-10-15**]**

   URINE CULTURE (Final [**2162-10-15**]):
      MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
      AND/OR GENITAL CONTAMINATION.

[**2162-10-12**] MRI L SPINE
1.  Acute/subacute compression fracture or Schmorl's node in the
superior
endplate of L2 with less than 50% vertebral body height loss and
no
retropulsion.
2.  Mild degenerative changes of the lumbar spine with grade 1
anterolisthesis
of L5 over S1 and bilateral pars defects at this level. No
evidence of
compression of the distal spinal cord or of cauda equina
syndrome.
3.  Large heterogeneous mass involving the interpolar region of
the left
kidney is partially visualized.  Further evaluation with
dedicated renal
ultrasound is recommended. As the patient had been discharged,
attempts were made to contact the patient's primary care
physican (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4026**]) both at the office number provided
in the paging system and at the pager number subsequently
provided by the office, but this was unsuccessful. Results were
therefore posted to the critical communications dashboard at
11:50 am, approximately 3 hours after discovery of the findings.


[**2162-10-15**] CT HEAD
Multiple hyperdense metastatic lesions with surrounding
vasogenic edema within the cerebrum.  An MRI with contrast is
recommended for further evaluation.

[**2162-10-15**] CT C SPINE
1.  Metastatic lesion resulting in osseous destruction of the
left C2 and C3 lamina and facet joint as well as the C3 pedicle,
with adjacent epidural soft tissue mass extending into the
neural and transverse foramina. MRI of the cervical spine with
contrast is recommended for further evaluation.
2.  Lytic metastases involving the second ribs bilaterally.
3.  Moderate cervical spondylosis.

[**2162-10-15**] MRI C SPINE
1.  Abnormal enhancing mass involving the left C2-C3 facet joint
extending into the posterior epidural space and left C2-C3
neural foramen without abnormal signal of the cord most likely
representing metastatic disease in this patient with widespread
metastases.
2.  Multilevel degenerative changes of the cervical spine.
3.  Bilateral atelectasis.

[**2162-10-15**] MRI BRAIN
1.  Multiple supratentorial peripherally enhancing masses with
associated
edema and mild mass effect, consistent with widespread
metastases.  No
evidence of midline shift or herniation.
2.  Extensive sinus disease.
[**2162-10-15**] MRI C AND T SPINE
1.  Abnormal enhancing mass involving the left C2-C3 facet joint
extending into the posterior epidural space and left C2-C3
neural foramen without abnormal signal of the cord most likely
representing metastatic disease in this patient with widespread
metastases.
2.  Multilevel degenerative changes of the cervical spine.
3.  Bilateral atelectasis.

FEMUR [**2162-10-15**]
There is a mildly angulated subcapital fracture of the proximal
femur. There are multiple lytic lesions seen in the mid and
distal femur.

[**2162-10-15**] CT CHEST AND ABDOMEN
1.  Large left renal interpolar ill-defined heterogeneous mass
measuring 7.7 x 5.0 x 7.1 cm compatible with renal cell
carcinoma.
2.  Widespread distribution of pathologically enlarged lymph
nodes in the
mediastinum, hila and left paraaortic space along with a lytic
lesion in the left iliac [**Doctor First Name 362**] and left femoral neck.  These
findings are consistent with metastatic sites of disease.
3.  Right femoral neck fracture.
4.  Large fat density lesion within the left gluteus medius
muscle with focal high-density nodules which could represent a
liposarcoma or lipoma.  Presence of internal nodules favor
liposarcoma.
5.  Left upper pole renal cysts.
6.  Gallstone.
7.  L2 vertebral Schmorl's node.

[**2162-10-18**] RENAL BIOPSY PATHOLOGY
Kidney, core needle biopsy: Renal cell carcinoma, suggestive of
clear cell type

[**2162-10-20**] BONE SCAN
RADIOPHARMACEUTICAL DATA:
   26.0 mCi Tc-[**Age over 90 **]m MDP ([**2162-10-20**]);
The patient was injected with radiotracer but was no images were
obtained due to patient agitation and refusal of the study.

[**2162-10-22**] RIGHT FEMORAL REAMINGS PATHOLOGY
DIAGNOSIS: Femoral neck reamings, Metastatic renal cell
carcinoma

[**2162-11-3**] RIGHT ELBOW PLAIN FILMS
IMPRESSION:  Lucent area in the distal humerus which could
represent a metastatic lesion.

