CHIEF COMPLAINT: Transfer from OSH with new brain mass

PRESENT ILLNESS: 45yo man brought to OSH on [**3-15**] after being found down and
unresponsive at his sisters home.  At OSH, he was given narcan
with little response.  Thus, he was intubated and started on
pressors for hypotension.  He was found to be in DKA and ARF.
Pt transferred to [**Hospital1 18**] for management of brain mass found on CT
scan.

MEDICAL HISTORY: DMII
Hyperlipidemia
HTN
Polysubstance abuse, including IVDU.  Drug of choice is heroin,
but pt occasionally uses cocaine.  Reports having tried "every"
illicit substance.  Reports little ETOH use.
Smokes ~3ppd

MEDICATION ON ADMISSION: NPH 70u SC QAM/ 60u SC QPM (no sliding scale)
Enalapril 10mg
Lipitor 20mg
vicodin 2 pills q4 hrs
neurontin 300po tid
albuterol inh prn
advair [**Hospital1 **] (not compliant with)

ALLERGIES: Morphine / Demerol / Codeine

PHYSICAL EXAM: V: Tc 97.6 Tmax 99.1F HR 95 (80-113) BP 127/97 (123-153/58-97)
RR 28 96%RA 1730/1200
Gen: sleeping, but easily awakened, obese, occasionally agitated

FAMILY HISTORY: Mother alive with DM, HTN.  Father living--? medical problems

SOCIAL HISTORY: Divorced.  Has been living with sister in [**Name (NI) 14663**].  Has 3
children and grandchildren who he is trying to rebuild
relationship with.  Unemployed, but used to work as metal
worker.  Has had difficult time finding employment since leaving
prison.  Extensive illicit drug use.  Has been in detox multiple
times.  Prior incarceration for assault & battery (reportedly
for going after someone who tried to harm his sister).
Smokes 3 PPD smoker x many years.  Rarely uses alcholol.
Benign neoplasm of cerebral meninges,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Acute kidney failure, unspecified,Opioid abuse, unspecified,Benign neoplasm of adrenal gland,Polyneuropathy in diabetes,Poisoning by heroin,Accidental poisoning by heroin,Unspecified essential hypertension,Other and unspecified hyperlipidemia
Ben neo cerebr meninges,DMII neuro uncntrld,Acute kidney failure NOS,Opioid abuse-unspec,Benign neoplasm adrenal,Neuropathy in diabetes,Poisoning-heroin,Acc poison-heroin,Hypertension NOS,Hyperlipidemia NEC/NOS
Admission Date:  [**2168-3-17**]              Discharge Date:   [**2168-3-23**]

Date of Birth:  [**2122-11-24**]             Sex:   M

Service: MEDICINE

Allergies:
Morphine / Demerol / Codeine

Attending:[**First Name3 (LF) 30**]
Chief Complaint:
Transfer from OSH with new brain mass

Major Surgical or Invasive Procedure:
Intubated


History of Present Illness:
45yo man brought to OSH on [**3-15**] after being found down and
unresponsive at his sisters home.  At OSH, he was given narcan
with little response.  Thus, he was intubated and started on
pressors for hypotension.  He was found to be in DKA and ARF.
Pt transferred to [**Hospital1 18**] for management of brain mass found on CT
scan.

Past Medical History:
DMII
Hyperlipidemia
HTN
Polysubstance abuse, including IVDU.  Drug of choice is heroin,
but pt occasionally uses cocaine.  Reports having tried "every"
illicit substance.  Reports little ETOH use.
Smokes ~3ppd

Social History:
Divorced.  Has been living with sister in [**Name (NI) 14663**].  Has 3
children and grandchildren who he is trying to rebuild
relationship with.  Unemployed, but used to work as metal
worker.  Has had difficult time finding employment since leaving
prison.  Extensive illicit drug use.  Has been in detox multiple
times.  Prior incarceration for assault & battery (reportedly
for going after someone who tried to harm his sister).
Smokes 3 PPD smoker x many years.  Rarely uses alcholol.

