CHIEF COMPLAINT: Right facial droop, left face and arm numbness

PRESENT ILLNESS: Patient is a 56 year old right handed female with pastmedical
history of breast cancer 10-15 years ago, pleural effusion, DVT
and PE who presented to [**Hospital1 18**] on [**2114-9-17**] for evaluation of left
face and arm numbness and right facial
droop.

MEDICAL HISTORY: 1. Breast cancer status post right mastectomy and chemotherapy
15
years ago
2. Pleural effusion
3. DVT and PE 7 years ago

MEDICATION ON ADMISSION: 1. Coumadin 10 mg po qHS
2. Arimidex 1 mg po qd
3. Lasix 40 mg po qd
4. Potassium KCL

ALLERGIES: Percodan / Percocet / Cerebyx / Phenytoin

PHYSICAL EXAM: Tm: 99.0  Tc: 98.4  BP: 97/69 (97-150/66-87)  HR: 78 (76-140s)
Vent AC 600x12 ([**11-14**]) with FiO2 0.40
Gen: WD/WN, sitting up in bed comfortably, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Decreased breath sounds over right hemithorax. Coarse
breath sounds on left. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: Mother with stroke in her 70s. Sister with history of breast
cancer, died from brain mets.

SOCIAL HISTORY: Married, with 3 children. Lives with husband,daughter, son and
grandchildren. She is a homemaker. No tobacco,valcohol, drug
use.
Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Intracerebral hemorrhage,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Sinoatrial node dysfunction,Personal history of malignant neoplasm of breast,Anemia, unspecified,Conjunctivitis, unspecified,Personal history of venous thrombosis and embolism
Sec mal neo brain/spine,Secondary malig neo lung,Intracerebral hemorrhage,Acute respiratry failure,Meth sus pneum d/t Staph,Protein-cal malnutr NOS,Urin tract infection NOS,Sinoatrial node dysfunct,Hx of breast malignancy,Anemia NOS,Conjunctivitis NOS,Hx-ven thrombosis/embols
Admission Date:  [**2114-9-17**]              Discharge Date:   [**2114-10-15**]

Date of Birth:  [**2057-11-29**]             Sex:   F

Service: NEUROLOGY

Allergies:
Percodan / Percocet / Cerebyx / Phenytoin

Attending:[**First Name3 (LF) 618**]
Chief Complaint:
Right facial droop, left face and arm numbness


Major Surgical or Invasive Procedure:
-Status post tracheostomy
-Status post PEG
-Status post dental extraction of 3 teeth

History of Present Illness:
Patient is a 56 year old right handed female with pastmedical
history of breast cancer 10-15 years ago, pleural effusion, DVT
and PE who presented to [**Hospital1 18**] on [**2114-9-17**] for evaluation of left
face and arm numbness and right facial
droop.

Patient was in her usual state of health until about one week
ago when she reports having "the flu". She then had several days
of nausea and vomiting and malaise. Two days prior to admission
her daughter her right eye was "droopy". On evening prior to
admission, her whole right face was drooped. Then, on morning of
admission, she awoke at 6am with left arm and face numbness.
This
was associated with a vertiginous sensation as well. Daughter
noted that her speech was slurred. No nausea or vomiting,
headaches, blurry vision, double vision, lightheadedness,
paresthesias, weakness or incoordination. She went to [**Hospital1 56809**] for evaluation. Head CT there with pontine
hemorrhage.

Transferred to [**Hospital1 18**] for further evaluation. On initial arrival,
heart rate 70-80s and sinus, BP 138/90, oxygen 93/RA and 98%/2L.
While in ED, she received 2 units of FFP. However, she reported
that her symptoms worsened. She felt that her speech was more
slurred, she was having difficulty managing her saliva and
secretions, and had vertical diplopia. Repeat head CT showed
interval worsening in the size of her bleed, from 8-12 mm. While
in ED, she went into atrial fibrillation with rapid ventricular
response; Diltiazem 20mg IV resulted in rate control.

After arrival to the neurology floor, she continued having
difficulty managing her secretions. On several occasions, her
oxygen saturation drooped into the 80s. She was transferred to
the ICU for closer monitoring. She received Factor VIIa. She was
electively intubated in early am on [**9-18**].


