CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 69 M with small lung CA metastatic to brain on recent outpatient
corticosteroid taper who was brought to the ED by EMS after an
acquaintance reported altered mental status. Reportedly seen
normal around 6:30-6:45 PM and then at 7:30 PM was confused,
ataxic, and aphasic. On arrival in the ED, a code stroke was
called. His initial oral temp was 100F. Minimally responsive
with left eye gaze. He was observed to havea an possible seizure
activity, described as generalized tonic movements with eye
deviation to the left only lasting 40 secs. Given ativan 2 mg IV
with resolution. Respirations became more rapid and shallow so
was intubated without complication given depressed sensorium
after induction with etomidate and succinylcholine. SBP dropped
to 80s with propofol sedation. Subsequently spiked rectal temp
102.6. Blood cx sent, given vanc 1 g, CTX 2 g IV. Head CT showed
right temporoparietal vasogenic edema signifying underlying
lesion, no ICH, and underlying small vessel ischemic disease.
Given dexamethasone 10 mg IV and dilantin 1000 mg IV after
evaluation by neurology. Also reportedly had coffee ground out
of NGT - given protonix IV. Vital signs prior to transfer 102.6
91 132/70 100% on Vt 500 f16 peep 5 fiO2 100%.
.
On the floor, pt arrived intubated unresponsive, sedated with
propafol. Vent settings were AC with volume control at 500Vt,
PEEP 5, FiO2 of 100% which was decreased to 50%.
.
Of note, Pt was initially diagnosed with small lung cancer in
[**2178-5-25**]. S/P 4 cycles fo chemo with Cisplatin/Etoposide, s/p
radiation tx to mediastinum, hilum, and lung mass, s/p
phrophylatic whole brain radiation. Following brain MRI in
[**1-/2179**] showed 2 metastatic lesions for which he received gamma
knife to brain lesions. He has also developed horseness due to
partially paralysed left vocal cord r/t cancer
.
Review of systems:
(+) Per HPI, as per his daughter he was coughing the day before.

MEDICAL HISTORY: Lung CA metastatic to brain
hypercholesterol
BPH

MEDICATION ON ADMISSION: MVI I tab once daily
-Mucinex 600mg twice daily
-Decadron 1.5 mg, 2 tablets [**Hospital1 **] last dose on [**6-6**]
-Pepcid 20mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.3, HR 85, BP 142/69, RR 19, Sat 100% on vent ( AC
500Vt, PEEP 5, FiO2 50%, RR 16 )
General: Pale, with hue discoloration, cachetic, Non-responsive
in no acute distress
HEENT: Sclera anicteric, MM dry, NG tube to sx small amount of
coffee ground fluid in the tube
Neck: supple, prominet EJ, no LAD
Lungs: Clear to auscultation bilaterally, expect for crackles at
the bases L >R.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley-> BSD with clear yellow urine
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives independently with his son who has mental retartdation.
He retired ~ 1 year ago around the time of his diagnosis. He has
a daughter who is physician, [**Name10 (NameIs) **] on [**Location 85397**]. He
drinks on average 2-4 beers per day. He has >50 pack years
smoking hx, he quit in [**2178-5-25**].
Other convulsions,Cerebral edema,Unspecified septicemia,Sepsis,Acute respiratory failure,Secondary malignant neoplasm of brain and spinal cord,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of bronchus and lung,Personal history of tobacco use,Unilateral paralysis of vocal cords or larynx, partial
Convulsions NEC,Cerebral edema,Septicemia NOS,Sepsis,Acute respiratry failure,Sec mal neo brain/spine,BPH w/o urinary obs/LUTS,Hx-bronchogenic malignan,History of tobacco use,Vocal paral unilat part
Admission Date:  [**2179-6-11**]              Discharge Date:   [**2179-6-17**]

Date of Birth:  [**2109-12-12**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2195**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Mechanical Ventilation
Arterial Line
Cental Line

History of Present Illness:
69 M with small lung CA metastatic to brain on recent outpatient
corticosteroid taper who was brought to the ED by EMS after an
acquaintance reported altered mental status. Reportedly seen
normal around 6:30-6:45 PM and then at 7:30 PM was confused,
ataxic, and aphasic. On arrival in the ED, a code stroke was
called. His initial oral temp was 100F. Minimally responsive
with left eye gaze. He was observed to havea an possible seizure
activity, described as generalized tonic movements with eye
deviation to the left only lasting 40 secs. Given ativan 2 mg IV
with resolution. Respirations became more rapid and shallow so
was intubated without complication given depressed sensorium
after induction with etomidate and succinylcholine. SBP dropped
to 80s with propofol sedation. Subsequently spiked rectal temp
102.6. Blood cx sent, given vanc 1 g, CTX 2 g IV. Head CT showed
right temporoparietal vasogenic edema signifying underlying
lesion, no ICH, and underlying small vessel ischemic disease.
Given dexamethasone 10 mg IV and dilantin 1000 mg IV after
evaluation by neurology. Also reportedly had coffee ground out
of NGT - given protonix IV. Vital signs prior to transfer 102.6
91 132/70 100% on Vt 500 f16 peep 5 fiO2 100%.
.
On the floor, pt arrived intubated unresponsive, sedated with
propafol. Vent settings were AC with volume control at 500Vt,
PEEP 5, FiO2 of 100% which was decreased to 50%.
.
Of note, Pt was initially diagnosed with small lung cancer in
[**2178-5-25**]. S/P 4 cycles fo chemo with Cisplatin/Etoposide, s/p
radiation tx to mediastinum, hilum, and lung mass, s/p
phrophylatic whole brain radiation. Following brain MRI in
[**1-/2179**] showed 2 metastatic lesions for which he received gamma
knife to brain lesions. He has also developed horseness due to
partially paralysed left vocal cord r/t cancer
.
Review of systems:
(+) Per HPI, as per his daughter he was coughing the day before.