[**2162-10-30**] EEG
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of diffuse background slowing with mixed theta and delta
activity suggesting moderate diffuse encephalopathy. There is no
focal slowing or epileptiform features recorded. Compared with
the recording yesterday, the delta slowing is more prominent
suggesting worsening encephalopathy.

[**2162-11-5**] CT HEAD WITHOUT CONTRAST
IMPRESSION:  Similar size and distribution of bilateral
vasogenic edema without evidence of increased herniation.
Minimal effacement of the bilateral sulci and left lateral
ventricle is similar to prior.  No new intracranial hemorrhage.

[**2162-11-5**] RIGHT ELBOW PLAIN FILM
IMPRESSION:  Lucent area in the distal humerus which could
represent a
metastatic lesion.

[**2162-11-5**] TISSUE, RIGHT RADIUS LESION PATHOLOGY
DIAGNOSIS: Radius, left, lesion: Metastatic renal cell carcinoma

URINE CULTURE (Final [**2162-11-9**]):
      PSEUDOMONAS AERUGINOSA.    >100,000 ORGANISMS/ML..
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------     2 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------     1 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S

Blood Culture, Routine (Final [**2162-11-11**]):
      PSEUDOMONAS AERUGINOSA.    FINAL SENSITIVITIES.
         Piperacillin/Tazobactam sensitivity testing performed
by [**First Name8 (NamePattern2) 3077**]
         [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             PSEUDOMONAS AERUGINOSA
                             |
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
MEROPENEM-------------     1 S
PIPERACILLIN/TAZO-----       S
TOBRAMYCIN------------   <=1 S

Brief Hospital Course:
55-year-old male with DM-I, CAD status post inferior MI,
hypertension, hyperlipidemia, and depression who presented to
the ED with altered mental status and was found to be in DKA and
with head imaging concerning for new metastatic lesions. Had
stay in ICU for management of DKA, was unfortunately found to
have metastatic renal cell carcinoma, and was transferred to
oncology service for management.

ICU COURSE:
Upon admission, the patient was admitted to the ICU for
management of his DKA. ICU course is as follows, by problem:
- DKA: Likely precipitated by insulin noncompliance (does not
recall taking insulin prior to admission). Infectious etiology
unlikely as U/A and CXR are reassuring, was afebrile. Any stress
can precipitate DKA; neoplastic process may trigger
hyperglycemia. This improved with fluids and insulin drip and he
was transitioned to subcutaneous insulin and oral food.
- Metastatic lesions: CT head and C-spine concerning for
metastatic lesions.  Previous MRI L-spine also showed renal
mass. Suspicion for neoplastic process was high. At that time,
tissue diagnosis was unclear. Suspected to have primary renal
carcinoma. He was treated wtih steroids and keppra for cerebral
edema. He had a biopsy on [**2162-10-18**] prior to transfer from the
ICU. This eventually revealed renal cell carcinoma, suggestive
of clear cell type.
- Prerenal Acute kidney Injury: Cr increased to 1.5 from
baseline 1.1, improved with IVF.

HOSPITALIZATION SUMMARY:
The remainder of his acute and chronic issues throughout his
hospitalization are discussed below. Mr. [**Known lastname **] was
hospitalized for an extended period of time (approximately one
month). His course by problem is summarized as follows:

1) Diabetic ketoacidosis - As discussed in the ICU course above,
Mr. [**Known lastname **] presented with DKA. This was successfully
controlled in the ICU, after which he was transferred to the
floor.

2) Renal cell carcinoma, suggestive of clear cell type - Mr.
[**Known lastname **] underwent biopsy on [**2162-10-18**] demonstrating renal cell
carcinoma. He unfortunately has widely metastatic disease to
bone and brain. Prior to presentation, he fell to his right side
and suffered pathologic fracture. An attempt for bone scan
resulted in an acute delirious state with severe agitation - the
scan was aborted (discussed below). MRI revealed diffuse
metastatic cerebral disease as well, as above. He received 5
fractions of whole-brain radiation for suppression of CNS
involvement. He underwent orthopedic repair of his pathologic
fracture on [**2162-10-22**], after which he received 5 fractions to his
right femur as well. Biopsy during this procedure revealed
metastatic renal cell carcinoma. He received one dose of
radiation to a lesion in his distal right humerus as well. Upon
discharge, Mr. [**Known lastname **] had developed a contracture of his
right arm, likely secondary to pain from this lesion and
cerebral disease. Mr. [**Known lastname **] suffered a pathologic fracture
of his left radius during his hospitalization. This was caused
by a wrist restraint. The indications for this restraint is
discussed below. He had ORIF on [**2162-11-3**]. Biopsies of this site
demonstrated metastatic RCC. He did not undergo nephrectomy.

