CHIEF COMPLAINT: Fatigue and Shortness of breath

PRESENT ILLNESS: 72M with 3-month h/o glioblastoma (presented with right
homonymous hemianopsia) s/p involved-field radiation therapy and
temozolomide (last dose on [**2179-7-22**]) presents with several days
of shortness of breath and several weeks of fatigue/abulia.
Sent to OSH for CTA, which revealed large bilateral PEs.  Dr.
[**Last Name (STitle) 724**] (neuro-oncologist) was made aware and requested that the
patient come to [**Hospital1 18**] for heparin drip and admission to the
hospital for further management.

MEDICAL HISTORY: - Non-insulin dependent diabetes
- Glioblastoma:
(1) a gadolinium-enhanced head MRI on [**2179-4-22**] that showed
an enhancing mass in the left occipital lobe,
(2) a brain biopsy on [**2179-4-24**] and the pathology report was
gemistocytic glioblastoma,
(3) Involved-field cranial irradiation with concomitant
temozolomide from [**2179-5-4**] to [**2179-6-15**],
(4) Adjuvant temozolomide given [**2179-7-19**] - [**2179-7-22**], did not
receive 5th day of therapy due to fatigue

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. MetFORMIN (Glucophage) 500 mg PO DAILY Start: In am
2. MethylPHENIDATE (Ritalin) 5 mg PO 8AM AND 2PM Start: In am
3. Dexamethasone 4 mg PO Q12H
4. LeVETiracetam 750 mg PO BID
5. Acetaminophen w/Codeine 25 mg PO ONE HOUR BEFORE CHEMOTHERAPY

ALLERGIES: Bactrim

PHYSICAL EXAM: Admission Physical Exam:
VS: 98.2, 68, 120/72, 23, 97%
GENERAL: responsive and appropriate to verbal stimuli but giving
one-word answers only, NAD.
NEURO: Deferred due to fatigue
HEENT: NCAT, PERRL
CARDIAC: RRR, S1/S2, no m/r/g
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: No c/c/e, 2+ pulses DP/PT

FAMILY HISTORY: -mother died at age [**Age over 90 **] from Alzheimer's disease
-father died at age 39 from a ruptured aortic abdominal aneurysm
-sister with multiple sclerosis
-2 brothers who are healthy

SOCIAL HISTORY: He is a retired mechanic.  He smoked 5 packs of cigarettes for 5
years but stopped in [**2129**].  He does not drink alcohol or use
illicit drugs.
Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Malignant neoplasm of occipital lobe,Hypotension, unspecified,Other ill-defined conditions,Other malaise and fatigue,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Personal history of tobacco use
Pulm embol/infarct NEC,Ac DVT/emb prox low ext,Mal neo occipital lobe,Hypotension NOS,Ill-define condition NEC,Malaise and fatigue NEC,DMII wo cmp nt st uncntr,Hx of irradiation,Hx antineoplastic chemo,History of tobacco use
Admission Date:  [**2179-8-3**]              Discharge Date:   [**2179-8-6**]

Date of Birth:  [**2107-1-29**]             Sex:   M

Service: MEDICINE

Allergies:
Bactrim

Attending:[**First Name3 (LF) 1436**]
Chief Complaint:
Fatigue and Shortness of breath

Major Surgical or Invasive Procedure:
IVC filter placement

History of Present Illness:
72M with 3-month h/o glioblastoma (presented with right
homonymous hemianopsia) s/p involved-field radiation therapy and
temozolomide (last dose on [**2179-7-22**]) presents with several days
of shortness of breath and several weeks of fatigue/abulia.
Sent to OSH for CTA, which revealed large bilateral PEs.  Dr.
[**Last Name (STitle) 724**] (neuro-oncologist) was made aware and requested that the
patient come to [**Hospital1 18**] for heparin drip and admission to the
hospital for further management.