Family History:
Mother alive with DM, HTN.  Father living--? medical problems

Physical Exam:
V: Tc 97.6 Tmax 99.1F HR 95 (80-113) BP 127/97 (123-153/58-97)
RR 28 96%RA 1730/1200
Gen: sleeping, but easily awakened, obese, occasionally agitated

HEENT: Abrasion on chin, PERRL, EOMI, anicteric sclera, OP
clear, MMM, no erythema, exudate or oral lesions
Neck: obese, no LAD
CV: distant S1, S2, RRR
Pulm: occasional insp and exp wheezes b/l
Abd: obese, somewhat firm, nontender
Ext: WWP, mult eccyhmoses and abrasions
Neuro: CN II-XII intact; [**6-18**] prx and distal UE and LE strength
b/l, sensation intact to light touch b/l, gait wnl
skin: multi abrasions and eccymoses on extremities. Right prox
UE with healed scar (from stab wound and gun shot wound and
police dog bite)


Pertinent Results:
Discharge Labs:
[**2168-3-17**] 09:12PM   WBC-11.7* RBC-4.59* HGB-13.4* HCT-38.3*
MCV-84 MCH-29.1 MCHC-34.8 RDW-15.3
[**2168-3-17**] 11:00PM   GLUCOSE-253* UREA N-39* CREAT-1.4* SODIUM-134
POTASSIUM-6.7* CHLORIDE-102 TOTAL CO2-23 ANION GAP-16
[**2168-3-17**] 09:12PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
.
Discharge Labs:
[**2168-3-21**] 09:30AM BLOOD WBC-8.3 RBC-4.63 Hgb-13.3* Hct-38.3*
MCV-83 MCH-28.7 MCHC-34.6 RDW-14.6 Plt Ct-223
[**2168-3-21**] 09:30AM BLOOD Glucose-162* UreaN-11 Creat-0.7 Na-136
K-4.3 Cl-99 HCO3-26 AnGap-15
[**2168-3-21**] 09:30AM BLOOD Phenyto-4.2*
.
.
Imaging:
[**3-17**] CXR: The endotracheal tube terminates 3.6 cm above the
carina. An NG tube terminates in the gastric fundus with the
sidehole above the GE junction. The heart size is at the upper
border of normal. There is mild interstitial edema. No sizable
effusions or consolidations are seen.
.
[**3-17**] CT Head w/o contrast: 4.1 x 3.8 x 5 cm left frontal mass
lesion arising from the left frontal skull/dura consistent with
the given history of meningioma. The mass and associated edema
cause 5 mm contralateral midline shift and slight compression of
the left lateral ventricle. No evidence of acute intracranial
hemorrhage.
.
[**3-18**]/ MR [**Name13 (STitle) 430**]: Extra-axial left frontal mass lesion resulting in
edema of the underlying left frontal lobe. The lesion is most
consistent with a meningioma as suggested in the given history.
Although considered much less likely, the differential diagnosis
also could include dural-based lymphoma, sarcoid or a
metastasis. However, there are no features suggestive of these
alternate diagnoses.
.
EKG: NSR 90, Nml axis. Nml intervals. Nml QT. No ST changes.
.
INDICATION: 45-year-old man with new brain mass of unclear
primary.
CT OF CHEST WITH IV CONTRAST: No parenchymal consolidation or
pleural effusion is noted. There are multiple small 2-mm nodules
at the right lung periphery that most likely represent airspace
disease. The appearances of heart, pericardium, and great
vessels are unremarkable. No pathologically enlarged
mediastinal, hilar, or axillary lymphadenopathy is seen.
CT OF ABDOMEN WITH IV CONTRAST: The liver, gallbladder, spleen,
pancreas, right adrenal gland, and right kidney are
unremarkable. There is a 2.3 x 1.5 cm nodule in the left adrenal
gland that does not have the appearance of the adenoma. There is
a small hypodense lesion within the upper pole of the left
kidney that cannot be further characterized. No pathologically
enlarged retroperitoneal or mesenteric lymphadenopathy is seen.
Loops of small and large bowel are unremarkable. No free air or
gas is seen within the abdomen.
CT OF PELVIS WITH IV CONTRAST: The rectum, sigmoid colon, the
urinary bladder, and distal ureters are unremarkable. The
prostate gland contains areas of calcification. No
pathologically enlarged inguinal or pelvic lymphadenopathy is
seen.
BONE WINDOWS: No concerning lytic or sclerotic lesion is seen.
Multiple sclerotic areas within the vertebral bodies of thoracic
vertebrae most likely represent degenerative change.
IMPRESSION:
1. A 2.3 x 1.5 cm nodule in the left adrenal gland that does not
have the appearance of adenoma. This nodule can be further
characterized by dedicated adrenal study.
2. Multiple 2-mm nodules in the right lung periphery most likely
represent airspace disease.
3. No pathologically enlarged lymphadenopathy is noted within
the chest, abdomen, and pelvis.
********ADDENDUM***********
After complete assesssment of the left adrenal nodule in the
non-contrast, post-contrast, and 3-minute delayed images, we
believe that this mass is most likely adenoma,especially the low
attenuation on pre-contrast images. No further study is
recommended for followup of left adrenal nodule.