Systemic therapy, including [**Last Name (LF) 76383**], [**First Name3 (LF) **] to be discussed at
an outpatient appointment with Dr. [**Last Name (STitle) **].

3) Altered mental status - He continued to exhibit altered
mental status throughout his hospitalization. While his mental
status waxed and waned throughout his stay, he generally was
oriented to place and person, but not time. His altered mental
status is likely multifactorial. Initially upon transfer to the
floor, he had a large component of ICU delirium and resolving
DKA. Equally significantly, Mr. [**Known lastname **] has a significant
amount of CNS metastatic disease burden, including frontal lobe
mets - these undoubtedly play a large role in his poor
cognition/executive functioning. Electrolyte abnormalities also
contributed to his AMS - hypercalcemia specifically, discussed
further below. Finally, iatrogenic causes of his poor mental
status included significant opioid and steroid requirements.

To treat his CNS metastases, he completed 5 fractions of
whole-brain radiation during his stay. Cerebral edema was
controlled with dexamethasone prior to and following WBXRT.
Unfortunately, his mental status did not improve significantly
following WBXRT. A series of head CT scans without contrast
demonstrated stable cerebral edema. Steroids were slowly tapered
while hospitalized; repeat CT scans did not demonstrate rebound
edema either to XRT or to steroid taper. He was discharged on a
regimen of dexamethasone 2 mg PO daily. Plans for continued
taper and steroid discontinuance were to be addressed at a
follow-up appointment with Dr. [**Last Name (STitle) 6570**] of neuro-oncology (he
will have an MRI on [**2162-11-29**] prior to this appointment).

On [**2162-10-20**], bone scan was attempted to determine sites of bony
involvement. This procedure was unfortunately halted due to
patient's extreme agitation and aggressive behavior during the
procedure. This pattern of sudden-onset/waxing-and-[**Doctor Last Name 688**]
agitation persisted for several days, often triggered by
radiation or radiaographic procedures. Etiology is unclear. This
was very obviously demonstrative of hyperactive delirium.
Initial attempts to correct his delirium using frequent
redirection, normal sleep-wake cycles when possible, and
minimizing benzodiazepines (thought to be disinhibiting frontal
lobe behavior). Unfortunately, he did not respond to these
measures, and required periodic intravenous haloperidol. The
psychiatry service was consulted for management recommendations.
Initially, standing and escalating doses of haloperidol were
attempted to correct his agitation. While this did indeed
minimize his agitation, it resulted in over-sedation and
constant somnolence. Haloperidol was exchanged for standing
quetiapine at bedtime, which seemed to encourage normal
sleep-wake cycle and did not create excessive sedation. (As
patient's mental status started to improve and agitation
subsided, this medication was changed from standing to PRN - he
infrequently required it by discharge). Mr. [**Known lastname **]
experienced an unfortunate and significant complication from his
agitation. He required restraints overnight due to acute
agitation. During this episode, he was actively removing his
clothes, intravenous lines, therapeutic devices (ankle
contracture-prevention boots and pneuamtic compression devices),
and surgical dressings. He did not respond to low dose sedating
agents, and required soft mitts to prevent further harm to
himself and interference with his care. He managed to remove
these mitts and continued with his agitation as above,
necessitating wrist restraints. These restraints were removed as
soon as possible. Follow-up physical examination identified soft
tissue swelling and tenderness to palpation of his left wrist. A
plain film x-ray identified fracture. This was repaired in the
OR, and a metastatic lesion was diagnosed at the site of
fracture - which corresponded with the site of restraint.

Electrolyte abnormalities were a component of his poor
mentation. Mr. [**Known lastname **] was hypercalcemic - likely secondary
to a combination of bony metastases (major contributing factor)
and paraneoplastic PTHrP (minor factor). This was though to
perhaps play a role in his agitation as discussed above.
Hypercalcemia was corrected via a combination of continuous IV
fluids and single doses of calcitonin and pamidronate. This did
not yield significant improvement in his mentation, though it
did return his calcium levels to normal ranges. IV fluids were
discontinued prior to discharge.

An EEG approximately one week prior to discharge was suggestive
of diffuse metabolic encephalopathy.

