CHIEF COMPLAINT: Dizziness and headache

PRESENT ILLNESS: 42y woman with metastatic breast cancer (HER-2 positive) with
hepatic involvement, C-spine/L-spine and hip involvement (s/p
lumpectomy in [**2180**]; radiation treatment to bony mets; ongoing
chemotherapy). She now presents with mild frontal headache of 2
weeks duration, then 3 days of dizzyness with nausea and
vomiting.  MRI brain today showed multiple intracranial lesions
including the largest in the right cerebellar hemisphere
measuring 2cm in diameter with brain stem compression.
.
The headache has been mild and easily treated with simple
analgaesics (tylenol only). Nausea developed 3d ago with single
vomit 3d ago and nil since. She has been feeling slightly
unsteady on her feet without falling or clearly veering to
either the right or the left. After discussion with her
oncologist yesterday. decadron 4mg was started [**Hospital1 **]. She has now
had 2 doses and symptoms have resolved. She was admitted to the
Oncology [**Hospital1 **] following MRI and received a further 10mg iv
dexamethasone and 50g mannitol pending clinical review and
review of imaging study.

MEDICAL HISTORY: 1. Breast cancer
2. S/p Cholecystectomy 9 years ago
.
ONCOLOGIC HISTORY:
She had been diagnosed metastatic disease in [**7-/2184**]; primary
Her2+, ER+.  Her disease progression had been dramatic and in
[**Month (only) **], her CA27.29 level had been [**Numeric Identifier 3652**].  At that time, she
had had severe icterus and hyperbilirubinemia due to metastatic
disease.  She had also been immobile because of the widely
metastatic disease to the skeleton.  She had at that time been
hospitalized.  She had then received Herceptin as well as
carboplatin and Taxol in the hospital and then as an outpatient
in late [**2183**]. She achieved a complete remission with CA27-29
levels in the normal range. She also had skeletal metastases
that
required radiation which was done in [**Location (un) 3844**] (C-spine,
L-spine and hip). She is left with a weakness of the extension
of
the fingers.  The strength in the elbow as well as shoulder area
is [**4-15**] versus strength in the right hand is [**2-13**] and only [**1-16**] in
the extensor portion of her fingers.

MEDICATION ON ADMISSION: Xeloda
Herceptin weekly
Zomeda weekly (Trastuzamab)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-96 BP-128/73 HR-80 RR-20 O2Sat 98% RA   Wt 239.7 lb
Gen: Obese. Seated on the side of the bed. Kyphosis with short
appearing neck.
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation
Back: No point tenderness
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: [**Name (NI) **] mother and father with hyperlipidemia.  No cancer
history.

SOCIAL HISTORY: Patient lives with husband in [**Name (NI) **]. She has 2 children 12 and 16.
Walks around home with walked but has not been able to do more
than that since the beginning of [**Month (only) 216**]. Quit smoking 3 months
ago,  before that smoked 1 PPD for 20 years.
Secondary malignant neoplasm of brain and spinal cord,Malignant neoplasm of liver, secondary,Obstructive hydrocephalus,Personal history of malignant neoplasm of breast
Sec mal neo brain/spine,Second malig neo liver,Obstructiv hydrocephalus,Hx of breast malignancy
Admission Date:  [**2186-4-27**]              Discharge Date:   [**2186-5-2**]

Date of Birth:  [**2143-11-3**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2024**]
Chief Complaint:
Dizziness and headache

Major Surgical or Invasive Procedure:
Right-sided ventriculoperitoneal shunt placement with endoscopic
assistance


History of Present Illness:
42y woman with metastatic breast cancer (HER-2 positive) with
hepatic involvement, C-spine/L-spine and hip involvement (s/p
lumpectomy in [**2180**]; radiation treatment to bony mets; ongoing
chemotherapy). She now presents with mild frontal headache of 2
weeks duration, then 3 days of dizzyness with nausea and
vomiting.  MRI brain today showed multiple intracranial lesions
including the largest in the right cerebellar hemisphere
measuring 2cm in diameter with brain stem compression.
.
The headache has been mild and easily treated with simple
analgaesics (tylenol only). Nausea developed 3d ago with single
vomit 3d ago and nil since. She has been feeling slightly
unsteady on her feet without falling or clearly veering to
either the right or the left. After discussion with her
oncologist yesterday. decadron 4mg was started [**Hospital1 **]. She has now
had 2 doses and symptoms have resolved. She was admitted to the
Oncology [**Hospital1 **] following MRI and received a further 10mg iv
dexamethasone and 50g mannitol pending clinical review and
review of imaging study.

