CHIEF COMPLAINT: This is a 70 year old male with upper
gastrointestinal bleed and alcohol withdrawal, transferred to
[**Hospital1 69**] at the request of family
and intubated on transfer for airway protection.

PRESENT ILLNESS: The patient presented to [**Hospital3 **] Medical Center by the family with concern for three
to four days of multiple falls due to worsening balance, gait
abnormality, intermittent slurred speech and word finding
difficulties and expressive aphasia.  The patient stated he
"didn't feel right".  The patient denied any head trauma,
loss of consciousness, dizziness.  Cardiac and neurologic
review of systems are negative, although the family noted a
recent change in his personality and increased alcohol
consumption.  In addition, the patient noted black stool
times one week, cough productive of yellow sputum times three
days.  The patient's vital signs were normal in the Emergency
Department.  His laboratories were notable for a hematocrit
of 26.0, potassium 5.6, blood urea nitrogen 61, creatinine
1.5.  Chest x-ray showed a 7.0 centimeter lesion in the
posterior right upper lobe, thought to be a rounded mass
versus collapsed lung distal to an endobronchial lesion.
Head CT showed multiple small calcified ring enhancing
lesions, with the differential diagnoses of metastases,
syssarcosis or abscesses.

MEDICAL HISTORY: 1.  Hypertension.
2.  Peripheral vascular disease.
3.  Nephrolithiasis.
4.  Hiatal hernia.
5.  Tobacco abuse.
6.  Alcohol abuse.
7.  High cholesterol.
8.  Seasonal allergies.
9.  Colonic tubular adenoma, status post colonoscopy in
[**2131-2-27**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a retired rocket scientist,
currently a part-time teacher at [**University/College 5130**] [**Location (un) **].  On
admission to [**Hospital3 **] Medical Center, he admitted to
drinking twenty shots of vodka per day, Cage questionnaire
was positive.  The patient has a significant smoking history
of three packs per day times twenty to forty years.
Malignant neoplasm of upper lobe, bronchus or lung,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of other digestive organs and spleen,Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Alcohol withdrawal,Alcohol abuse, unspecified,Orthostatic hypotension,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage
Mal neo upper lobe lung,Sec mal neo brain/spine,Sec mal neo GI NEC,Gastrointest hemorr NOS,Acute respiratry failure,Alcohol withdrawal,Alcohol abuse-unspec,Orthostatic hypotension,Gstr/ddnts NOS w/o hmrhg
Admission Date:  [**2134-1-26**]       Discharge Date:  [**2134-2-8**]

Date of Birth:   [**2063-11-12**]       Sex:  M

Service:  MEDICINE

CHIEF COMPLAINT:  This is a 70 year old male with upper
gastrointestinal bleed and alcohol withdrawal, transferred to
[**Hospital1 69**] at the request of family
and intubated on transfer for airway protection.

HISTORY OF PRESENT ILLNESS:  The patient presented to [**Hospital3 **] Medical Center by the family with concern for three
to four days of multiple falls due to worsening balance, gait
abnormality, intermittent slurred speech and word finding
difficulties and expressive aphasia.  The patient stated he
"didn't feel right".  The patient denied any head trauma,
loss of consciousness, dizziness.  Cardiac and neurologic
review of systems are negative, although the family noted a
recent change in his personality and increased alcohol
consumption.  In addition, the patient noted black stool
times one week, cough productive of yellow sputum times three
days.  The patient's vital signs were normal in the Emergency
Department.  His laboratories were notable for a hematocrit
of 26.0, potassium 5.6, blood urea nitrogen 61, creatinine
1.5.  Chest x-ray showed a 7.0 centimeter lesion in the
posterior right upper lobe, thought to be a rounded mass
versus collapsed lung distal to an endobronchial lesion.
Head CT showed multiple small calcified ring enhancing
lesions, with the differential diagnoses of metastases,
syssarcosis or abscesses.

For the patient's lung and brain masses, the patient was
started on intravenous Dilantin on the advice of neurology,
and a chest CT was ordered.

With regards to his upper gastrointestinal bleed, his
hematocrit dropped from 26.0 to 22.0 in the first night with
occult blood positive stool.  Gastric lavage was negative.
Upper endoscopy showed superficial linear erosions in the
lower third of the esophagus, mild nonerosive gastritis and
duodenitis with no erosions or bleeding.  He continued to
have orthostatic hypotension.  He received a total of three
units of packed red blood cells, and then was transferred to
the Intensive Care Unit.  His hematocrit was stable since the
evening of [**2134-1-24**].  The plan was to repeat the colonoscopy
after his alcohol withdrawal had resolved.