(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
.


Past Medical History:
Lung CA metastatic to brain
hypercholesterol
BPH


Social History:
Pt lives independently with his son who has mental retartdation.
He retired ~ 1 year ago around the time of his diagnosis. He has
a daughter who is physician, [**Name10 (NameIs) **] on [**Location 85397**]. He
drinks on average 2-4 beers per day. He has >50 pack years
smoking hx, he quit in [**2178-5-25**].

Family History:
NC

Physical Exam:
Vitals: T: 98.3, HR 85, BP 142/69, RR 19, Sat 100% on vent ( AC
500Vt, PEEP 5, FiO2 50%, RR 16 )
General: Pale, with hue discoloration, cachetic, Non-responsive
in no acute distress
HEENT: Sclera anicteric, MM dry, NG tube to sx small amount of
coffee ground fluid in the tube
Neck: supple, prominet EJ, no LAD
Lungs: Clear to auscultation bilaterally, expect for crackles at
the bases L >R.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley-> BSD with clear yellow urine
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema


Pertinent Results:
Admission Labs: [**2179-6-11**] 08:23PM
GLUCOSE-119* LACTATE-1.0 NA+-135 K+-3.7 CL--93* TCO2-30 UREA
N-14 CREAT-1.1
WBC-3.5* RBC-3.61* HGB-12.1* HCT-34.7* MCV-96 PLT COUNT-264
PT-10.8 PTT-22.9 INR(PT)-0.9
FIBRINOGE-346

Discharge Labs: [**2179-6-17**] 09:00AM
WBC-4.3 RBC-3.67* Hgb-12.0* Hct-36.0* MCV-98 Plt Ct-269
Glucose-84 UreaN-12 Creat-0.8 Na-138 K-3.9 Cl-100 HCO3-31

Chest CT:
1. No PE identified. Extreme lung bases were not imaged.
2. Moderate bilateral non-hemorrhagic pleural effusions
associated with basal atelectases.
3. Spiculated nodule in the left upper lobe not significantly
changed in size from [**2179-5-7**] with bronchial wall thickening and
peribronchial opacities in the apical posterior segments in LUL
similar in appearance to prior study.
4. Spiculated opacity in the right apex also without significant
change.
5. Paraseptal and centrilobular emphysema.
6. Right hilar and subcarinal lymphadenopathy, increased in size
from
[**2179-2-19**].

Head MRI: There are two ring-enhancing parenchymal lesions.
There is a 1.8
cm round lesion in the posterior right temporal lobe, which
demonstrates
evidence of chronic blood products on the gradient echo
sequence. The rim of this lesion also demonstrates slow
diffusion, which may indicate
hypercellularity. The nonenhancing center of the lesion does not
demonstrate slow diffusion, suggesting that this does not
represent an abscess. There is moderate vasogenic edema
involving the right temporal, occipital, and parietal lobes. The
second ring-enhancing lesion is located in the posterior left
temporal lobe. It is round, measuring 1.1 cm. There are no
associated blood products or diffusion abnormalities. There is
mild associated vasogenic edema.


Brief Hospital Course:
69 yo with metastatic small cell lung cancer who presents with
change in MS, fever and seizeures who was found to have
vasogenic edema.

# Seizure: Intubated in ED for airway protection. MRI showed two
previously known metastatic lesions. He was evaluated by
neurology and started on levetiracetam, dexamethasone, and
phenytoin. He was also evaluated by radiation oncology. Dilantin
was tapered off as Keppra was increased, and he is being
discharged on Keppra and Decadon alone. If his steroids are to
be continued long-term, he should be started on Ca/Vit
D/Bisphosphonate/Bactrim. PPI continued at discharge but can be
discontinued when steroids are stopped. The patient was
instructed that he should not drive until he has been
seizure-free for 6 months.

# Fever: Initial concern for aspiration pneumonia vs. ventilator
associated pneumonia. Multiple chest X-rays showed no evidence
of infection and antibiotics were stopped. He had no fevers
while on the general medicine floor.

# Shortness of breath: Patient had an acute episode of shortness
of breath on [**2179-6-15**] after being laid flat for removal of a
central line. He improved with supportive care alone. Chest CTA
showed no evidence of emboli or infiltrates, but did show small
bilateral pleural effusions, likely related to volume
resuscitation in the ICU. Patient improved and had oxygen
saturations of 97-99% on room air.