She has had no other symptoms of weakness, paraesthesias, visual
including diplopia or hearing problems, speech or swallowing
difficulties or facial droop. She has otherwise been well
without fever, chills, respiratory symptoms or diarrhoea.


Past Medical History:
1. Breast cancer
2. S/p Cholecystectomy 9 years ago
.
ONCOLOGIC HISTORY:
She had been diagnosed metastatic disease in [**7-/2184**]; primary
Her2+, ER+.  Her disease progression had been dramatic and in
[**Month (only) **], her CA27.29 level had been [**Numeric Identifier 3652**].  At that time, she
had had severe icterus and hyperbilirubinemia due to metastatic
disease.  She had also been immobile because of the widely
metastatic disease to the skeleton.  She had at that time been
hospitalized.  She had then received Herceptin as well as
carboplatin and Taxol in the hospital and then as an outpatient
in late [**2183**]. She achieved a complete remission with CA27-29
levels in the normal range. She also had skeletal metastases
that
required radiation which was done in [**Location (un) 3844**] (C-spine,
L-spine and hip). She is left with a weakness of the extension
of
the fingers.  The strength in the elbow as well as shoulder area
is [**4-15**] versus strength in the right hand is [**2-13**] and only [**1-16**] in
the extensor portion of her fingers.

She has been fully functional since the spring of [**2184**] and has
been ECOG performance status 0. In [**2185-12-12**] her CA [**05**]-29
started to climb and we started Xeloda in addition to the
continued Herceptin that she has taken in 3-week intervals since
fall of [**2183**]. Restaging in early [**Month (only) 958**] of 07 revealed improved
findings in the torso. She did not want to undergo a MRI of her
head at that point.  Her last CA27-29 was 99 (down from
previous).

Social History:
Patient lives with husband in [**Name (NI) **]. She has 2 children 12 and 16.
Walks around home with walked but has not been able to do more
than that since the beginning of [**Month (only) 216**]. Quit smoking 3 months
ago,  before that smoked 1 PPD for 20 years.


Family History:
[**Name (NI) **] mother and father with hyperlipidemia.  No cancer
history.


Physical Exam:
T-96 BP-128/73 HR-80 RR-20 O2Sat 98% RA   Wt 239.7 lb
Gen: Obese. Seated on the side of the bed. Kyphosis with short
appearing neck.
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation
Back: No point tenderness
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

Neurologic examination:
Mental status: Awake and alert, cooperative with exam, normal
affect.  Oriented to person, place, and date.  Attentive, says
[**Doctor Last Name 1841**] backwards.  Speech is fluent with normal comprehension and
repetition; naming intact. No dysarthria.  Registers [**2-11**],
recalls
[**2-11**] in 5 minutes.  No right left confusion. No evidence of
apraxia or neglect.

Cranial Nerves:
Pupils equally round and reactive to light, 4 to 2 mm
bilaterally. Visual fields are full to confrontation.
Extraocular
movements intact bilaterally, no nystagmus. Sensation intact
V1-V3.  Facial movement symmetric.  Hearing intact to quiet
voice.  Palate elevation symmetrical.  Sternocleidomastoid and
trapezius normal bilaterally. Tongue midline, movements intact

Motor:
Normal bulk bilaterally. Tone normal. No observed myoclonus or
tremor
No pronator drift
  [**Doctor First Name **] Tri [**Hospital1 **]  WF WE FE FF  IP  H  Q DF PF TE TF
R  5   5   5  5  5  5-  5   5   5  5  5  5  5  5
L  5   5   5  5  5  5-  5   5   5  5  5  5  5  5

Sensation: Intact to light touch, vibration and proprioception
throughout. No extinction to DSS

Reflexes:
+1 UE bilat and difficult to elicit in the LE.
Toes downgoing right and withdrawal.