For his alcohol withdrawal, he was started on Oxazepam
protocol and given multivitamin Thiamine and Folate.  He
became agitated on [**2134-1-23**], requiring posy and restraints.
On [**2134-1-24**], he became hypertensive to 210/130, requiring
control with Nitroglycerin paste and Clonidine.  He was
transferred to [**Hospital1 69**] at the
request of the family.  In order to stabilize for transfer,
he required sedation with Propofol and consequent
endotracheal intubation.

PAST MEDICAL HISTORY:
1.  Hypertension.
2.  Peripheral vascular disease.
3.  Nephrolithiasis.
4.  Hiatal hernia.
5.  Tobacco abuse.
6.  Alcohol abuse.
7.  High cholesterol.
8.  Seasonal allergies.
9.  Colonic tubular adenoma, status post colonoscopy in
[**2131-2-27**].

OUTPATIENT MEDICATIONS:
1.  Lisinopril 40 mg p.o. once daily.
2.  Simvastatin 40 mg p.o. once daily.
3.  Fexofenadine.
4.  Aspirin 325 mg p.o. once daily.
5.  Potassium Chloride 20 meq p.o. once daily.
6.  Multivitamin.
7.  Folate.

TRANSFER MEDICATIONS:
1.  Protonix 40 mg intravenous twice a day.
2.  Gatifloxacin 40 mg intravenous once daily.
3.  Dilantin 100 mg intravenous three times a day.
4.  Diltiazem 7.5 mg intravenous four times a day.
5.  Diazepam 10 mg intravenous q2hours and 10 mg intravenous
q2hours p.r.n.
6.  Clonidine 0.1 mg patch.
7.  Propofol drip.
8.  Nitroglycerin paste two inches.
9.  Haldol 2 to 4 mg intravenous q2-3hours.

SOCIAL HISTORY:  The patient is a retired rocket scientist,
currently a part-time teacher at [**University/College 5130**] [**Location (un) **].  On
admission to [**Hospital3 **] Medical Center, he admitted to
drinking twenty shots of vodka per day, Cage questionnaire
was positive.  The patient has a significant smoking history
of three packs per day times twenty to forty years.

PHYSICAL EXAMINATION:  Vital signs revealed temperature 98.8,
pulse 73, blood pressure 111/palpable.  In general, the
patient is an intubated elderly male who occasionally
struggles against restraints.  Possible mild palmar erythema
but no spider nevi or caput medusa.  Head, eyes, ears, nose
and throat - pink conjunctiva, no icterus, pupils are equal,
round, and reactive to light and accommodation.  The neck
revels seven centimeter jugular venous distention above the
right atrium.  Cor - regular rate and rhythm with physiologic
splitting of S2.  The lungs are clear to auscultation
bilaterally.  The abdomen is positive bowel sounds, soft,
nondistended, no flank dullness or fluid wave.  Liver
palpable two centimeters below the right costal margin.
Extremities - good peripheral pulses, no cyanosis, clubbing
or edema.

LABORATORY DATA:  White blood cell count 7.6, hematocrit
32.1, platelets 259,000.  Prothrombin time 13.8, INR 1.3,
partial thromboplastin time 30.1.  Sedimentation rate 55.
Sodium 140, potassium 3.9, chloride 107, bicarbonate 22,
blood urea nitrogen 11, creatinine 0.8, glucose 114, ALT 10,
AST 18, alkaline phosphatase 78, total bilirubin 0.6, albumin
3.0, calcium 8.0, phosphorus 3.4, magnesium 1.8.

CT of the brain with and without contrast revealed hyperdense
edema in both temporal lobes.  Hyperdensity in superior left
parietal lobe.  Small areas of calcification in the right
temporal lobe and bilateral frontal and parietal lobes.

HOSPITAL COURSE:  In short, this is a 70 year old male with
new brain lesions, apparent lung mass with endobronchial
obstruction, ETOH withdrawal requiring deep Propofol sedation
and endotracheal intubation for interhospital transfer.

