CHIEF COMPLAINT: weakness, dizziness

PRESENT ILLNESS: Mr. [**Known lastname **] is a 79 yo M with h/o stage IIIa NSCLC on chemo
(Alimta), CAD s/p BMS to LAD on ASA/Plavix, and AFib on Coumadin
who presented to the ED today for weakness. Pt reports that he
received a 1/2 dose of chemotherapy (Alimta + neulasta) 3 weeks
ago and has in general been feeling weak since then. It had been
decided to stop this secondary to toxicity (likely
pancytopenia).

MEDICAL HISTORY: 1. CAD s/p NSTEMI ([**11-19**]) s/p LAD BMS
2. RUL NSCL Ca
- FDG-avid right paratracheal, tracheobronchial and precarinal
nodes (dx'd [**2113**])
- completed 2 cycles of cisplatin & etoposide. Second cycle dose
reduced due to pancytopenia with the first cycle.
- completed radiation [**2115-1-3**].
- started cycle 1 of alimta on [**2115-7-30**]
3. GERD
4. Hypertension
5. Hyperlipidemia
6. Gout
7. Skin Cancer
8. s/p Tonsillectomy

MEDICATION ON ADMISSION: allopurinol 100 mg daily
atorvastatin 80 mg daily
clopidogrel 75 mg daily
folic acid 1 mg daily
metoprolol 50 mg [**Hospital1 **] (recently halved since starting chemo)
pantoprazole 40 mg daily
compazine 5 mg 1-2 tabs q6h PRN nausea
warfarin 2.5 mg 1-2 tabs daily
ASA 325 mg daily
calcium-Vitamin D
docusate sodium 100 mg [**Hospital1 **]
melatonin 5 mg qhs
psyllium husk

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission PE:
Vitals: T:afebrile BP:127/76 P:91  R: 18 O2: 92%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, ecchymosis around L eye oropharynx
clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffusely rhonchorus, RUL very decreased breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, pulsatile descending aorta ~ 5cm
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.  L knee with pre-patellar effusion, ttp, diffuse
echymoses throughout le
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: Two brothers died of MIs, one who was in his 50s and one who was
in his 60s when they died.
Sister - died of [**Name (NI) 4278**] Lymphoma in her 40s

SOCIAL HISTORY: Home: Married, with 5 adult children
Occupation: Retired civil engineer
EtOH: former heavy alcohol use, quit 13 years ago
Drugs: Denies
Tobacco: former smoker, quit 30 years ago
Acute posthemorrhagic anemia,Malignant neoplasm of upper lobe, bronchus or lung,Contusion of lower leg,Effusion of joint, lower leg,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Abnormal coagulation profile,Unspecified essential hypertension,Fall from other slipping, tripping, or stumbling,Esophageal reflux,Other and unspecified hyperlipidemia,Old myocardial infarction,Personal history of antineoplastic chemotherapy,Long-term (current) use of anticoagulants,Personal history of other malignant neoplasm of skin,Percutaneous transluminal coronary angioplasty status,Gout, unspecified
Ac posthemorrhag anemia,Mal neo upper lobe lung,Contusion of lower leg,Joint effusion-l/leg,Atrial fibrillation,Crnry athrscl natve vssl,Abnrml coagultion prfile,Hypertension NOS,Fall from slipping NEC,Esophageal reflux,Hyperlipidemia NEC/NOS,Old myocardial infarct,Hx antineoplastic chemo,Long-term use anticoagul,Hx-skin malignancy NEC,Status-post ptca,Gout NOS
Admission Date:  [**2118-5-31**]              Discharge Date:   [**2118-6-3**]

Date of Birth:  [**2038-11-15**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3016**]
Chief Complaint:
weakness, dizziness


Major Surgical or Invasive Procedure:
none

History of Present Illness:
Mr. [**Known lastname **] is a 79 yo M with h/o stage IIIa NSCLC on chemo
(Alimta), CAD s/p BMS to LAD on ASA/Plavix, and AFib on Coumadin
who presented to the ED today for weakness. Pt reports that he
received a 1/2 dose of chemotherapy (Alimta + neulasta) 3 weeks
ago and has in general been feeling weak since then. It had been
decided to stop this secondary to toxicity (likely
pancytopenia).