Ultimately, his altered mental status was attributed to a
combination of CNS disease, prolonged hospital stay, and
opioids/steroids. Upon discharge, Mr. [**Known lastname **] mental
status had improved from his admission to the oncology floor. He
remained oriented to person and place, and demonstrated
increased insight into his condition. He exhibited word finding
difficulties, but was generally appropriate in his
communication. He was able to participate in a discussion
regarding his goals of care and transition to rehab, stating
"Let's go for it".

4) Pseudomonas urosepsis - On [**2162-11-5**] he spiked a fever to 103.
He was somnolent during this period (attributed to fentanyl
patch sedation). The fentanyl patch was removed; his mentation
improved considerably over the next 12 hours. Initial empiric
antibiotics included vancomycin and meropenem. Urine and blood
cultures grew pan-sensitive Pseudomonas. His antibiotic regimen
was tailored to ciprofloxacin 500mg PO BID. He did not spike
more fevers, and follow-up blood cultures were negative for
bacterial growth.

5) Glucose control - Throughout his stay, he demonstrated a wide
range of blood glucose levels. Per his wife, his type I diabetes
was very difficult to control prior to this hospitalization,
with periods of both hypo- and hyperglycemia at home.

6) Pain control - Mr. [**Known lastname **] pain control requirement
changed throughout his hospitalization. Upon admission, he
required analgesia for control of bony metastasis pain. He
underwent 2 surgical procedures for fracture repair. He received
radiation to right femur and distal right humerus which improved
pain control. He required a combination of oral hydrmorphone,
intravenous morphine, transdermal fentanyl, and acetaminophen
during his stay. Upon discharge, his pain was adequately
controlled with hydromorphone 2-4 mg PO Q4H:PRN.

7) Hypertension: Systolic BP initially elevated after extubation
in the ICU. His blood pressure was then well-controlled while on
the oncology floor. Home doses of metoprolol were continued.

8) Coronary artery disease - Stable throughout his
hospitalization. He was continued on his home rosuvastatin and
metoprolol.

===========================================
TRANSITIONAL ISSUES:
- CODE STATUS: Mr. [**Known lastname **] was full code throughout his
stay.
- EMERGENCY CONTACT: [**Name (NI) 2808**] [**Name (NI) **], wife, [**Telephone/Fax (1) 76384**]
- STEROID TAPER: Discharged on dexamethasone 2mg PO daily.
Further tapering/discontinuance to be addressed by Dr. [**Last Name (STitle) 6570**]
and medical-oncology team. Appointment pending with Dr. [**Last Name (STitle) 6570**],
[**Telephone/Fax (1) 1844**].
- ANTIBIOTIC REGIMEN: Receiving ciprofloxacin 500mg PO q12hr to
complete course of anti-pseudomonal treament for urosepsis.
Final day of antibiotics = [**2162-11-18**].
- HEMATOLOGY-ONCOLOGY: Follow-up appointment to be created with
Dr. [**Last Name (STitle) **] for consideration of systemic therapy after
discharge. Office number [**Telephone/Fax (1) 13016**].
- GLYCEMIC CONTROL: Needs gentle titration of sliding scale and
long acting insulin for goal glucose 100-200 throughout the day.

Medications on Admission:
BUPROPION HCL - bupropion HCl XL 300 mg 24 hr tablet, extended
release
1 Tablet(s) by mouth daily <i>No Substitution</i>
CHLORTHALIDONE - chlorthalidone 25 mg tablet
1 Tablet(s) by mouth daily <i>No Substitution</i>
FLUOXETINE [PROZAC] - Prozac 20 mg capsule
3 Capsule(s) by mouth DAILY
FLUTICASONE -  (Not Taking as Prescribed) - fluticasone 50
mcg/actuation Nasal Spray, Susp
2 spays(s) nasal q day
INSULIN ASPART [NOVOLOG FLEXPEN] - Novolog Flexpen 100 unit/mL
Sub-Q
20 units before each meal (three times a day).
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL Sub-Q
45 units at bedtime <i>No Substitution</i>
LORAZEPAM - lorazepam 0.5 mg tablet
1 Tablet(s) by mouth at night as needed for anxiety Do not take
while drinking alcohol or operating machinery as medication can
cause sedation
METFORMIN - metformin ER 1,000 mg tablet,extended release 24hr
1 Tablet(s) by mouth daily <i>No Substitution</i>
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr
2 Tablet(s) by mouth DAILY (Daily)
MODAFINIL [PROVIGIL] - Provigil 200 mg tablet
1 Tablet(s) by mouth q a.m. and q 3 hrs later take 1st tab upon
awakening and 2nd 3 hrs later
NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet
1 Tablet(s) sublingually every 5 minutes up to 3 tablets total
as
needed for chest pain
ROSUVASTATIN [CRESTOR] - Crestor 40 mg tablet
1 (One) Tablet(s) by mouth daily
SILDENAFIL [VIAGRA] - Viagra 100 mg tablet
[**1-27**] Tablet(s) by mouth daily several times a month. Use one hour
prior to activity.
TIZANIDINE - tizanidine 4 mg tablet
1 tablet(s) by mouth twice a day as needed for back pain
ZOLPIDEM - zolpidem 5 mg tablet
1 Tablet(s) by mouth at bedtime for use with CPAP only
ASPIRIN -  (OTC; Dose adjustment - no new Rx) - aspirin 81 mg
tablet,delayed release
One Tablet by mouth once a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - One Touch Ultra
Test Strips
use to monitor blood suagr four times a day or as directed
INSULIN NEEDLES (DISPOSABLE) [BD INSULIN PEN NEEDLE UF ORIG] -
BD
Insulin Pen Needle UF Orig 29 x [**1-25**]"
to be used with insulin pen three times a day