Medications on Admission:
MVI I tab once daily
-Mucinex 600mg twice daily
-Decadron 1.5 mg, 2 tablets [**Hospital1 **] last dose on [**6-6**]
-Pepcid 20mg daily


Discharge Medications:
1. Dexamethasone 4 mg PO/NG Q8H
Disp #*30 Day(s) Refills:*0
2. LeVETiracetam 1000 mg PO/NG [**Hospital1 **]
Disp #*30 Day(s) Refills:*0
3. Pantoprazole 40 mg PO Q12H
Disp #*30 Day(s) Refills:*0


Discharge Disposition:
Home

Discharge Diagnosis:
Lung Cancer
Seizure


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted with seizures and were initially treated in
the ICU. You were started on steroids and anti-seizure
medications and had no further witnessed seizures. While on the
medical floor you had an episode of shortness of breath, which
was thought to be secondary to mucous vs. fluid in your lungs.
You had a chest CT which showed no evidence of infection or
clot.


Followup Instructions:
Please follow-up with your outpatient Oncologist and Radiation
Oncologist, and arrange follow-up with a neurologist as well.
{'Other convulsions,Cerebral edema,Unspecified septicemia,Sepsis,Acute respiratory failure,Secondary malignant neoplasm of brain and spinal cord,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of bronchus and lung,Personal history of tobacco use,Unilateral paralysis of vocal cords or larynx, partial'}


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: 69 M with small lung CA metastatic to brain on recent outpatient
corticosteroid taper who was brought to the ED by EMS after an
acquaintance reported altered mental status. Reportedly seen
normal around 6:30-6:45 PM and then at 7:30 PM was confused,
ataxic, and aphasic. On arrival in the ED, a code stroke was
called. His initial oral temp was 100F. Minimally responsive
with left eye gaze. He was observed to havea an possible seizure
activity, described as generalized tonic movements with eye
deviation to the left only lasting 40 secs. Given ativan 2 mg IV
with resolution. Respirations became more rapid and shallow so
was intubated without complication given depressed sensorium
after induction with etomidate and succinylcholine. SBP dropped
to 80s with propofol sedation. Subsequently spiked rectal temp
102.6. Blood cx sent, given vanc 1 g, CTX 2 g IV. Head CT showed
right temporoparietal vasogenic edema signifying underlying
lesion, no ICH, and underlying small vessel ischemic disease.
Given dexamethasone 10 mg IV and dilantin 1000 mg IV after
evaluation by neurology. Also reportedly had coffee ground out
of NGT - given protonix IV. Vital signs prior to transfer 102.6
91 132/70 100% on Vt 500 f16 peep 5 fiO2 100%.
.
On the floor, pt arrived intubated unresponsive, sedated with
propafol. Vent settings were AC with volume control at 500Vt,
PEEP 5, FiO2 of 100% which was decreased to 50%.
.
Of note, Pt was initially diagnosed with small lung cancer in
[**2178-5-25**]. S/P 4 cycles fo chemo with Cisplatin/Etoposide, s/p
radiation tx to mediastinum, hilum, and lung mass, s/p
phrophylatic whole brain radiation. Following brain MRI in
[**1-/2179**] showed 2 metastatic lesions for which he received gamma
knife to brain lesions. He has also developed horseness due to
partially paralysed left vocal cord r/t cancer
.
Review of systems:
(+) Per HPI, as per his daughter he was coughing the day before.

MEDICAL HISTORY: Lung CA metastatic to brain
hypercholesterol
BPH

MEDICATION ON ADMISSION: MVI I tab once daily
-Mucinex 600mg twice daily
-Decadron 1.5 mg, 2 tablets [**Hospital1 **] last dose on [**6-6**]
-Pepcid 20mg daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T: 98.3, HR 85, BP 142/69, RR 19, Sat 100% on vent ( AC
500Vt, PEEP 5, FiO2 50%, RR 16 )
General: Pale, with hue discoloration, cachetic, Non-responsive
in no acute distress
HEENT: Sclera anicteric, MM dry, NG tube to sx small amount of
coffee ground fluid in the tube
Neck: supple, prominet EJ, no LAD
Lungs: Clear to auscultation bilaterally, expect for crackles at
the bases L >R.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: foley-> BSD with clear yellow urine
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema

FAMILY HISTORY: NC

SOCIAL HISTORY: Pt lives independently with his son who has mental retartdation.
He retired ~ 1 year ago around the time of his diagnosis. He has
a daughter who is physician, [**Name10 (NameIs) **] on [**Location 85397**]. He
drinks on average 2-4 beers per day. He has >50 pack years
smoking hx, he quit in [**2178-5-25**]. 

### Response:
{'Other convulsions,Cerebral edema,Unspecified septicemia,Sepsis,Acute respiratory failure,Secondary malignant neoplasm of brain and spinal cord,Hypertrophy (benign) of prostate without urinary obstruction and other lower urinary tract symptom (LUTS),Personal history of malignant neoplasm of bronchus and lung,Personal history of tobacco use,Unilateral paralysis of vocal cords or larynx, partial'}