Past Medical History:
1. Breast cancer status post right mastectomy and chemotherapy
15
years ago
2. Pleural effusion
3. DVT and PE 7 years ago


Social History:
Married, with 3 children. Lives with husband,daughter, son and
grandchildren. She is a homemaker. No tobacco,valcohol, drug
use.


Family History:
Mother with stroke in her 70s. Sister with history of breast
cancer, died from brain mets.


Physical Exam:
Tm: 99.0  Tc: 98.4  BP: 97/69 (97-150/66-87)  HR: 78 (76-140s)
Vent AC 600x12 ([**11-14**]) with FiO2 0.40
Gen: WD/WN, sitting up in bed comfortably, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Decreased breath sounds over right hemithorax. Coarse
breath sounds on left. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

Neuro:
Mental status: Sleepy but arousable. Cooperative with exam. Able
to follow simple midline and appendicular commands. Able to make
needs known by writing on pad of paper.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 2.5 to 2 mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: On neutral gaze, eyes are deviated to the left with
right beating nystagmus. On right lateral gaze, eyes do not
cross midline. Upgaze impaired with vertical nystagmus, some
rotatory component.
V, VII: Unable to fully assess with ETT but appears to have
right UMN palsy. Decreased sensation left hemiface.
VIII: Unable to fully assess.
IX, X: Unable to assess with ETT.
[**Doctor First Name 81**]: Shoulder shrug strong.
XII: Tongue to right around ETT.

Motor: Normal bulk and tone. No abnormal movements or tremors.
Strength full.

Sensation: Decreased to light touch over left hemibody.

Reflexes: B T Br Pa Ac
Right     1 1 1  0  0
Left      1 1 1  0  0

Grasp reflex absent. Right toe upgoing. Left toe equivocal.

Coordination: Slowed but accurate on left FNF. Dysmetric right
FNF.

Gait: Unable to assess.


Pertinent Results:
[**2114-9-17**] 12:20PM   WBC-8.1 RBC-4.15* HGB-12.1 HCT-35.0* MCV-84
MCH-29.1 MCHC-34.5 RDW-14.1
[**2114-9-17**] 12:20PM   NEUTS-74.4* LYMPHS-21.2 MONOS-3.5 EOS-0.5
BASOS-0.5
[**2114-9-17**] 12:20PM   PLT COUNT-258
[**2114-9-17**] 12:20PM   PT-18.9* PTT-29.3 INR(PT)-2.2
[**2114-9-17**] 12:20PM   GLUCOSE-107* UREA N-15 CREAT-0.6 SODIUM-141
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-32* ANION GAP-12
[**2114-9-17**] 12:20PM   CALCIUM-9.1 PHOSPHATE-3.5 MAGNESIUM-1.9

-----
CT head w/o contrast [**2114-9-17**]: A rounded hyperdensity is again
noted in the right pontomedullary junction. This is slightly
larger than on the prior study, now measuring 12 x 11 mm in
size. In addition, this extends slightly more superiorly into
the pons and slightly more inferiorly into the medulla. No new
areas of hemorrhage are identified. Streak artifact is again
identified within this area which limits evaluation of
surrounding edema. There is no mass effect or hydrocephalus.
[**Doctor Last Name **]-white matter differentiation remains preserved. The osseous
structures are normal.
-----
MRI head w/o contrast and MRA head [**2114-9-17**]: Multiplanar T1 and
T2W images of the brain was obtained. MRA of the Circle of
[**Location (un) 431**] was performed. Correlation is made to the CT examination
dated [**2114-9-17**]. As seen on the CT examination, there is
a small 1 cm lesion of increased T2 signal along the right
pontomedullary junction which demonstrates magnetic
susceptibility on gradient echo images suggestive of a small
cavernoma or a calcified lesion due to the increased density
seen on the CT exam and magnetic susceptibility. FLAIR images
demonstrate a similar but smaller lesion near the left middle
cerebellar peduncle. Additional evaluation of the brain with
Gadolinium enhanced MRI in both axial and coronal planes would
be recommended. The ventricular system is symmetrical without
hydrocephalus. The 4th ventricle is in the midline. There is
normal signal flow void within the intracranial portions of the
carotid and basilar arteries. MRA of the Circle of [**Location (un) 431**]
demonstrates patent distal vertebrobasilar circulation. No
aneurysms are seen along the posterior circulation. The
visualized anterior, middle, and posterior cerebral arteries are
patent. The exam is insensitive to detect tiny aneurysms less
than 3 mm in diameter.
-----
CT Chest, Abdomen, Pelvis [**2114-9-20**]:
CT OF THE CHEST WITH IV CONTRAST: There are multiple enlarged
lymph nodes in the left supraclavicular and prevascular regions,
the largest is in the left supravicular region measuring
approximately 12 x 19 mm. The patient is intubated. The trachea
and left main stem bronchi and its tributaries are widely
patent. There is obstruction within the central right airways
with complete opacification of the more distal airways and the
entire right lung. There is a mixed low and high attenuation
density of the collapsed right lung. There is a small loculated
effusion at the posterior inferior right thoracic cavity with a
thickened wall. The distal right main pulmonary artery is
obstructed. Posterior atelectatic changes are noted within the
left lung. At the superior aspect of the superior segment of the
left lower lobe there is a pleural based nodular density
measuring approximately 6 x 10 mm. The patient is status post
right mastectomy and surgical clips are noted in the right
axilla consistent with lymph node dissection. A porta cath is
noted in the superior left chest wall.