Coordination: finger-nose-finger very slight ataxia, heel to
shin
normal, RAMs normal.

Gait: Narrow based, steady.

Romberg: Negative


Pertinent Results:
MRI BRAIN [**2186-4-27**]: There are innumerable enhancing lesions
throughout the brain and cerebellum. All of these lesions are
associated with areas of vasogenic edema.  The largest of these
lesions is in the anterior right cerebellar hemisphere measuring
2.3 x 3.4 cm.  A large amount of vasogenic edema is present with
mass effect upon the fourth ventricle as well as the medulla and
pons.  There is no evidence of hydrocephalus at this time.
There is a well-circumscribed 2-cm cystic structure in the
region of the pineal, most consistent with a pineal cyst.  There
is also mass effect upon the cerebellar tonsils. The largest
supratentorial metastasis lies within the left frontal lobe and
measures 1.2 cm. There is diffusely low signal throughout the
skull which would be most consistent with diffuse osseous
metastases from breast cancer.
IMPRESSION:  Innumerable intracranial supra and infratentorial
metastases. The largest lesion is in the right cerebellar
hemisphere with a large amount of vasogenic edema.  There is
mild mass effect upon the fourth ventricle with no hydrocephalus
at this time.  There is mild displacement of the brainstem to
the left. There is also mass effect in the posterior fossa
causing inferior tonsillar migration.  No evidence of tonsillar
herniation at this time.
.
TTE [**2186-5-2**]: The left atrium is normal in size. Left ventricular
wall thicknesses are normal. The left ventricular cavity size is
normal. Overall left ventricular systolic function is normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) are mildly thickened.
There is no aortic valve stenosis. No aortic regurgitation is
seen.  The mitral valve leaflets are mildly thickened. Trivial
mitral regurgitation is seen. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
.
CT CHEST/ABDOMEN/PELVIS [**2186-5-2**]: Radiology Report CT ABD W&W/O C
Study Date of [**2186-5-1**] 2:00 PM


[**Last Name (LF) **],[**First Name3 (LF) **] M. OMED 11R [**2186-5-1**]
CT CHEST W/CONTRAST; CT ABD W&W/O C   Clip # [**Clip Number (Radiology) 63987**]
Reason: baseline eval prior to starting new therapy. Please
create o
Contrast: OPTIRAY

   [**Hospital 93**] MEDICAL CONDITION:
42 year old female patient with met breast cancer
   REASON FOR THIS EXAMINATION:
baseline eval prior to starting new therapy. Please create
oncology table
including all measurable disease as TARGET lesions with these as
BASELINE
MEASUREMENTS. thanks
   CONTRAINDICATIONS for IV CONTRAST:
None.



Final Report
INDICATION:  Metastatic breast cancer, to evaluate baseline
prior to starting
to new therapy.

COMPARISON:  [**2186-1-20**] CT torso.

TECHNIQUE:  Non-contrast axial CT images of the abdomen and
pelvis were
obtained followed by contrast-enhanced axial CT images of the
chest, abdomen
and pelvis as well as three minute delays of the kidneys only.
Multiplanar
reformatted images were also submitted for review.

CT CHEST WITH CONTRAST:  No axillary, hilar, or mediastinal
lymphadenopathy is
seen.  The heart, great vessels, and pericardium appear
unremarkable.  No
pleural or pericardial effusion.  Previously noted platelike
opacity in the
medial right upper lobe is not well seen today.  The remainder
of the lungs
appear clear and there is no evidence of mass.  The airways are
patent to the
level of segmental bronchi bilaterally.