Brief Hospital Course:

# Brain Mass:  The pt was found to have brain mass at OSH after
presenting with mental status changes/loss of consciousness in
the setting of heroin overdose and DKA.  Pt was transferred to
[**Hospital1 18**], where he was initially under the care of neurosurgery.
He underwent repeat head CT and MR, which revealed 4.1 x 3.8 x 5
cm left frontal mass w/ edema, causing 5 mm contralateral
midline shift and slight compression of the left lateral
ventricle.   Based on imaging, the lesion is thought to be most
consistent with a meningioma.  Although much less likely,
dural-based lymphoma, sarcoid or a metastasis are also possible.
 To evaluate for the latter, the pt underwent pan-CT, which was
unremarkable except for a left adrenal nodule that was thought
to be an adenoma.
Pt underwent HIV testing, which was negative for HIV
anti-bodies.  Pt reports never having shared needles in past.
Despite the size of the brain mass, the pt showed no neurologic
deficits.  He was treated with dexamethasone & phenytoin for
seizure prophylaxis.  Dr. [**Last Name (STitle) **] of neurosurgery plans to
perform brain biopsy (vs. craniotomy) on Mr. [**Known lastname 26495**] as an
outpatient (potentially on [**4-13**]).  Of note, the pt is
scheduled to have his phenytoin level checked as an
outpatient??????his level was 4.2 on [**2168-3-21**], at which time his dose
was increased from 200 to 300mg
.
# DM:  Pt reportedly has type II DM.  He presented to OSH with
DKA.  Etiology of his DKA was thought to be from poorly
controlled DM, particularly in the setting of heroin overdose.
Infectious workup was unrevealing.  Pt admits to having poorly
controlled DM prior to admission.  His FSBS often ran in
400-500??????s.  He was only on NPH at home without sliding scale.
Shortly after transfer to [**Hospital1 18**], the pt was transitioned off
insulin drip.  [**Last Name (un) **] was consulted.  They recommended
continuing NPH along with Humalog sliding scale.  These were
uptitrated as the pt had numerous FSBS in the 400 range.  Pt was
seen by nutrition and counseled about the importance of
maintaining a diabetic diet.  He is scheduled to follow-up with
Dr. [**Last Name (STitle) **] at [**Last Name (un) **] on [**2168-3-30**].  He was discharged on
humalog sliding scale and NPH.
.
# Substance abuse ?????? Pt has a h/o polysubstance abuse, starting
from his early teenage years.  He has also been incarcerated in
past for assault and battery.  His urine tox screen at OSH was
reportedly (+) for opiods and cocaine.  The pt reports abusing
opiods recently, though he had been clean for a period of time
last year.  Following release from prison last spring, he was
clean from about 6months.  However, he explains that he relapsed
because he could not find a job and had ??????too much time on [his]
hands.??????  Additionally, he states that he has chronic pain, which
has been attributed to LE neuropathy, for which he
self-medicates with heroin as well as vicodin.  Pt expresses the
wish to stop abusing illegal substances and clean-up his life.
He is interested in trying methadone.  [**Female First Name (un) 71304**] ([**Hospital1 18**] Addiction
Counselor) spoke w/ the pt and gave him numbers for addiction
resources and methadone clinics.  The pt was in contact with
some of these clinics prior to discharge.
.
#Anxiety/Pscyh issues: pt??????s psychiatric history is not
completely clear.  He has reportedly been on mood stabilizers in
the past.  However, he had not on any prior to hospitalization.
He was seen by psychiatry while hospitalized.  They felt that he
may have a mood disorder.  However, in the acute setting, with
the pt having just learned that of his brain tumor, they were
unable to discern whether his behavior was primarily from a mood
disorder or from response to the stressful situation.  Given
this, they felt that no mood stabilizers should be started, nor
any SSRI??????s, as these might activate a hypomanic episode.
Because the pt had significant anxiety as well as difficulty
sleeping they recommended Seroquel, at least as a temporizing
measure.  The pt seemed to respond well to this.  Once he is
clean of substance abuse, the pt may be referred to [**Hospital1 18**]
psychiatry, until then it is recommended that he seek counseling
and psychiatric care at [**Location (un) 14221**] Mental Health facility, where
he has gone in the past for care.  (Of note, [**Hospital1 18**]??????s psychiatry
department does not have a substance abuse program, thus, they
defer care of pt??????s with substance abuse problems until they are
clean).
.
# Neuropathy ?????? the pt reportedly has LE neuropathy which causes
a throbbing, tingling pain in both legs, but is worse in his
right leg.  The cause of the neuropahthy is unclear though it
could potentially be related to his DM.  He was on neurontin and
vicodin as an outpatient.  His dose of neurontin was increased
during this hospitalization and he was given oxycontin with
breakthrough oxycodone for his pain (instead of vicodin).  His
lower extremity motor and sensation exams were intact.  Because
of his pain, he began using a cane while hospitalized.
.
# HTN ??????  Pt was tapered off clonidine, which he had been on as
an outpatient; he was started on metoprolol; and his ACEi was
changed from enalapril to lisinopril.  His blood pressure on
discharge ranged from systolic of 120??????s to 140??????s.
.
# ARF ?????? on admission, the pt was in ARF from diabetic
ketoacidosis.  This resolved with IVF.  His creatinine peaked at
1.6 and trended down to 0.7 at the time of discharge.
.
# Skin Abrasions ?????? pt was noted to have multiple skin lesions [**Company **] he time of admission.  The question of Kaposi??????s sarcoma was
raised (prior to knowing the pt??????s HIV status).  He was seen by
dermatology, who felt the lesions were most c/w skin abrasions.