In the ED, initial vitals were 98.3 85 116/78 18 98%.  Labs were
significant for urine glucose of 1000 and ketones of 10.  Bicarb
21 down from 27 the day prior and BUN 27, Cr 0.6. Patient given
Heparin drip with bolus.  While in the ED, he became hypotensive
to systolics in the 80s, but responsive to 1L NS.  He is not a
candidate for lysis given his glioblastoma.  Patient was seen by
cardiology for possible clot retrieval, but BLE ultrasound
showed non-occlusive thrombus in left popliteal [**Last Name (LF) 5703**], [**First Name3 (LF) **] went to
cath lab for IVC filter and transfer to the CCU for further
monitor.

In the cath lab, the patient received IVC filter through right
femoral [**First Name3 (LF) 5703**] with no complications.

On arrival to the floor, patient remained stable without
complaints but was lethargic.
.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
.


Past Medical History:
- Non-insulin dependent diabetes
- Glioblastoma:
(1) a gadolinium-enhanced head MRI on [**2179-4-22**] that showed
an enhancing mass in the left occipital lobe,
(2) a brain biopsy on [**2179-4-24**] and the pathology report was
gemistocytic glioblastoma,
(3) Involved-field cranial irradiation with concomitant
temozolomide from [**2179-5-4**] to [**2179-6-15**],
(4) Adjuvant temozolomide given [**2179-7-19**] - [**2179-7-22**], did not
receive 5th day of therapy due to fatigue


Social History:
He is a retired mechanic.  He smoked 5 packs of cigarettes for 5
years but stopped in [**2129**].  He does not drink alcohol or use
illicit drugs.

Family History:
-mother died at age [**Age over 90 **] from Alzheimer's disease
-father died at age 39 from a ruptured aortic abdominal aneurysm
-sister with multiple sclerosis
-2 brothers who are healthy

Physical Exam:
Admission Physical Exam:
VS: 98.2, 68, 120/72, 23, 97%
GENERAL: responsive and appropriate to verbal stimuli but giving
one-word answers only, NAD.
NEURO: Deferred due to fatigue
HEENT: NCAT, PERRL
CARDIAC: RRR, S1/S2, no m/r/g
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: No c/c/e, 2+ pulses DP/PT


Pertinent Results:
Admission:

[**2179-8-2**] 05:30PM BLOOD WBC-9.4 RBC-4.63 Hgb-14.8 Hct-45.5 MCV-98
MCH-31.9 MCHC-32.4 RDW-16.2* Plt Ct-144*
[**2179-8-2**] 05:30PM BLOOD Neuts-85.5* Lymphs-10.2* Monos-4.0
Eos-0.1 Baso-0.2
[**2179-8-2**] 05:30PM BLOOD Plt Ct-144*
[**2179-8-2**] 05:30PM BLOOD  WBC-9.4 Lymph-10* Abs [**Last Name (un) **]-940 CD3%-83
Abs CD3-784 CD4%-47 Abs CD4-443 CD8%-35 Abs CD8-325 CD4/CD8-1.4
[**2179-8-2**] 05:30PM BLOOD UreaN-24* Creat-0.6 Na-142 K-3.9 Cl-99
HCO3-27 AnGap-20
[**2179-8-2**] 05:30PM BLOOD ALT-45* AST-19 AlkPhos-47 TotBili-0.7
[**2179-8-2**] 05:30PM BLOOD Calcium-9.7 Phos-3.0 Mg-2.3
[**2179-8-2**] 05:30PM BLOOD TSH-0.49

In-house labs:

Studies:
MRI head [**2179-8-2**] - Stable left occipital rim-enhancing lesion
without significant increase in blood volume, but with increased
choline and decreased NAA in voxels 4 and 14, which may be
suggestive of neoplasm.  Mildly increased vasogenic edema
compared to the prior examination.

BLE US in ED [**2179-8-3**] - Nonocclusive thrombus in the left
popliteal [**Month/Day/Year 5703**].
CTA at OSH [**2179-8-3**] - large bilateral pleural effusions
TTE [**2179-8-4**] - Mild right ventricular cavity dilation with free
wall hypokinesis. Mild pulmonary artery systolic hypertension.
Normal left ventricular cavity size and regional/global systolic
function.