CT OF THE ABDOMEN WITH IV CONTRAST: The liver, pancreas, spleen,
adrenal glands, kidneys, ureters, and small/large bowel loops
are unremarkable. There is layering high attenuation material
within the gallbladder suggestive of layering sludge. There is
gallbladder wall thickening or gallstones. There is no
lymphadenopathy or free fluid.

CT OF THE PELVIS WITH IV CONTRAST: The uterus, adnexa, sigmoid
colon, rectum, distal ureters, and urinary bladder are
unremarkable. Surgical clips are noted adjacent to the uterine
fundus. There is no lymphadenopathy or free fluid.

There are no suspicious lytic or sclerotic osseous lesions.
-----
MRI head with and without contrast [**2114-9-22**]: Since the previous
MRI study there is now evidence of subacute hemorrhage with
increased T1 and decreased T2 signal identified in the right
side of the pontomedullary junction. The previously seen
surrounding edema has also increased which involves now the
medulla and the posterior portion of the pons. No distinct
enhancement is seen in this region. A second area of increased
T2 signal with subtle enhancement is identified in the left
middle cerebral peduncle which is unchanged from the previous
study. No midline shift or hydrocephalus is seen. There are no
other distinct areas of abnormal enhancement noted. IMPRESSION:
Interval new hemorrhage with subacute characteristics in the
right pontomedullary junction with increased edema. No distinct
enhancement is seen in this region given the presence of blood
products. However in the presence of a second small enhancing
lesion in the left middle cerebral peduncle, and given the
patient's clinical history, these findings are suggestive of
metastatic lesions. No hydrocephalus is seen.


Brief Hospital Course:
Patient is a 56 year old female with past medical history of
breast cancer 15 years ago, DVT/PE admitted on [**2114-9-17**] after 2
day history of right facial droop, left hemibody numbness. Exam
with left gaze preference, impaired right lateral gaze with
nystagmus, impaired upgaze with vertical and rotatory nystagmus,
right central 7th palsy, altered palatal and gag function,
diminished sensation over left hemibody and right dysmetria. In
terms of localization, her findings point to lesion in right
lower pons/upper medulla. Indeed, she has hemorrhage at right
pontomedullary junction, 12x11mm. In light of location and
history of breast ca, hemorrhagic transformation of underlying
mass was a concern.

She was admitted to the Neurology/Neurosurgical ICU. Neuro
checks were performed every hour. Initially, she was started on
Mannitol and Decadron. These were both weaned [**2114-9-19**]. Goal
systolic blood pressure was <130. All antiplatelets and
anticoagulant agents were held.  Repeat MRI with gadolinium to
assess for underlying mass demonstrated enhancement of
hemorrhagic mass and second enhancing lesion in cerebellum.
Oncology was consulted. Patient actively refusing chemotherapy
and/or radiotherapy but is actively discussing other treatment
options with Oncology.