CT OF THE ABDOMEN WITH CONTRAST:  Two small round subcentimeter
hypodensities
within the right lobe of the liver are unchanged from prior
studies (4:26, and
4:7).  Linear hyperdense bands compatible with scarring are
unchanged and
there is no definite evidence of metastatic disease.  Surgical
clips related
to prior cholecystectomy are again seen.  The pancreas, adrenal
glands, and
spleen are unremarkable.  The kidneys enhance symmetrically and
excrete
contrast normally.  No pathologically enlarged lymph nodes, free
fluid, or
free air is identified.  The peritoneal portion of a
ventriculoperitoneal
shunt is identified on top of the liver anteriorly.

CT OF THE PELVIS WITH CONTRAST:  Diverticulosis is again
appreciated.  The
bladder, uterus, adnexa, and rectum appear unremarkable.  No
pathologically
enlarged lymph nodes or free fluid is seen.

BONE WINDOWS:  The appearance of diffuse sclerotic and lytic
metastasis
throughout the visualized osseous structures is unchanged.
Healing fracture
deformity of the left ilium is again noted.  Partial compression
fracture of
T9 is not significantly changed.  Lower cervical and upper
thoracic
compression deformities also appear unchanged.  Multiple
bilateral healed rib
fractures appear unchanged.

IMPRESSION:
1.  No evidence of disease progression with diffuse osseous
metastasis again seen.  Again, metastatic disease in the femur
increases the risk of hip fracture.
2.  Unchanged appearance of the liver with persistent treatment
effect from prior metastasis.




Brief Hospital Course:
Ms. [**Known lastname 2152**] is a 42 yo woman with known metastatic breast cancer
involving liver and bone, now with multiple intracranial mets
including right cerebellar mass 2.3x3.4cm with brain stem
compression, midline shift and inferior migration of cerebellar
tonsils.  She was initially admitted from home to the Oncology
floor appearing clinically well and neurologically intact.  On
review of the MRI report, however, urgent consults to Radiation
Oncology, Neurosurgery, and Neuro-oncology were placed.  She
received an IV dose of Decadron 10 mg x 1 and Mannitol 50 g x 1.
 All consultants arrived to evaluated her within an hour of
arrival, and it was decided that she should be transferred to an
ICU level bed under the care of the Neurosurgical service given
the impending tonsillar herniation.  The following morning she
was taken to the OR for placement of a right
ventriculoperitoneal shunt.  Her surgical procedure was
uncomplicated and she was transferred back to the Oncology
service for further care.  She continued on dexamethasone with
famotidine as GI prophylaxis.  In discussion of plans for futher
care, the decision was made to enroll Ms. [**Known lastname 2152**] in an ongoing
clinical trial of WBRT with Lapatinib and Trastuzumab
(Herceptin).  She underwent a pre-enrollment TTE and CT torso
while in-patient.  On the day of discharge, she had a planning
meeting with Radiation Oncology.  She was discharged to home,
asymptomatic, and will return for XRT as an outpatient.  She
will undergo the first session of radiation therapy on [**5-9**]
after she has completed the 14-day chemotherapy washout period.



Medications on Admission:
Xeloda
Herceptin weekly
Zomeda weekly (Trastuzamab)


Discharge Medications:
1. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
Disp:*120 Tablet(s)* Refills:*1*
2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*1*


Discharge Disposition:
Home

Discharge Diagnosis:
Brain metastases
Metastatic breast cancer


Discharge Condition:
Good, neurologically intact


Discharge Instructions:
You can keep your abdominal wounds open to air, without any
dressings.
.
You can also keep your head incision open to air without
dressings.  You should not wash your hair for the next 10 days,
or until otherwise instructed by Neurosurgery.
.
You should seek immediate medical attention if you experience
fevers, headaches, vomiting, loss of balance, confusion, or
dizziness.