Brief Hospital Course:
72M with 3-month h/o glioblastoma s/p radiation therapy and
temozolomide (last dose on [**2179-7-22**]) presents with several days
of shortness of breath and several weeks of fatigue/abulia,
diagnosed as bilateral PE and L DVT.

Active:
# PE: Patient initially present with SOB and fatigue and found
to have bilateral PE by CTA at OSH.  Transferred here by his
neuro-oncologist for further management.    Started on hep gtt
in ED.  Experienced transient hypotension in the ED with SBP to
the 80s that was fluid responsive.  Not a candidate for
thrombolysis or clot retrieval given glioblastoma and clot
burden in lower extremeties.  Sent to cath lab [**2179-8-3**] for IVC
filter placement and transferred to CCU.  No post cath
complications.  He has been hemodynamically stable here in the
CCU with pressures in the 110s.  Hep gtt was continued to goal
PTT at 60-80.  He was transitioned to long-term anticoagulation
with lovenox 1 mg/kg for continued therapy of his PE
indefinitely, given setting of malignancy.  Transthoracic
echocardiogram [**2179-8-4**] showed mild right ventricular cavity
dilation with free wall hypokinesis and mild pulmonary artery
systolic hypertension.  IVC filter will likely be left in
permanently per Dr. [**First Name (STitle) **] [**Name (STitle) **].

Chronic:
# Glioblastoma:  He is s/p involved-field cranial irradiation
with concomitant
temozolomide from [**2179-5-4**] to [**2179-6-15**].  However, given profound
fatigue, his neuro-oncoligist will hold off on additional cycles
of temozolomide chemotherapy for the time being.  He was
continued on his home dose of dexamethasone and keppra upon
admission, but keppra discontinued prior to discharge per
neuro-oncology recommendations, since it may be partially
responsible for his spurts of anger, he has not had any seizures
yet, and peritumoral edema appears to be controlled well with
dexamethasone.  Palliative care assisting with discussion on
long-term goals of care.

# Abulia/Fatigue: Has improved with methylphenidate treatment in
recent weeks.  Methylphenidate was continued during the
admission.

# Diabetes: Stable.  Patient was maintained on ISS while in
house and his home metformin was held.

Transitional:
# PCP [**Name Initial (PRE) 1102**]: Follow with Dr. [**Last Name (STitle) 724**] as an outpatient.
# Will need to discuss duration of anticoagulation therapy with
Dr. [**Last Name (STitle) 724**] at follow up visit

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. MetFORMIN (Glucophage) 500 mg PO DAILY Start: In am
2. MethylPHENIDATE (Ritalin) 5 mg PO 8AM AND 2PM Start: In am
3. Dexamethasone 4 mg PO Q12H
4. LeVETiracetam 750 mg PO BID
5. Acetaminophen w/Codeine 25 mg PO ONE HOUR BEFORE CHEMOTHERAPY

6. Omeprazole 20 mg PO DAILY Start: In am
7. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
8. Replesta *NF* (cholecalciferol (vitamin D3)) 1 tab Oral once
per month
9. Temozolomide 300 mg IV DAILY BEDTIME
10. Ondansetron Dose is Unknown  IV ONE HOUR BEFORE CHEMO


Discharge Medications:
1. Dexamethasone 8 mg PO DAILY
2. MethylPHENIDATE (Ritalin) 5 mg PO 8AM AND 2PM
3. Omeprazole 20 mg PO DAILY
4. Enoxaparin Sodium 100 mg SC Q12H
RX *enoxaparin 100 mg/mL 100 mg twice a day Disp #*56 Syringe
Refills:*2
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. Os-Cal 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral Daily
7. Replesta *NF* (cholecalciferol (vitamin D3)) 1 tab Oral once
per month
8. Acetaminophen w/Codeine 25 mg PO QHS:PRN pain


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary:
-Pulmonary emboli secondary to malignancy
Secondary

Secondary:
-Glioblastoma
-Diabetes (non insulin dependent)
-Abulia

Discharge Condition:
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Activity Status: Ambulatory - Independent.