Medications on Admission:
NPH 70u SC QAM/ 60u SC QPM (no sliding scale)
Enalapril 10mg
Lipitor 20mg
vicodin 2 pills q4 hrs
neurontin 300po tid
albuterol inh prn
advair [**Hospital1 **] (not compliant with)


Discharge Medications:
1. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3)
Capsule PO TID (3 times a day) for 4 weeks.
Disp:*252 Capsule(s)* Refills:*1*
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed for headache: tylenol
3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q4H (every 4 hours) as needed for shortness of breath or
wheezing.
Disp:*1 inhaler* Refills:*2*
4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours).
Disp:*100 Tablet(s)* Refills:*1*
6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
7. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Humalog 100 unit/mL Solution Sig: Follow scale  Subcutaneous
brkfast, lunch, dinner, bedtime.
Disp:*5 vials* Refills:*2*
9. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1)
puff Inhalation twice a day.
Disp:*1 diskus* Refills:*2*
10. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
11. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR
Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily).
Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2*
12. OxyContin 10 mg Tablet Sustained Release 12HR Sig: Three (3)
Tablet Sustained Release 12HR PO twice a day for 7 days.
Disp:*42 Tablet Sustained Release 12HR(s)* Refills:*0*
13. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO every twelve
(12) hours: For anxiety/sleep.
Disp:*60 Tablet(s)* Refills:*2*
14. One Touch UltraSoft Lancets     Misc Sig: One (1) lancet
Miscellaneous Brkfast, lunch, dinner, bedtime.
Disp:*2 packages* Refills:*2*
15. One Touch Test Strip Holders     Misc Sig: One (1)
Miscellaneous Brkfast, lunch, dinner, bedtime.
Disp:*200 test strips* Refills:*2*
16. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifty
Six (56) units
units Subcutaneous Breakfast and Bedtime.
Disp:*3 vials* Refills:*2*
17. Insulin Syringe-Needle U-100 1 mL 29 x [**2-16**]   Syringe Sig:
One (1)  Miscellaneous with insulin.
Disp:*180 syringes* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Primary:
1.  Right Frontal Brain Mass NOS.
2.  Diabetic Ketoacidosis.
3.  Opioid Overdose.
4.  Polysubstance Abuse.
5.  2.3 x 1.5 cm nodule in the left adrenal gland (thought to be
adenoma by CT)
6.  Multiple 2-mm nodules in the right lung periphery
7.  Hypertension.
8.  Hyperlipidemia.


Discharge Condition:
Good, ambulating, sugars mostly in 200's.


Discharge Instructions:
You presented to the hospital with extremely high blood sugar
levels that (on top of your heroin use) caused you to lose
consciousness, have kidney failure, and breathing problems.
If you do not follow a diabetic diet and avoid sugars,
juices,and carbohydrate [**Doctor First Name **] foods, you may have this problem
again.  It is extremely important that you follow the diet and
give yourself the insulin.  Your sugars will also be elevated
because of the dexamethasone (steroid) that you are on for your
brain mass.
.
It is not yet clear what your brain mass is.  It will be
biopsied (small sample taken) to determine this.
.
Please follow-up with your appointments as scheduled and call if
you have any questions.
.
You are being started on many new medications.
For you diabetes:
-NPH 56 units at breakfast and at dinner time.
-Humalog sliding scale (please follow the scale given)
.
For seizure prevention (from your brain mass):
-Dexamethasone
-Phenytoin
.
For your blood pressure:
-Lisinopril
-Toprol XL
.
For your anxiety and sleep:
-Quetiapine (ie, Seroquel)
.
For your leg pain:
-Neurontin (at a higher dose)
-Oxycodone
-Tylenol
.
For your high cholesterol:
-Lipitor
.
Please do not take your enalapril or metformin.
If necessary, take your inhalers.