His son, who is accompanying him today, reports that for the
past 3 days, he has been feeling more weak and was unable to
transfer him from the bed to the bathroom. Patient also reports
feeling significantly more dizzy upon standing then usual. He
notes having lost about 9 lbs in the past 3 weeks secondary to
chemotherapy and decreased appetitite. Pt reports he was coming
in for a pre-scheduled appointment today, but when his son
[**Name (NI) 20227**]'t get him into the car secondary to weakness/dizziness,
he called his oncologist who instructed him to come in through
the ED.
.
Of note, pt fell this past Friday on the way into his apartment.
He did not hit his head and reported he "plopped" down on his
bottom. Given the structure of the stairwell, he was unable to
move his foot and twisted his L knee that is painful upon
movement.
.
In the ED, initial VS were: 98.0 110/65 85 18 96% 4L NC. Exam
notable for guaiac + yellow stool. EKG unremarkable ( 88 bpm,
normal axis, normal intervals, TWI in V2 (old)). Labs notable
for Hgb/HCT 6.9/22.5 (baseline 27-30), INR 11.8, Cr 1.6
(baseline). Bedside echo showed no pericardial effusion. CXR
without acute process and knee x-ray showed moderate
suprapatellar joint effusion. GI recommended that OMED consult
them on floor. Patient was ordered for 2 units RBC and 2 units
FFP. He received vitamin K 10mg IV in ED and FFP but has not yet
received pRBC. Vitals prior to transfer: 138/88 80 100% RA.
.
On arrival to the MICU, pt is mentating well, HD stable.
.
ROS:  denies hematemasis, melena or hematochezia.  Denies
abdominal pain or lower extremity weakness.


Past Medical History:
1. CAD s/p NSTEMI ([**11-19**]) s/p LAD BMS
2. RUL NSCL Ca
- FDG-avid right paratracheal, tracheobronchial and precarinal
nodes (dx'd [**2113**])
- completed 2 cycles of cisplatin & etoposide. Second cycle dose
reduced due to pancytopenia with the first cycle.
- completed radiation [**2115-1-3**].
- started cycle 1 of alimta on [**2115-7-30**]
3. GERD
4. Hypertension
5. Hyperlipidemia
6. Gout
7. Skin Cancer
8. s/p Tonsillectomy


Social History:
Home: Married, with 5 adult children
Occupation: Retired civil engineer
EtOH: former heavy alcohol use, quit 13 years ago
Drugs: Denies
Tobacco: former smoker, quit 30 years ago


Family History:
Two brothers died of MIs, one who was in his 50s and one who was
in his 60s when they died.
Sister - died of [**Name (NI) 4278**] Lymphoma in her 40s

Physical Exam:
Admission PE:
Vitals: T:afebrile BP:127/76 P:91  R: 18 O2: 92%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, ecchymosis around L eye oropharynx
clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffusely rhonchorus, RUL very decreased breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, pulsatile descending aorta ~ 5cm
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.  L knee with pre-patellar effusion, ttp, diffuse
echymoses throughout le
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

Discharge PE:
VS: Tm 98.6 126-152/70-86 80-108 18-20 92-94RA
8h: -352 / 60PO
24h: -880 / 700PO
General: Alert, oriented, no acute distress, + ecchymosis
underneath L eye
HEENT: Sclera anicteric, MMM, EOMI, PERRL
Neck: supple
CV: irregular rhythm, S1 S2
Lungs: course breath sounds throughout, otherwise good air
movement
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. L knee effusion improving, non tender to palpation, no
increased warmth or erythema, no pain with knee flexion or
extension, + large ecchymosis on the posterior L thigh with
extension to the L upper thigh, entire area nontender to
palpation --> bruise continuing to fade
Neuro: moving all extremities spontaneously, normal muscle
strength and sensation throughout