1.  Oncology - As already noted, the patient was noted to
have right upper lobe endobronchial mass on chest x-ray
concerning for carcinoma, especially given the findings of
what appeared to be multiple brain metastases no head CT.  CT
of the chest, abdomen and pelvis revealed a large right upper
lobe mass, two liver lesions in the right lobe, pancreatic
mass in the body of the pancreas, read as principal lung
neoplasm, with metastatic foci.  Head CT from [**2134-1-26**],
showed metastatic lesions in the frontal, parietal and
temporal lobes, with moderate edema, minimal mass effect and
some calcification.  The patient received bronchoscopy.  The
pathology on the bronchoscopy was consistent with nonsmall
cell lung cancer.  Given these imaging findings and the
patient's changed mental status, he was given a very poor
prognosis with his Stage IV nonsmall cell lung cancer.  The
patient was seen by oncology.  He was also seen by radiation
oncology.  There was general agreement that head radiation
therapy would be the initial starting point for palliative
treatment.  However, because the family was able to
communicate with the patient and actually saw some
improvement in his mental status over the past several weeks,
especially since extubation, they decided to hold off on head
radiation therapy, understanding that radiation therapy while
it could provide further improvement in his mental status, it
could also have negative effect too.  Instead, the patient
was kept on Dexamethasone which was eventually tapered down
to 4 mg four times a day.

2. Mental status changes - Once the patient was extubated, he
initially was still quite somnolent, giving only one word
answers.  Over the period of about one week, however, the
patient became much more alert.  He was always oriented to
person, some times to place, but this was variable.  He was
never oriented to time and his attention was severely
impaired.  The patient's mental status changes most probably
can be attributed to his multiple brain metastases, however,
it is odd that the patient did not show any focal signs even
with a greatly limited neurologic examination.  Other sources
of mental status change included high Ativan load with poor
clearing, effect of Dilantin, Wernicke's syndrome. There is
also concern for carcinomatosis meningitis, however, given
that the patient was improving, this was not worked up.  The
patient's Dilantin was stopped, but his steroids were
continued.  Head magnetic resonance scan on [**2134-1-31**], showed
multiple foci of enhancement, edema in both cerebral
hemispheres, posterior fossa consistent with metastatic
disease, no hydrocephalus, mass shift, hemorrhage or left
meningeal enhancement that might suggest meningitis.  Once
again, the family held off on head radiation therapy given
the patient's improving mental status.  They were willing to
give it a try, however, should his mental status deteriorate.

3.  Alcohol withdrawal - The patient did not show any sign of
withdrawal once he was extubated.  He was kept on Clonidine
at 0.5 mg p.o. twice a day.

4.  Gastrointestinal bleed - The patient's hematocrit was
noted to decrease from 30.7 to 27.5 on [**2134-1-31**].  However,
the patient did not overtly pass any blood, and his
hematocrit remained stable.

5.  FEN - Initially once he was extubated, the patient had a
nasogastric tube.  He received swallowing evaluation with
nasogastric tube in place and was noted to be a silent
aspirator.  However, once the nasogastric was removed, repeat
video swallowing study revealed that he, in fact, was not
aspirating.  The patient was kept on aspiration precautions
given his waxing and [**Doctor Last Name 688**] mental status.  He was kept on
pureed solids and thin liquids with one to one supervision.

6.  Psychiatric - The patient was noted to have reversed
sleep/wake cycles.  He was asleep most of the day but was up
a lot of the night trying to get out of bed.  For this
reason, he required a sitter which further complicated his
disposition planning.  The patient was written for low dose
Ambien at night as needed to help him sleep.

CONDITION ON DISCHARGE:  Fair.

MEDICATIONS ON DISCHARGE:
1.  Regular insulin sliding scale.
2.  Protonix 40 mg p.o. once daily.
3.  Folate 1 mg p.o. once daily.
4.  Thiamine 100 mg p.o. once daily.
5.  Multivitamin one tablet p.o. once daily.
6.  Lisinopril 40 mg p.o. once daily.
7.  Clonidine 0.5 mg p.o. twice a day.
8.  Dexamethasone 4 mg p.o. four times a day.
9.  Lopressor 25 mg p.o. twice a day.
10. Ambien 5 mg p.o. q.h.s. p.r.n. insomnia.

DISCHARGE INSTRUCTIONS:  At this point in time, it is unclear
which facility the patient will be going to.  The family does
not feel that they can handle the patient on their own.  The
patient will likely go to Hospice care.

DISCHARGE DIAGNOSES:
1.  Metastatic nonsmall cell lung cancer.
2.  Mental status changes, likely secondary to brain
metastases.
3.  Alcohol withdrawal.
4.  Gastrointestinal bleed.
5.  Hypertension.