Followup Instructions:
Please have your blood drawn Monday morning (as early as
possible) at in the [**Company 191**] ([**Hospital3 **]) clinic on the
[**Hospital Ward Name 516**] of [**Hospital3 **].  Ask in the lobby for directions if
necessary. The laboratory opens at 7:30am.  This is to check
your Phenytoin level.
.
You have an appointment with your new primary care doctor,
DR. [**First Name8 (NamePattern2) **] [**Name (STitle) 815**] on Tuesday [**2168-3-29**] at 2:30pm.
Phone:[**Telephone/Fax (1) 250**].  The appointment will be in the [**Hospital **] clinic in the Sharpiro building on the [**Hospital Ward Name 516**] of
[**Hospital3 **].
.
You have an appointment with your new diabetes doctor, DR. [**Last Name (STitle) **],
at [**Last Name (un) **] in the adult diabetes clinic next Wednesday [**2168-3-30**]
at 2:30pm.  If you have questions, please call ([**Telephone/Fax (1) 29714**].
.
You have surgery scheduled with Dr. [**Last Name (STitle) 9904**] of Neurosurgery on
[**2168-4-13**].  [**Doctor First Name **] from the neurosurgery department
will call you this Friday to give you a pre-op appointment
sometime before your surgery.  If you have any questions about
this, please call ([**Telephone/Fax (1) 26566**].
.
Please follow-up at the [**Hospital6 71305**] #[**Telephone/Fax (1) 70428**].  You
should seek mental health care there until you can be seen by
psychiatry at [**Hospital1 **].
.
Please follow-up with the methadone clinic that you have
contact[**Name (NI) **].
{'Benign neoplasm of cerebral meninges,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Acute kidney failure, unspecified,Opioid abuse, unspecified,Benign neoplasm of adrenal gland,Polyneuropathy in diabetes,Poisoning by heroin,Accidental poisoning by heroin,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}


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: Transfer from OSH with new brain mass

PRESENT ILLNESS: 45yo man brought to OSH on [**3-15**] after being found down and
unresponsive at his sisters home.  At OSH, he was given narcan
with little response.  Thus, he was intubated and started on
pressors for hypotension.  He was found to be in DKA and ARF.
Pt transferred to [**Hospital1 18**] for management of brain mass found on CT
scan.

MEDICAL HISTORY: DMII
Hyperlipidemia
HTN
Polysubstance abuse, including IVDU.  Drug of choice is heroin,
but pt occasionally uses cocaine.  Reports having tried "every"
illicit substance.  Reports little ETOH use.
Smokes ~3ppd

MEDICATION ON ADMISSION: NPH 70u SC QAM/ 60u SC QPM (no sliding scale)
Enalapril 10mg
Lipitor 20mg
vicodin 2 pills q4 hrs
neurontin 300po tid
albuterol inh prn
advair [**Hospital1 **] (not compliant with)

ALLERGIES: Morphine / Demerol / Codeine

PHYSICAL EXAM: V: Tc 97.6 Tmax 99.1F HR 95 (80-113) BP 127/97 (123-153/58-97)
RR 28 96%RA 1730/1200
Gen: sleeping, but easily awakened, obese, occasionally agitated

FAMILY HISTORY: Mother alive with DM, HTN.  Father living--? medical problems

SOCIAL HISTORY: Divorced.  Has been living with sister in [**Name (NI) 14663**].  Has 3
children and grandchildren who he is trying to rebuild
relationship with.  Unemployed, but used to work as metal
worker.  Has had difficult time finding employment since leaving
prison.  Extensive illicit drug use.  Has been in detox multiple
times.  Prior incarceration for assault & battery (reportedly
for going after someone who tried to harm his sister).
Smokes 3 PPD smoker x many years.  Rarely uses alcholol. 

### Response:
{'Benign neoplasm of cerebral meninges,Diabetes with neurological manifestations, type II or unspecified type, uncontrolled,Acute kidney failure, unspecified,Opioid abuse, unspecified,Benign neoplasm of adrenal gland,Polyneuropathy in diabetes,Poisoning by heroin,Accidental poisoning by heroin,Unspecified essential hypertension,Other and unspecified hyperlipidemia'}