On hospital day #1, she was intubated for inability to protect
airway and difficulty handling secretions. Chest XRay showed
opacification of right hemithorax and mediastinal shift. She
underwent flexible and rigid bronch with tissue biopsies samples
taken. Chest CT demonstrated multiple enlarged lymph nodes,
collapsed right lung and left sided pleural based density
concerning for malignancy. Pathology from her right mainstem
tumor mass was  consistent with metastatic adenocarcinoma of
breast origin. We were unable to wean patient from ventilator,
likely related to collapsed right lung and poor lung volumes.
Tracheostomy was performed [**2114-9-25**]. Patient continues to rely
on mechanical ventilation.

While on telemetry monitoring, patient was noted to have
intermittent rapid atrial fibrillation alternating with sinus
bradycardia. She was seen by cardiolgoy. Esmolol or diltiazem
was recommended as needed for rate control. TSH was within
normal limits.

PEG tube was placed [**2114-9-26**]. Due to location of her hemorrhagic
tumor, patient is likely to have difficulties with swallowing
and speech function as she has decreased palatal, tongue, and
gag functions.

In terms of infectitious disease issues, patient spiked a
temperature on [**2114-9-26**]. Sputum culture showed S. Aurea.  Urine
culture had gram positive bacteria. She was started on
Vancomycin empirically while identification and sensitivities
were pending on cultures.

The day prior to discharge she was started on a right eye patch
to be used intermittently to alleviate her diplopia. She also
has a right conjunctivitis that is being treated with drops.

We discussed the patient's disposition with oncology, who stated
that they had had a lengthy conversation with the patient and
her daughter on [**9-28**], at which time the patient had adamantly
refused any chemotherapy or further therapeutic interventions.
Arimidex or tamoxifen are not therapeutic candidates because
they have already been used in her treatment regimen in the
past. Oncology requested that she make a follow up appointment
with Dr. [**Last Name (STitle) **] if she is interested in further therapy.


Medications on Admission:
1. Coumadin 10 mg po qHS
2. Arimidex 1 mg po qd
3. Lasix 40 mg po qd
4. Potassium KCL


Discharge Medications:
1. Vancomycin 1000 mg iv q12
2. Reglan 10 mg po qid
3. senna 1 tab po bid prn constipation
4. prochlorperazine 10 mg IV q6 hours prn nausea
5. magnesium sulfate 2 gm IV qday prn Mg<2
6. Potassium chloride 40 meq IV qday prn K<3.5
7. Tocopheryl 400 ml pg qday
8. Esmolol 25 mcg/kg/min titrate to HR<110
9. Dulcolax 100 mg po bid
10. Insulin sliding scale

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
Metastatic breast cancer, with hemorrhage in right
pontomedullary junction, likely secondary to metastasis.

Discharge Condition:
Stable

Discharge Instructions:
Neuro: Neuro checks, supportive care
Onc: Pt should follow up with oncology (Dr.[**Name (NI) 8949**] office)
as an outpatient if she wishes to pursue therapy
Optho: Pt needs eye patch on R eye intermittently to alleviate
diplopia, also eye drops for conjunctivitis
CV: Continue esmolol for rate control. Pt has hx of intermittent
rapid atrial fibrillation, but has been stable from that
perspective for many days
Resp: Follow O2 sats, continue ventilation through trach
ID: Continue vancomycin x14 day course (last day will be [**10-10**]),
recommend reculturing if she spikes
HEME: follow hematocrit, transfuse for hematocrit <30, last
transfusion was [**9-28**]
GI: continue PEG tube feeds, follow electrolytes
Prophylaxis: pneumoboots, insulin sliding scale, proton pump
inhibitor


Followup Instructions:
Follow up with oncology: Call Dr.[**Name (NI) 8949**] office at
[**Telephone/Fax (1) 6568**] to schedule appointment

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]



Name:  [**Known lastname 10601**],[**Known firstname 511**]                   Unit No:   [**Numeric Identifier 10602**]

Admission Date:  [**2114-9-17**]              Discharge Date:   [**2114-10-15**]

Date of Birth:  [**2057-11-29**]             Sex:   F

Service: NEUROLOGY

Allergies:
Percodan / Percocet / Cerebyx / Phenytoin

Attending:[**First Name3 (LF) 608**]
Chief Complaint:
Facial droop and L sided sensory loss