Discharge Instructions:
Dear Mr [**Known lastname **],
It was a pleasure taking care of you while you were admitted to
[**Hospital1 **] [**First Name (Titles) **] [**Last Name (Titles) **].  You were admitted after being
found to have blood clots in your lungs. A filter was placed in
one of the large vessels in your chest to prevent future blood
clots from traveling from your legs to your lungs.  You were
started on heparin, a medication that helps dissolve and prevent
further clots.  You were found to have low blood pressure in the
emergency department, so you were given fluids, and transferred
to the CCU for further care.  Your blood pressures were OK while
under our care.

Medications STARTED:
-enoxaparin (lovenox) for treatment of your pulmonary embolism

Medications DISCONTINUED:
-levetiracetam (keppra) for seizure prophylaxis

Followup Instructions:
Please call Dr. [**Last Name (STitle) 724**] at [**Telephone/Fax (1) 1844**] for follow-up appointment
as soon as you are discharged.
{'Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Malignant neoplasm of occipital lobe,Hypotension, unspecified,Other ill-defined conditions,Other malaise and fatigue,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Personal history of tobacco use'}


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: Fatigue and Shortness of breath

PRESENT ILLNESS: 72M with 3-month h/o glioblastoma (presented with right
homonymous hemianopsia) s/p involved-field radiation therapy and
temozolomide (last dose on [**2179-7-22**]) presents with several days
of shortness of breath and several weeks of fatigue/abulia.
Sent to OSH for CTA, which revealed large bilateral PEs.  Dr.
[**Last Name (STitle) 724**] (neuro-oncologist) was made aware and requested that the
patient come to [**Hospital1 18**] for heparin drip and admission to the
hospital for further management.

MEDICAL HISTORY: - Non-insulin dependent diabetes
- Glioblastoma:
(1) a gadolinium-enhanced head MRI on [**2179-4-22**] that showed
an enhancing mass in the left occipital lobe,
(2) a brain biopsy on [**2179-4-24**] and the pathology report was
gemistocytic glioblastoma,
(3) Involved-field cranial irradiation with concomitant
temozolomide from [**2179-5-4**] to [**2179-6-15**],
(4) Adjuvant temozolomide given [**2179-7-19**] - [**2179-7-22**], did not
receive 5th day of therapy due to fatigue

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientFamily/Caregiver.
1. MetFORMIN (Glucophage) 500 mg PO DAILY Start: In am
2. MethylPHENIDATE (Ritalin) 5 mg PO 8AM AND 2PM Start: In am
3. Dexamethasone 4 mg PO Q12H
4. LeVETiracetam 750 mg PO BID
5. Acetaminophen w/Codeine 25 mg PO ONE HOUR BEFORE CHEMOTHERAPY

ALLERGIES: Bactrim

PHYSICAL EXAM: Admission Physical Exam:
VS: 98.2, 68, 120/72, 23, 97%
GENERAL: responsive and appropriate to verbal stimuli but giving
one-word answers only, NAD.
NEURO: Deferred due to fatigue
HEENT: NCAT, PERRL
CARDIAC: RRR, S1/S2, no m/r/g
ABDOMEN: Soft, NT/ND, BS+
EXTREMITIES: No c/c/e, 2+ pulses DP/PT

FAMILY HISTORY: -mother died at age [**Age over 90 **] from Alzheimer's disease
-father died at age 39 from a ruptured aortic abdominal aneurysm
-sister with multiple sclerosis
-2 brothers who are healthy

SOCIAL HISTORY: He is a retired mechanic.  He smoked 5 packs of cigarettes for 5
years but stopped in [**2129**].  He does not drink alcohol or use
illicit drugs. 

### Response:
{'Other pulmonary embolism and infarction,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Malignant neoplasm of occipital lobe,Hypotension, unspecified,Other ill-defined conditions,Other malaise and fatigue,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Personal history of tobacco use'}