Pertinent Results:
Admission labs:
[**2118-5-31**] 05:26PM   LD(LDH)-386* TOT BILI-0.8
[**2118-5-31**] 05:26PM   IRON-49
[**2118-5-31**] 05:26PM   calTIBC-216* HAPTOGLOB-119 FERRITIN-1365*
TRF-166*
[**2118-5-31**] 05:26PM   HCT-18.0*
[**2118-5-31**] 05:26PM   PT-25.9* PTT-35.3 INR(PT)-2.5*
[**2118-5-31**] 05:26PM   RET AUT-0.8*
[**2118-5-31**] 12:12PM   GLUCOSE-108* UREA N-32* CREAT-1.6* SODIUM-139
POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
[**2118-5-31**] 12:12PM   estGFR-Using this
[**2118-5-31**] 12:12PM   WBC-9.2 RBC-2.34*# HGB-6.9*# HCT-22.5*#
MCV-96 MCH-29.6 MCHC-30.8* RDW-15.6*
[**2118-5-31**] 12:12PM   NEUTS-86.8* LYMPHS-7.9* MONOS-4.9 EOS-0.2
BASOS-0.2
[**2118-5-31**] 12:12PM   PLT COUNT-317#
[**2118-5-31**] 12:12PM   PT-113.9* PTT-65.6* INR(PT)-11.8*

[**2118-5-31**]
blood cx X2: Pending

[**2118-5-31**]
Non contrast abdomen CT (wet read)
1. No evidence of bleed in the abdomen/pelvis to explain the hct
drop.
2. Small pericardial effusion. Extensive coronary
calcifications. Post
radiation fibrotic changes in the right lower lobe, small
gallstone.
3. Extensive atherosclerotic calcification of the abdominal
aorta and visceral branches, with aneurysmal dilation of long
segment of the infrarenal aorta measuring 3.8 cm, previously 3.3
cm. Ectasia of the right common iliac artery, 1.8cm. Left renal
artery origin stenosis with mild post stenotic dilation.

CXR [**2118-5-31**]
Post-treatment changes seen in the right upper lung.  No
evidence
of acute cardiopulmonary process.

EKG: 88 bpm, normal axis, normal intervals, TWI in V2 (old)

Leg ultrasound
CONCLUSION:
Suprapatellar hematoma predominantly laterally in the left knee.

Contralateral right knee hypoechoic oval-shaped lesion with a
discrete tail.  Peripheral nerve sheath tumor is considered.
MRI suggested.

Discharge labs:

[**2118-6-3**] 07:05AM BLOOD WBC-7.5 RBC-3.03* Hgb-9.4* Hct-28.2*
MCV-93 MCH-31.0 MCHC-33.3 RDW-16.7* Plt Ct-251
[**2118-6-3**] 07:05AM BLOOD Neuts-85.2* Lymphs-7.1* Monos-7.0 Eos-0.6
Baso-0.1
[**2118-6-3**] 07:05AM BLOOD PT-15.2* PTT-31.3 INR(PT)-1.4*
[**2118-6-3**] 07:05AM BLOOD Glucose-78 UreaN-25* Creat-1.2 Na-140
K-4.1 Cl-101 HCO3-34* AnGap-9
[**2118-6-2**] 06:50AM BLOOD LD(LDH)-434*
[**2118-6-3**] 07:05AM BLOOD Calcium-8.7 Phos-2.6* Mg-2.5

Brief Hospital Course:
Mr. [**Known lastname **] is 79M with h/o stage IIIa NSCLC on chemo (Alimta),
CAD s/p BMS to LAD in [**2113**] on ASA/Plavix, and AFib on Coumadin
who initially presented to ED for weakness, found to have crit
of 18 and supratherapeutic INR, admitted to the MICU, with work
up for acute bleeding negative thus far and s/p 3U PRBCs with
appropriate bump in crit.

# anemia: The patient initially presented with new crit drop in
the setting of chemotherapy about three weeks ago.  It is
possible that this new anemia is related to chemo, however,
given the acute nature of drop, a more acute process is likely.
 Hemolysis labs were also normal.  The patient also had CT scan
that was negative for retroperitoneal bleed.  Of note, he was
noted to have guaic positive stools.  Specifically, in the
setting of a recent fall and having a supratherapeutic INR, more
likely that there was some bleeding into his L thigh, especially
given the overlying area of ecchymosis.  An ultrasound was done
that showed evidence of small hematoma.  The patient received
three units PRBC in total during this admission, and upon
discharge, the patient's crits were stable.

# dizziness/lethargy: The patient reported that he was feeling
dizziness with standing in the days preceding presentation.
Likely that he was symptomatic from his anemia.  While on the
floor, the patient reported feeling well and denied having any
dizziness.  He was discharge home with PT.