Major Surgical or Invasive Procedure:
none

Brief Hospital Course:
Addendum:
Oncology service met with Pt and her daughter on [**10-1**] and
discussed the therapeutic options. They recommended radiation
therapy, but also gave the option of [**Last Name (LF) 10644**], [**First Name3 (LF) **] anti-estrogen
therapy given qmonth. Ms. [**Known lastname **] expressed her wishes to discuss
the options with her family before deciding on therapy.
She will follow up with her outpatient oncologist (not Dr.
[**Last Name (STitle) **] when she feels prepared to do so.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 49**] - [**Location (un) 50**]

Discharge Diagnosis:
Metastatic Breast Cancer
Pontomedullary junction hemorrhage

Discharge Condition:
fair

Discharge Instructions:
see prior instructions

                             [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**]

Completed by:[**2114-10-2**]

Name:  [**Known lastname 10601**],[**Known firstname 511**]                   Unit No:   [**Numeric Identifier 10602**]

Admission Date:  [**2114-9-17**]              Discharge Date:   [**2114-10-15**]

Date of Birth:  [**2057-11-29**]             Sex:   F

Service: MEDICINE

Allergies:
Percodan / Percocet / Cerebyx / Phenytoin

Attending:[**First Name3 (LF) 10603**]
Chief Complaint:
here for XRT

Major Surgical or Invasive Procedure:
XRT

History of Present Illness:
     56 yo F with metastatic breast cancer to brain and lung
presented to [**Hospital1 8**] [**2114-9-17**] with L face/arm numbness, R facial
droop, found to have pontine hemorrhage likely [**12-18**]
pontinemedulary met.  She was initially treated with mannitol,
decadron and fiven FFP, factor VIIa and electively intubated for
difficulty in managing secretions.  Head imadging revealed
hemorrhage in the R pontomedullary junction and a met in the
cerebellum.  Bronch with lung/LN mediastinum bx revealed
adenocarcinoma of breast origin.
     Due to a collapsed lung ([**12-18**] tumor invasion) the patient
could not be weaned and a trach was placed on [**2114-9-25**].  Also PEG
placed the following day due to difficulty swallowing.  On [**9-26**]
the pt spiked a fever growing MRSA in her sputum and GPC in her
urine (likely skin contam).  3 teeth were extracted [**12-18**] decay.
Pt also started on vanc [**9-26**] for a 14 day course.
     Pt also had been having intermittant episodes of A-fib
which were controled with dilt and prn esmolol.  TSH normal.
She initially declined any further treatment from the hospital
and was almost discharged.  However the pt decided that she
would like to have palliative XRT.  She will receive 1 dose a
day x 5 days starting [**10-4**].
     On presentation to the micu the pt was comfortable.  She
complained of mild jaw pain from where her teeth had been
extracted.  This has been treated well with tylenol/codeine.  No
CP/SOB/HA.  Her last BM was today.  Has back pain when lays flat
for long periods.  She is able to transfer OOB to chair [**12-19**]
hours/day.


Past Medical History:
1. Breast cancer status post right mastectomy and chemotherapy
15
years ago
2. Pleural effusion
3. DVT and PE 7 years ago


Social History:
Married, with 3 children. Lives with husband,daughter, son and
grandchildren. She is a homemaker. No tobacco,valcohol, drug
use.


Family History:
Mother with stroke in her 70s. Sister with history of breast
cancer, died from brain mets.


Physical Exam:
PE - T 100  P 45-79  BP 108/60
     PS 8/5/30%  with TV 350/RR 24/O2 sat 96%
Gen- A+Ox3, not able to speak b/c trach, lying in bed
comfortably
HEENT - Patch or R eye, MMM, s/p R lower jaw extraction no
bleeding
Cor- RRR no murmur
Chest- decreased BS at based b/l
Abd- S/NT/ND +BS
Ext- 1+ edema b/l, DP 2+ b/l
Neuro- L pupil round reactive, left lateral gaze, R facial
droop, R eye injected, strength 5/5 b/l, sensation R>L
mild dysmetria finger to nose on the R


Pertinent Results:
Labs [**10-3**]
WBC 9.9 Hct 31 Plt 317   PT 13.7 PTT 22.0 INR 1.2
Na 140 K 3.8 Cl 102 HCO3 33 BUN 26 Cr 0.5 Glu 123
Ca 8.9 Mg 2.0 PO4 5.4

CXR - [**9-25**] opacification of R hemithorax [**12-18**] obstructing tumor.

