CHIEF COMPLAINT: altered mental status

PRESENT ILLNESS: 76 y/o female with h/o metastatic breast cancer p/w altered
mental status (slurred speech, acting "funny" per daughter)
after receiving two units of blood during scheduled visit.
Parametics noted fever to 101.8, and she developed hypoxia to
the 70%'s on RA, which responded to 100% on a NRB.

MEDICAL HISTORY: Metastatic Right Breast Cancer with Mets to L4/L5
HTN
Hyperlipidemia
DM
Depression
Anxiety

MEDICATION ON ADMISSION: Lisinopril 40 mg QD
Doxazosin 8 mg QHS
Furosemide 10 mg QD
Fluoxetine 20 mg QD
Calcium and Vit D
Fentanyl patch 50 mcg Q72H

ALLERGIES: Penicillins / Percocet / Neurontin / Codeine

PHYSICAL EXAM: T 97.6 HR 60 BP 118/41 RR 12 O2 Sat 99% on 4L NC
Comfortable, not tachypneic
No scleral icterus, PERRL, EOMI, no nystagmus
No cerviacl LAD, JVP to mid neck
Left Axillary lymph node palpable
Heart regular with systolic murmur at LUSB, S2 present
Dullness and decreased breath sounds over right lower lung
fields, no rales or wheezes
Abd nondistended, good bowel sounds, soft, nontender
No peripheral edema, good pulses
Neuro exam with orientation to person, place, time. Able to do
simple calulations and counbt down from 20 by 4's. Able to name
objects without dificulty. Strength 5/5 throughout. Coordination
intact. Toes downgoing.

FAMILY HISTORY: NC

SOCIAL HISTORY: denies alcohol, drug use, Smoked [**12-14**] ppd x 20 yrs, quit 20 yrs
ago
Lives at senior living facility.
Secondary malignant neoplasm of pleura,Secondary malignant neoplasm of bone and bone marrow,Drug-induced delirium,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Antiallergic and antiemetic drugs causing adverse effects in therapeutic use,Personal history of malignant neoplasm of breast,Other and unspecified hyperlipidemia,Anticoagulants causing adverse effects in therapeutic use,Anemia in neoplastic disease,Dysthymic disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Second malig neo pleura,Secondary malig neo bone,Drug-induced delirium,Acute kidney failure NOS,Chronic kidney dis NOS,Adv eff anallrg/antemet,Hx of breast malignancy,Hyperlipidemia NEC/NOS,Adv eff anticoagulants,Anemia in neoplastic dis,Dysthymic disorder,DMII wo cmp nt st uncntr,Hy kid NOS w cr kid I-IV
Admission Date:  [**2134-11-20**]              Discharge Date:   [**2134-11-23**]

Date of Birth:  [**2058-11-13**]             Sex:   F

Service: MEDICINE

Allergies:
Penicillins / Percocet / Neurontin / Codeine

Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
altered mental status

Major Surgical or Invasive Procedure:
Pleurex placement


History of Present Illness:
76 y/o female with h/o metastatic breast cancer p/w altered
mental status (slurred speech, acting "funny" per daughter)
after receiving two units of blood during scheduled visit.
Parametics noted fever to 101.8, and she developed hypoxia to
the 70%'s on RA, which responded to 100% on a NRB.

In ED noted to have large Right pleural [**First Name3 (LF) 17838**] (has chronic
right pleural [**First Name3 (LF) 17838**], last [**First Name3 (LF) 58770**] 1.3 L on [**10-28**]/6), with a
question of underlying PNA. Given cefepime. Head CT was negative
for bleed or large mass. Concern for PE, but given Cr 2.5, and
inability to tolerate MRI in past, started on heparin
empirically for PE.

ROS: Has been getting aranesp Q4 wks(last on [**2134-11-17**]) and
pamiodronate Q8wks (last [**2134-10-14**]). Received falsodex (last
[**2134-9-15**]). SHe does report orthopnea, occasional leg swelling,
decreased functional status. She denies, fever, chills,
headache, light sensitivity, chest pain, shortness of breath,
abdominal pain, diarrhea, arthralgias, or myalgias. She does
reports nausea and vomiting over the last several weeks
associted with a new cancer medication, which has stopped since
stopping the medication.

Past Medical History:
Metastatic Right Breast Cancer with Mets to L4/L5
HTN
Hyperlipidemia
DM
Depression
Anxiety

Social History:
denies alcohol, drug use, Smoked [**12-14**] ppd x 20 yrs, quit 20 yrs
ago
Lives at senior living facility.