Followup Instructions:
You are scheduled to have your sutures removed on Tuesday, [**5-9**] at 11 a.m.  Dr.[**Name (NI) 9034**] office is located on the [**Location (un) 470**]
of the [**Hospital Unit Name **] at [**Last Name (NamePattern1) 20120**]on [**Hospital1 18**] [**Hospital Ward Name 12837**].  Please call [**Telephone/Fax (1) 1669**] if you have questions.
.
You are scheduled to begin brain radiation next Tuesday [**5-9**]
at 9:30 a.m. You should come to basement of the Finaird Building
on the [**Hospital1 18**] [**Hospital Ward Name 516**].  Please call [**Telephone/Fax (1) 9710**] if you have
questions prior to your appointment.
.
[**Name6 (MD) **] [**Last Name (NamePattern4) 17688**], MD
Oncology
Phone:[**Telephone/Fax (1) 22**]
Date/Time:[**2186-5-10**] 2:30 p.m.
{'Secondary malignant neoplasm of brain and spinal cord,Malignant neoplasm of liver, secondary,Obstructive hydrocephalus,Personal history of malignant neoplasm of breast'}


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: Dizziness and headache

PRESENT ILLNESS: 42y woman with metastatic breast cancer (HER-2 positive) with
hepatic involvement, C-spine/L-spine and hip involvement (s/p
lumpectomy in [**2180**]; radiation treatment to bony mets; ongoing
chemotherapy). She now presents with mild frontal headache of 2
weeks duration, then 3 days of dizzyness with nausea and
vomiting.  MRI brain today showed multiple intracranial lesions
including the largest in the right cerebellar hemisphere
measuring 2cm in diameter with brain stem compression.
.
The headache has been mild and easily treated with simple
analgaesics (tylenol only). Nausea developed 3d ago with single
vomit 3d ago and nil since. She has been feeling slightly
unsteady on her feet without falling or clearly veering to
either the right or the left. After discussion with her
oncologist yesterday. decadron 4mg was started [**Hospital1 **]. She has now
had 2 doses and symptoms have resolved. She was admitted to the
Oncology [**Hospital1 **] following MRI and received a further 10mg iv
dexamethasone and 50g mannitol pending clinical review and
review of imaging study.

MEDICAL HISTORY: 1. Breast cancer
2. S/p Cholecystectomy 9 years ago
.
ONCOLOGIC HISTORY:
She had been diagnosed metastatic disease in [**7-/2184**]; primary
Her2+, ER+.  Her disease progression had been dramatic and in
[**Month (only) **], her CA27.29 level had been [**Numeric Identifier 3652**].  At that time, she
had had severe icterus and hyperbilirubinemia due to metastatic
disease.  She had also been immobile because of the widely
metastatic disease to the skeleton.  She had at that time been
hospitalized.  She had then received Herceptin as well as
carboplatin and Taxol in the hospital and then as an outpatient
in late [**2183**]. She achieved a complete remission with CA27-29
levels in the normal range. She also had skeletal metastases
that
required radiation which was done in [**Location (un) 3844**] (C-spine,
L-spine and hip). She is left with a weakness of the extension
of
the fingers.  The strength in the elbow as well as shoulder area
is [**4-15**] versus strength in the right hand is [**2-13**] and only [**1-16**] in
the extensor portion of her fingers.

MEDICATION ON ADMISSION: Xeloda
Herceptin weekly
Zomeda weekly (Trastuzamab)

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T-96 BP-128/73 HR-80 RR-20 O2Sat 98% RA   Wt 239.7 lb
Gen: Obese. Seated on the side of the bed. Kyphosis with short
appearing neck.
HEENT: NC/AT, moist oral mucosa
Neck: No tenderness to palpation
Back: No point tenderness
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
aBd: +BS soft, nontender
ext: no edema

FAMILY HISTORY: [**Name (NI) **] mother and father with hyperlipidemia.  No cancer
history.

SOCIAL HISTORY: Patient lives with husband in [**Name (NI) **]. She has 2 children 12 and 16.
Walks around home with walked but has not been able to do more
than that since the beginning of [**Month (only) 216**]. Quit smoking 3 months
ago,  before that smoked 1 PPD for 20 years. 

### Response:
{'Secondary malignant neoplasm of brain and spinal cord,Malignant neoplasm of liver, secondary,Obstructive hydrocephalus,Personal history of malignant neoplasm of breast'}