MRI head [**9-22**] - R pontomedullary hemorrhage, L middle cerebral
peduncle c/w met
CT chest [**9-20**] - There are multiple enlarged lymph nodes in the
left supraclavicular and prevascular regions, There is
obstruction within the central right airways with complete
opacification of the more distal airways and the entire right
lung. There is a mixed low and high attenuation density of the
collapsed right lung. There is a small loculated effusion at the
posterior inferior right thoracic cavity with a thickened wall.
The distal right main pulmonary artery is obstructed. Posterior
atelectatic changes are noted within the
left lung. At the superior aspect of the superior segment of the

left lower lobe there is a pleural based nodular density
measuring approximately 6 x 10 mm.


Brief Hospital Course:
A/P 56 yo F with met breast cancer who is chronically intubated
due to difficult managing secretions.  Transfered to [**Hospital Unit Name **]
inorder to receive palliative XRT to head and chest.

1) Metastatic Breast [**Name (NI) 10604**] Pt has stable neurological status.
Pt was followed by XRT and received 1 dose per day x 5 days to
head and chest.  She was placed on decadron 4mg [**Hospital1 **] to avoid
swelling.  Upon discharge the pt decided she may attempt to try
further palliative chemo.  She will go to rehab and contact her
primary oncologist Dr. [**Last Name (STitle) **].

2) MRSA pna- Pt completed her 14 day course of vanc.  She has
remained afebrile.  However as the XRT progressed she did
produce more purulent sputum.  The medical team felt that this
was from her collapsed lung which had been partially opened up
due to the XRT.

3) s/p trach and mech vent - Pt has been stable on the vent
since admission.  On [**10-6**] she was given a passy-muir valve to
allow her to speak.  She was able to tolerate this for 9 hours
and spoke with ease.  The pt was placed back on pressure support
at night.  She was then tired the next day and could only
tolerate being off the vent for 2-3 hours at a time.  She has
been allowed to dictate her care of when she would like to be on
the vent.  Her settings are pressure support [**8-21**] with an FiO2
of 30%.

4) Afib - HR remained stable throughout admission.  Ca channel
blocker and beta blocker held since HR is decreased.

5) R eye conjunctivitis and diplopia - Artificial tears and tear
ointment were used to keep her eye protected.  She has baseline
diplopia from her dysconjugate gaze.  When she wanted to watch
TV she would wear a patch.

6) Prophylaxis - pneumoboots, Insulin Sliding Scale, Protonix

7) Communication - with patient and daughter

DNR/DNI

Medications on Admission:
Medications on Admission:
1. Coumadin 10 mg po qHS
2. Arimidex 1 mg po qd
3. Lasix 40 mg po qd
4. Potassium KCL


Discharge Medications:
1. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) Appl
Ophthalmic  PRN (as needed).
2. Acetaminophen-Codeine 120-12 mg/5 mL Elixir Sig: 12.5-25 MLs
PO Q4H (every 4 hours) as needed for pain.
3. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic  PRN
(as needed).
4. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Therapeutic Multivitamin     Liquid Sig: One (1) Cap PO DAILY
(Daily).
6. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO
QIDACHS (4 times a day (before meals and at bedtime)).
7. Mineral Oil-Hydrophil Petrolat     Ointment Sig: One (1) Appl
Topical  TID (3 times a day) as needed.
8. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed.
9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed.
10. Prochlorperazine Edisylate 5 mg/mL Solution Sig: One (1)
Injection Q6H (every 6 hours) as needed for nausea.
11. Morphine Sulfate 2 mg/mL Syringe Sig: Two (2) mg Injection
Q3-4H () as needed for pain.
12. Dexamethasone Sodium Phosphate 4 mg/mL Solution Sig: Four
(4) mg Injection Q12H (every 12 hours): please give 4mg [**Hospital1 **] for
1 week then 2 mg [**Hospital1 **] for one week then 2 mg qday for one week.
Then stop.
13. Lorazepam 2 mg/mL Syringe Sig: Two (2) mg Injection Q4H
(every 4 hours) as needed for anxiety.
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1) see
sliding scale Injection ASDIR (AS DIRECTED): Please see attached
sliding scale.