Family History:
NC

Physical Exam:
T 97.6 HR 60 BP 118/41 RR 12 O2 Sat 99% on 4L NC
Comfortable, not tachypneic
No scleral icterus, PERRL, EOMI, no nystagmus
No cerviacl LAD, JVP to mid neck
Left Axillary lymph node palpable
Heart regular with systolic murmur at LUSB, S2 present
Dullness and decreased breath sounds over right lower lung
fields, no rales or wheezes
Abd nondistended, good bowel sounds, soft, nontender
No peripheral edema, good pulses
Neuro exam with orientation to person, place, time. Able to do
simple calulations and counbt down from 20 by 4's. Able to name
objects without dificulty. Strength 5/5 throughout. Coordination
intact. Toes downgoing.

Pertinent Results:
WBC 6.2
N:80.5 L:14.5 M:3.4 E:1.0 Bas:0.6
Hgb 12.0
Hct 34.4
Plt 150
MCV 88
.
Na 141
K 4.8
Cl 105
HCO3 27
BUN 56
Creat 2.5
Gluc 147
Ca: 8.2 Mg: 1.9 P: 5.1 D
Anion Gap 9
.
CK: 54  MB: Notdone  Trop-*T*: 0.07
.
ALT: 17   AST: 28    Tbili: 0.4    Alb: 3.5
[**Doctor First Name **]: 96 Lip: 82
.
PT: 13.0  PTT: 23.2  INR: 1.1
.
Urine Benzos, Barbs, Opiates, Cocaine, Amphet, Mthdne Negative
.
U/A: Spec [**Last Name (un) **] 1.015, Sm blood, 500 prot, 1 RBC, 1 WBC, few
bact, 1 epi
.
Urine Cx: Pending
Blood Cx x 2: Pending
.
[**11-20**] Lower Extremity Ultrasound ([**First Name9 (NamePattern2) **] [**Location (un) **]): No evidence
for deep vein thrombosis in the bilateral lower extremities.
.
[**11-20**] CXR: Portable AP chest dated [**2134-11-20**] is compared to the
prior [**2134-10-28**].  There has been interval development of a large
right pleural [**Month/Day/Year 17838**], which obscures the right heart border.
There is compressive atelectasis of the right lower lung lobe.
The heart size remains enlarged.  The aorta and hilar contours
are stable.  There is no pulmonary vascular congestion.  The
left lung is clear. IMPRESSION:  Interval accumulation of a
large right pleural [**Month/Day/Year 17838**] with compressive atelectasis of the
right lung.
.
[**11-20**] Head CT: No evidence for hemorrhage, mass effect, or acute
ischemic changes.  Please note that MRI is more sensitive in the
detection of acute ischemia.

Discharge labs:

wbc 4.1 hgb 11.1 hct 30.7 plt 82

137 103 55
-----------< 82
4.3 27 2.4

LDH 173
Tbili 0.5
B12 407, folate 9.4, haptoglovin 101, ferritin 702, TRF 167

Brief Hospital Course:
76 y/o female with metastatic breast cancer presents with
altered mental staus, fever, right pleural [**Month/Day (4) 17838**].
.
1. Altered Mental Status: Now cleared. Possibly related to
medication effect (?premedication with blood products). Resolved
quickly while in ICU. No evidence of infection. Tox screen
negative. CT head without bleed or mass. No significant
metabolic alterations. Could be [**1-14**] hypoxia with pleural
[**Month/Day (2) 17838**] as well. We avoided benadryl and other sedating meds
while she was in the hospital.
.
2. Fever: Could have been due to blood tranfusion, though no
documentation of fever after blood products. Occurred several
hours after transfusions. No evidence of infection and fever
resolved the day after the blood transfusion without any
antibiotics given except for cefepime in ED. All cultures
negative.
.
3.Hypoxia: Resolved after pleurex was done. This was thought to
be due to malignant [**Month/Day (2) 17838**]. Pleurex in 50% of people will
cause an auto-pleurodesis. Daughter instructed how to drain the
device. PE ruled out with CT with gadollinium. MI ruled out with
3 sets of ces and no changes on ekg. Patient has anemia, but had
just been given transfusion so this was probably not
contributing.
.
4. Right Pleural [**Month/Day (2) **]: Chronic, related to breast CA.
Pleurex done.
.
5. Breast Cancer: Metastatic Right Breast cancer. Was not due
for pamidroate or arinesp at this time. We continued fentanyl
patch for pain with bony mets.
.
6. Diabetes Mellitus: NOt on oral meds or insulin at home. Was
on sliding scale here but only required minimal insulin. No
sugars above 200. On diabetic diet.
.
7. HTN: well controlled in hospital. Continued lisinopril and
dozaxosin.
.
8. Depression/Anxiety:
- cont fluoxetine
.
9. Thrombocytopenia- plts trended down from 150-->82. Heparin
was stopped on the third day and heparin dep ab were sent.
Pneumoboots were used instead. Was not on ppi or any other abx.
Scheduled appt in 2 days with Dr. [**Last Name (STitle) 79**] to have cbc checked.
.
10. Anemia- based on iron studies, this is most likely anemia of
chronic disease [**1-14**] breast cancer. Not due for aranesp.
Hemolysis labs negative. Guaic negative. Not iron deficient and
b12 and folate were normal. Will have repeat cbc in 2 days with
heme-onc doctor, Dr. [**Last Name (STitle) 79**].