                            [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D.  [**MD Number(1) 4521**]

Dictated By:[**Name8 (MD) 4990**]
MEDQUIST36

D:  [**2134-2-6**]  23:10
T:  [**2134-2-7**]  09:41
JOB#:  [**Job Number **]


Name:  [**Known lastname 17351**], [**Known firstname **]         Unit No:  [**Numeric Identifier 17352**]

Admission Date:  [**2134-1-26**]     Discharge Date:  [**2134-2-11**]

Date of Birth:   [**2063-11-12**]     Sex:      M

Service:

ADDENDUM TO DISCHARGE SUMMARY

HOSPITAL COURSE:
1.  Mental status:  The patient continued to have improving
mental status throughout the remainder of his hospital stay
with fewer episodes of agitation at night.  However, the
patient continued to remain confused and disoriented.  He was
continued on a one to one sitter to prevent him from
wandering off the floor.  The medical team and consulting
neurologist felt that these continued mental status changes
were most consistent with diffuse cerebral edema secondary to
metastatic disease.  His metabolic panel was repeated and
normal.  His neurological examination had no focal deficits
at the time of discharge.  He was started on Risperidone 0.5
mg q.h.s. prior to discharge.

2.  Alcohol withdrawal:  The patient had a history of alcohol
withdrawal.  However, the patient's Clonidine was
discontinued prior to discharge.  The patient displayed no
evidence of alcohol withdrawal at this time.

MEDICATIONS ON DISCHARGE:  Please refer to page one.

DISCHARGE STATUS:  To rehab.

DISCHARGE INSTRUCTIONS:
1.  If the patient's mental status deteriorates and family
wishes to pursue radiation therapy the patient's family is to
contact Radiation/Oncology at [**Telephone/Fax (1) 17353**].
2.  If the patient has evidence of gastrointestinal bleed he
should be evaluated by Gastroenterology.
3.  The patient's mental status should be followed by rehab
neurologist.
4.  The patient is to follow up with Dr. [**Last Name (STitle) 8041**] in two
weeks.

                          [**First Name8 (NamePattern2) 77**] [**First Name4 (NamePattern1) 1495**] [**Last Name (NamePattern1) **], M.D.  [**MD Number(1) 8396**]

Dictated By:  [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
MEDQUIST36
D:  [**2134-5-13**]  07:29
T:  [**2134-5-14**]  09:20
JOB#:  [**Job Number 17354**]
{'Malignant neoplasm of upper lobe, bronchus or lung,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of other digestive organs and spleen,Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Alcohol withdrawal,Alcohol abuse, unspecified,Orthostatic hypotension,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}


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: This is a 70 year old male with upper
gastrointestinal bleed and alcohol withdrawal, transferred to
[**Hospital1 69**] at the request of family
and intubated on transfer for airway protection.

PRESENT ILLNESS: The patient presented to [**Hospital3 **] Medical Center by the family with concern for three
to four days of multiple falls due to worsening balance, gait
abnormality, intermittent slurred speech and word finding
difficulties and expressive aphasia.  The patient stated he
"didn't feel right".  The patient denied any head trauma,
loss of consciousness, dizziness.  Cardiac and neurologic
review of systems are negative, although the family noted a
recent change in his personality and increased alcohol
consumption.  In addition, the patient noted black stool
times one week, cough productive of yellow sputum times three
days.  The patient's vital signs were normal in the Emergency
Department.  His laboratories were notable for a hematocrit
of 26.0, potassium 5.6, blood urea nitrogen 61, creatinine
1.5.  Chest x-ray showed a 7.0 centimeter lesion in the
posterior right upper lobe, thought to be a rounded mass
versus collapsed lung distal to an endobronchial lesion.
Head CT showed multiple small calcified ring enhancing
lesions, with the differential diagnoses of metastases,
syssarcosis or abscesses.

MEDICAL HISTORY: 1.  Hypertension.
2.  Peripheral vascular disease.
3.  Nephrolithiasis.
4.  Hiatal hernia.
5.  Tobacco abuse.
6.  Alcohol abuse.
7.  High cholesterol.
8.  Seasonal allergies.
9.  Colonic tubular adenoma, status post colonoscopy in
[**2131-2-27**].

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: 

SOCIAL HISTORY: The patient is a retired rocket scientist,
currently a part-time teacher at [**University/College 5130**] [**Location (un) **].  On
admission to [**Hospital3 **] Medical Center, he admitted to
drinking twenty shots of vodka per day, Cage questionnaire
was positive.  The patient has a significant smoking history
of three packs per day times twenty to forty years. 

### Response:
{'Malignant neoplasm of upper lobe, bronchus or lung,Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of other digestive organs and spleen,Hemorrhage of gastrointestinal tract, unspecified,Acute respiratory failure,Alcohol withdrawal,Alcohol abuse, unspecified,Orthostatic hypotension,Unspecified gastritis and gastroduodenitis, without mention of hemorrhage'}