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 49**] - [**Location (un) 50**]

Discharge Diagnosis:
Metastatic Breast Cancer


Discharge Condition:
stable

Discharge Instructions:
[**Name (NI) 10605**] Pt is on pressure support [**8-21**] with FiO2 30%.  She uses
the vent at night to sleep and when she feels tired during the
day.  Otherwise the pt uses a passy-muir valve to talk and can
breathe on her own.  She needs an oxygen mask for her trach when
she off the vent.  Please titrate to O2 sat >95%.  Pt also needs
frequent suctioning due to her colapsed lung.  She has just
finished treatment for a pneumonia.  If she starts spiking
fevers or has an increased WBC please consider a relapse of the
pneumonia.

Eyes - Pt has a dysconjugate gaze from her brain metastases.
She has diplopia at base line.  She needs atrificial tears drops
or ointment applied to her eyes at least tid.  She wears a patch
over her right eye when she watches tv.

Glucose - the pt has increased blood sugar from her steroids.
She needs qid finger sticks.  Follow the insulin sliding scale
provided.

Neuro - please follow the patient's neuro exam q12h as she has
brain mets.

Nutrion - please continue tube feeds as written below.

Followup Instructions:
Contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 10606**] for initial
appointment.


                             [**Name6 (MD) 3359**] [**Last Name (NamePattern4) 3360**] MD [**MD Number(1) 3361**]

Completed by:[**2114-10-15**]
{'Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Intracerebral hemorrhage,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Sinoatrial node dysfunction,Personal history of malignant neoplasm of breast,Anemia, unspecified,Conjunctivitis, unspecified,Personal history of venous thrombosis and embolism'}


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: Right facial droop, left face and arm numbness

PRESENT ILLNESS: Patient is a 56 year old right handed female with pastmedical
history of breast cancer 10-15 years ago, pleural effusion, DVT
and PE who presented to [**Hospital1 18**] on [**2114-9-17**] for evaluation of left
face and arm numbness and right facial
droop.

MEDICAL HISTORY: 1. Breast cancer status post right mastectomy and chemotherapy
15
years ago
2. Pleural effusion
3. DVT and PE 7 years ago

MEDICATION ON ADMISSION: 1. Coumadin 10 mg po qHS
2. Arimidex 1 mg po qd
3. Lasix 40 mg po qd
4. Potassium KCL

ALLERGIES: Percodan / Percocet / Cerebyx / Phenytoin

PHYSICAL EXAM: Tm: 99.0  Tc: 98.4  BP: 97/69 (97-150/66-87)  HR: 78 (76-140s)
Vent AC 600x12 ([**11-14**]) with FiO2 0.40
Gen: WD/WN, sitting up in bed comfortably, NAD.
HEENT: NC/AT. Anicteric. MMM.
Neck: Supple. No masses or LAD. No JVD. No thyromegaly. No
carotid bruits.
Lungs: Decreased breath sounds over right hemithorax. Coarse
breath sounds on left. No R/R/W.
Cardiac: RRR. S1/S2. No M/R/G.
Abd: Soft, NT, ND, +NABS. No rebound or guarding. No HSM.
Extrem: Warm and well-perfused. No C/C/E.

FAMILY HISTORY: Mother with stroke in her 70s. Sister with history of breast
cancer, died from brain mets.

SOCIAL HISTORY: Married, with 3 children. Lives with husband,daughter, son and
grandchildren. She is a homemaker. No tobacco,valcohol, drug
use. 

### Response:
{'Secondary malignant neoplasm of brain and spinal cord,Secondary malignant neoplasm of lung,Intracerebral hemorrhage,Acute respiratory failure,Methicillin susceptible pneumonia due to Staphylococcus aureus,Unspecified protein-calorie malnutrition,Urinary tract infection, site not specified,Sinoatrial node dysfunction,Personal history of malignant neoplasm of breast,Anemia, unspecified,Conjunctivitis, unspecified,Personal history of venous thrombosis and embolism'}