Medications on Admission:
Lisinopril 40 mg QD
Doxazosin 8 mg QHS
Furosemide 10 mg QD
Fluoxetine 20 mg QD
Calcium and Vit D
Fentanyl patch 50 mcg Q72H

Discharge Medications:
1. Fentanyl 50 mcg/hr Patch 72HR Sig: One (1) Patch 72HR
Transdermal Q72H (every 72 hours).
Disp:*10 Patch 72HR(s)* Refills:*2*
2. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
Disp:*30 Capsule(s)* Refills:*2*
3. Doxazosin 4 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
Disp:*15 Tablet(s)* Refills:*2*
6. CALCIUM 500+D  Oral


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Primary
1. Pleural [**Hospital 17838**]
2. Altered mental status [**1-14**] medication

Secondary
1. Metastatic breast CA


Discharge Condition:
HD stable and afebrile.


Discharge Instructions:
You were admitted to the hospital because of altered mental
status and low O2 saturations. You were found to have a pleural
[**Month/Day (2) 17838**]. The pulmonary doctors [**Name5 (PTitle) 58770**] this [**Name5 (PTitle) 17838**].

Please take all medications as directed.

Please follow-up with all outpatient appointments.

Please return to the ED or seek medical advice if you experience
chest pain, fevers, shortness of breath or any other concerning
symptoms.

Followup Instructions:
Please follow-up with Dr. [**Last Name (STitle) 79**] to have your blood counts
checked. You have an appointment with Dr. [**Last Name (STitle) 79**] on Thursday
[**2134-11-25**] at 1 pm.
.
Please follow-up with your primary care doctor, Dr. [**Last Name (STitle) **]. You
have an appointment with her nurse practioner on Wednesday
[**12-1**] at 12:30 pm.
{'Secondary malignant neoplasm of pleura,Secondary malignant neoplasm of bone and bone marrow,Drug-induced delirium,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Antiallergic and antiemetic drugs causing adverse effects in therapeutic use,Personal history of malignant neoplasm of breast,Other and unspecified hyperlipidemia,Anticoagulants causing adverse effects in therapeutic use,Anemia in neoplastic disease,Dysthymic disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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: 76 y/o female with h/o metastatic breast cancer p/w altered
mental status (slurred speech, acting "funny" per daughter)
after receiving two units of blood during scheduled visit.
Parametics noted fever to 101.8, and she developed hypoxia to
the 70%'s on RA, which responded to 100% on a NRB.

MEDICAL HISTORY: Metastatic Right Breast Cancer with Mets to L4/L5
HTN
Hyperlipidemia
DM
Depression
Anxiety

MEDICATION ON ADMISSION: Lisinopril 40 mg QD
Doxazosin 8 mg QHS
Furosemide 10 mg QD
Fluoxetine 20 mg QD
Calcium and Vit D
Fentanyl patch 50 mcg Q72H

ALLERGIES: Penicillins / Percocet / Neurontin / Codeine

PHYSICAL EXAM: T 97.6 HR 60 BP 118/41 RR 12 O2 Sat 99% on 4L NC
Comfortable, not tachypneic
No scleral icterus, PERRL, EOMI, no nystagmus
No cerviacl LAD, JVP to mid neck
Left Axillary lymph node palpable
Heart regular with systolic murmur at LUSB, S2 present
Dullness and decreased breath sounds over right lower lung
fields, no rales or wheezes
Abd nondistended, good bowel sounds, soft, nontender
No peripheral edema, good pulses
Neuro exam with orientation to person, place, time. Able to do
simple calulations and counbt down from 20 by 4's. Able to name
objects without dificulty. Strength 5/5 throughout. Coordination
intact. Toes downgoing.

FAMILY HISTORY: NC

SOCIAL HISTORY: denies alcohol, drug use, Smoked [**12-14**] ppd x 20 yrs, quit 20 yrs
ago
Lives at senior living facility. 

### Response:
{'Secondary malignant neoplasm of pleura,Secondary malignant neoplasm of bone and bone marrow,Drug-induced delirium,Acute kidney failure, unspecified,Chronic kidney disease, unspecified,Antiallergic and antiemetic drugs causing adverse effects in therapeutic use,Personal history of malignant neoplasm of breast,Other and unspecified hyperlipidemia,Anticoagulants causing adverse effects in therapeutic use,Anemia in neoplastic disease,Dysthymic disorder,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