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**]

Discharge Diagnosis:
PRIMARY:
- metastatic renal cell carcinoma
SECONDARY:
- diabetic ketoacidosis
- acute confusional state
- metabolic encephalopathy
- right femur fracture
- left radius fracture


Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Dear Mr. [**Known lastname **],

You were admitted to [**Hospital1 18**] for complications related to your new
diagnosis of renal cell carcinoma (kidney cancer). We are very
sorry to learn of your cancer diagnosis. You had an extended
hospital stay, including time spent in the ICU, for management
of a variety of complications and challenges presented by your
disease.

You are being discharged to an extended-care facility to receive
further rehabilitation as you recover from your hospitalization.
You will be evaluated as an outpatient for consideration of
systemic therapy for your renal cell carcinoma (including agents
similar to chemotherapy). You should keep all your scheduled
appointments with your doctors.

Please tell the staff at the rehab facility if you experience
any of the following: headache, loss of conciousness, seizures,
increasing pain, chest pain, trouble breathing, difficulty
urinating, or any other symptoms that concern you.

The office number of Dr. [**Last Name (STitle) **] is listed below.

Followup Instructions:
Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD
Specialty: Hematology/Oncology
Location: [**Hospital1 18**]-DIVISION OF HEMATOLOGY/ONCOLOGY
Address: [**Location (un) **], [**Hospital Ward Name **] 9, [**Location (un) **],[**Numeric Identifier 718**]
Phone: [**Telephone/Fax (1) 13016**]
We are working on a follow up appointment for you to be seen by
Dr. [**Last Name (STitle) **] in oncology. You will be called at rehab with the
appointment. If you have not heard within 2 business days or
have questions, please call the number listed above.

Department: RADIOLOGY
When: MONDAY [**2162-11-29**] at 11:15 AM
With: RADIOLOGY MRI [**Telephone/Fax (1) 590**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 861**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: NEUROLOGY/NEURO-ONCOLOGY
When: MONDAY [**2162-11-29**] at 1 PM
With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12567**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1844**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Please discuss with the staff at the facility a follow up
appointment with a primary care provider when you are ready for
discharge.
{'Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Septicemia due to pseudomonas,Toxic encephalopathy,Acute kidney failure, unspecified,Sepsis,Secondary malignant neoplasm of brain and spinal cord,Hyperpotassemia,Pathologic fracture of other specified part of femur,Malignant neoplasm of kidney, except pelvis,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Cerebral edema,Hemiplegia, unspecified, affecting dominant side,Long-term (current) use of insulin,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric),Hypercalcemia,Physical restraints status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: altered mental status

PRESENT ILLNESS: 55-year-old male with DMII, CAD status post inferior MI,
hypertension, hyperlipidemia, and depression who presented to
the ED with altered mental status and was found to be in DKA and
with head imaging concerning for new metastatic lesions. Today,
neighbors called EMS as patient was lying on his floor naked and
screaming.  Wife was at work at the time.  At ED, initial vital
signs were 98.4 106 180/77 20 100% 6L.  Labs showed glucose 544,
anion gap 33, K 6.0, Cr 1.5 (baseline 1.1), WBC 16.2.  Pt states
that he did not take his insulin this morning. He was given
10units insulin and started on an insulin gtt at 8units/hr.  He
received a total of 3liters of IVFs while in ED.  He was also
given calcium gluconate for his hyperkalemia.  U/A showed few
bacteria; cxr was largely unremarkable

MEDICAL HISTORY: 1.  Coronary artery disease, status post inferior STEMI in [**2158**].
2.  Hypertension.
3.  Hyperlipidemia.
4.  Mitral regurg, mild on stress echo.
5.  Diabetes.
6.  Depression.