# L knee effusion: The patient was found to have L knee effusion
on plain film, likely in the setting of recent fall.  His knee
was monitored clinically, and on repeat ultrasound, the effusion
had resolved.

# CAD s/p BMS: The patient has history of CAD s/p BMS in [**2113**],
being maintained on ASA/Plavix.  His ASA and Plavix were
initially held.  After talking with his outpatient cardiologist,
it was decided to hold his Plavix indefinitely.  His metoprolol
and ASA were both restarted.  The patient was also continued on
his atorvastatin 80 mg daily.

# atrial fibrillation: The patient has a CHADS of 2.  His
coumadin was held initially given his supratherapeutic INR.
After getting FFP and Vitamin K, the patient's INR normalized.
Prior to discharge he was restarted on coumadin 2.5 mg daily. He
should have his INR checked on [**Last Name (LF) 766**], [**6-6**].  The patient's
rate was controlled with metoprolol 50 mg [**Hospital1 **].

# supratherapeutic INR: The patient was to found to have an INR
of 11.8 on admission. This was likely in the setting of
decreased PO intake in recent days due to his chemotherapy.  He
was given Vitamin K and FFP and his INR normalized.  The patient
was restarted on coumadin 2.5 mg upon discharge.

# NSCLC: The patient is s/p most recent treatment with neulasta
and alimta.  He was continued on compazine PRN.

Transitional Issues:
- ? peripheral nerve sheath tumor:  The patient was incidentally
found to have a hypoechoic lesion on his R knee.  As per
radiology, they suggested an MRI to further characterize the
lesion.

- The patient should have his INR checked on [**Hospital1 766**], [**2118-6-6**]
with results sent to Dr. [**Last Name (STitle) **] Address: [**Street Address(2) 80228**],
[**Location (un) **],[**Numeric Identifier 80229**] Phone: [**Telephone/Fax (1) 80227**] Fax: [**Telephone/Fax (1) 80230**]

Medications on Admission:
allopurinol 100 mg daily
atorvastatin 80 mg daily
clopidogrel 75 mg daily
folic acid 1 mg daily
metoprolol 50 mg [**Hospital1 **] (recently halved since starting chemo)
pantoprazole 40 mg daily
compazine 5 mg 1-2 tabs q6h PRN nausea
warfarin 2.5 mg 1-2 tabs daily
ASA 325 mg daily
calcium-Vitamin D
docusate sodium 100 mg [**Hospital1 **]
melatonin 5 mg qhs
psyllium husk

Discharge Medications:
1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. prochlorperazine maleate 5 mg Tablet Sig: 1-2 Tablets PO Q6H
(every 6 hours) as needed for nausea.
7. warfarin 2.5 mg Tablet Sig: 1-2 Tablets PO once a day.
8. aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day.
9. Calcium-Vitamin D  Oral
10. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a
day.
11. melatonin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
12. psyllium husk  Oral
13. Outpatient Lab Work
Please check INR on [**2118-6-6**] and please send results to Dr.
[**Last Name (STitle) **]

Address: [**Street Address(2) 80228**], [**Location (un) **],[**Numeric Identifier 80229**]
Phone: [**Telephone/Fax (1) 80227**]
Fax: [**Telephone/Fax (1) 80230**]


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
primary diagnosis:
anemia
lung cancer


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


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you while you were hospitalized
at [**Hospital1 18**].  You were admitted to the hospital because you were
weak and you were found to have a very low blood count and a
very high INR.  You were initially in the intensive care unit
and needed to get blood transfusions.  We did not find any
source of your bleeding, but we think it could have happened
when you fell.

We made the following changes to his medications:
INCREASE pantoprazole to 40 mg by mouth twice daily
STOP Plavix

Followup Instructions:
PCP [**Name Initial (PRE) **]:Thursday, [**6-9**] at 2pm
With:[**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 80231**],MD
Address: [**Street Address(2) 80228**], [**Location (un) **],[**Numeric Identifier 80229**]
Phone: [**Telephone/Fax (1) 80227**]

Hematology/Oncololgy:PENDING
With: Drs. [**Name5 (PTitle) **]/[**Doctor Last Name 10351**]
Phone:[**Telephone/Fax (1) 6568**]
**We are working on a follow up appointment with Drs.
[**Name5 (PTitle) **]/[**Doctor Last Name 10351**] in the next week. You will be called at home
with the appointment. If you have not heard within 2 business
days or have questions, please call [**Telephone/Fax (1) 6568**].

Department: NEUROLOGY
When: THURSDAY [**2118-9-1**] at 11:30 AM
With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name 11625**] [**Telephone/Fax (1) 558**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage


                             [**Name6 (MD) **] [**Name8 (MD) 831**] MD, [**Doctor First Name 3018**]

Completed by:[**2118-6-4**]
{'Acute posthemorrhagic anemia,Malignant neoplasm of upper lobe, bronchus or lung,Contusion of lower leg,Effusion of joint, lower leg,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Abnormal coagulation profile,Unspecified essential hypertension,Fall from other slipping, tripping, or stumbling,Esophageal reflux,Other and unspecified hyperlipidemia,Old myocardial infarction,Personal history of antineoplastic chemotherapy,Long-term (current) use of anticoagulants,Personal history of other malignant neoplasm of skin,Percutaneous transluminal coronary angioplasty status,Gout, 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: weakness, dizziness

PRESENT ILLNESS: Mr. [**Known lastname **] is a 79 yo M with h/o stage IIIa NSCLC on chemo
(Alimta), CAD s/p BMS to LAD on ASA/Plavix, and AFib on Coumadin
who presented to the ED today for weakness. Pt reports that he
received a 1/2 dose of chemotherapy (Alimta + neulasta) 3 weeks
ago and has in general been feeling weak since then. It had been
decided to stop this secondary to toxicity (likely
pancytopenia).

MEDICAL HISTORY: 1. CAD s/p NSTEMI ([**11-19**]) s/p LAD BMS
2. RUL NSCL Ca
- FDG-avid right paratracheal, tracheobronchial and precarinal
nodes (dx'd [**2113**])
- completed 2 cycles of cisplatin & etoposide. Second cycle dose
reduced due to pancytopenia with the first cycle.
- completed radiation [**2115-1-3**].
- started cycle 1 of alimta on [**2115-7-30**]
3. GERD
4. Hypertension
5. Hyperlipidemia
6. Gout
7. Skin Cancer
8. s/p Tonsillectomy

MEDICATION ON ADMISSION: allopurinol 100 mg daily
atorvastatin 80 mg daily
clopidogrel 75 mg daily
folic acid 1 mg daily
metoprolol 50 mg [**Hospital1 **] (recently halved since starting chemo)
pantoprazole 40 mg daily
compazine 5 mg 1-2 tabs q6h PRN nausea
warfarin 2.5 mg 1-2 tabs daily
ASA 325 mg daily
calcium-Vitamin D
docusate sodium 100 mg [**Hospital1 **]
melatonin 5 mg qhs
psyllium husk

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Admission PE:
Vitals: T:afebrile BP:127/76 P:91  R: 18 O2: 92%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, ecchymosis around L eye oropharynx
clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: diffusely rhonchorus, RUL very decreased breath sounds
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, pulsatile descending aorta ~ 5cm
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.  L knee with pre-patellar effusion, ttp, diffuse
echymoses throughout le
Neuro: CNII-XII intact, 5/5 strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact

FAMILY HISTORY: Two brothers died of MIs, one who was in his 50s and one who was
in his 60s when they died.
Sister - died of [**Name (NI) 4278**] Lymphoma in her 40s

SOCIAL HISTORY: Home: Married, with 5 adult children
Occupation: Retired civil engineer
EtOH: former heavy alcohol use, quit 13 years ago
Drugs: Denies
Tobacco: former smoker, quit 30 years ago 

### Response:
{'Acute posthemorrhagic anemia,Malignant neoplasm of upper lobe, bronchus or lung,Contusion of lower leg,Effusion of joint, lower leg,Atrial fibrillation,Coronary atherosclerosis of native coronary artery,Abnormal coagulation profile,Unspecified essential hypertension,Fall from other slipping, tripping, or stumbling,Esophageal reflux,Other and unspecified hyperlipidemia,Old myocardial infarction,Personal history of antineoplastic chemotherapy,Long-term (current) use of anticoagulants,Personal history of other malignant neoplasm of skin,Percutaneous transluminal coronary angioplasty status,Gout, unspecified'}