MEDICATION ON ADMISSION: BUPROPION HCL - bupropion HCl XL 300 mg 24 hr tablet, extended
release
1 Tablet(s) by mouth daily <i>No Substitution</i>
CHLORTHALIDONE - chlorthalidone 25 mg tablet
1 Tablet(s) by mouth daily <i>No Substitution</i>
FLUOXETINE [PROZAC] - Prozac 20 mg capsule
3 Capsule(s) by mouth DAILY
FLUTICASONE -  (Not Taking as Prescribed) - fluticasone 50
mcg/actuation Nasal Spray, Susp
2 spays(s) nasal q day
INSULIN ASPART [NOVOLOG FLEXPEN] - Novolog Flexpen 100 unit/mL
Sub-Q
20 units before each meal (three times a day).
INSULIN GLARGINE [LANTUS] - Lantus 100 unit/mL Sub-Q
45 units at bedtime <i>No Substitution</i>
LORAZEPAM - lorazepam 0.5 mg tablet
1 Tablet(s) by mouth at night as needed for anxiety Do not take
while drinking alcohol or operating machinery as medication can
cause sedation
METFORMIN - metformin ER 1,000 mg tablet,extended release 24hr
1 Tablet(s) by mouth daily <i>No Substitution</i>
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr
2 Tablet(s) by mouth DAILY (Daily)
MODAFINIL [PROVIGIL] - Provigil 200 mg tablet
1 Tablet(s) by mouth q a.m. and q 3 hrs later take 1st tab upon
awakening and 2nd 3 hrs later
NITROGLYCERIN - nitroglycerin 0.4 mg sublingual tablet
1 Tablet(s) sublingually every 5 minutes up to 3 tablets total
as
needed for chest pain
ROSUVASTATIN [CRESTOR] - Crestor 40 mg tablet
1 (One) Tablet(s) by mouth daily
SILDENAFIL [VIAGRA] - Viagra 100 mg tablet
[**1-27**] Tablet(s) by mouth daily several times a month. Use one hour
prior to activity.
TIZANIDINE - tizanidine 4 mg tablet
1 tablet(s) by mouth twice a day as needed for back pain
ZOLPIDEM - zolpidem 5 mg tablet
1 Tablet(s) by mouth at bedtime for use with CPAP only
ASPIRIN -  (OTC; Dose adjustment - no new Rx) - aspirin 81 mg
tablet,delayed release
One Tablet by mouth once a day
BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - One Touch Ultra
Test Strips
use to monitor blood suagr four times a day or as directed
INSULIN NEEDLES (DISPOSABLE) [BD INSULIN PEN NEEDLE UF ORIG] -
BD
Insulin Pen Needle UF Orig 29 x [**1-25**]"
to be used with insulin pen three times a day

ALLERGIES: lisinopril

PHYSICAL EXAM: T afebrile HR 78 BP 159/96 Spo2 95% on RA
General: Alert, oriented x 3, complaining of pain
HEENT: Sclera anicteric, dry MM, oropharynx clear, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: uncooperative with neuro exam, moving all extremities,
following commands, intact rectal tone, pain on LE strength exam

FAMILY HISTORY: Mother with brain tumor.  No other malignancies.

SOCIAL HISTORY: Lives with his wife and 8-year-old daughter.  [**Name (NI) **] drinks two
glasses of wine at night, not recently. Smokes roughly three
cigarettes a day.  No drug use. 

### Response:
{'Diabetes with ketoacidosis, type II or unspecified type, uncontrolled,Septicemia due to pseudomonas,Toxic encephalopathy,Acute kidney failure, unspecified,Sepsis,Secondary malignant neoplasm of brain and spinal cord,Hyperpotassemia,Pathologic fracture of other specified part of femur,Malignant neoplasm of kidney, except pelvis,Urinary tract infection, site not specified,Acute posthemorrhagic anemia,Cerebral edema,Hemiplegia, unspecified, affecting dominant side,Long-term (current) use of insulin,Old myocardial infarction,Percutaneous transluminal coronary angioplasty status,Unspecified essential hypertension,Other and unspecified hyperlipidemia,Tobacco use disorder,Obstructive sleep apnea (adult)(pediatric),Hypercalcemia,Physical restraints status,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
