CHIEF COMPLAINT: Cerebellar Brain Mass/Vertigo

PRESENT ILLNESS: 49-year-old female who was recently seen in outpatient clinic,
having been referred for a newly diagnosed intracranial lesion.
The patient was
worked up at an outside facility and presented with films
indicating an approximately 2 x 2.5 cm contrast enhancing
lesion, most consistent with a tentorial notch meningioma. Since
the patient is significantly symptomatic from this lesion, the
patient is also in need of a histopathological diagnosis to
further decide on treatment and management

MEDICAL HISTORY: s/p hysterectomy
Cerebal Palsy

MEDICATION ON ADMISSION: Antivert

ALLERGIES: Pollen Extracts

PHYSICAL EXAM: On Admission:
Patient is alert, oriented to person; place; date. Mildly
depressed affect, but pleasant. Full motor strength throughout
upper and lower extremities.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, resides at home with husband in [**Name (NI) 14663**]. No history
of tobacco or illicit substances.
Hemangioma of intracranial structures
Hemangioma intracranial
Admission Date:  [**2152-6-15**]              Discharge Date:   [**2152-6-19**]

Date of Birth:  [**2103-2-23**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Pollen Extracts

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Cerebellar Brain Mass/Vertigo

Major Surgical or Invasive Procedure:
[**6-15**]: Suboccipital craniotomy for mass resection


History of Present Illness:
49-year-old female who was recently seen in outpatient clinic,
having been referred for a newly diagnosed intracranial lesion.
The patient was
worked up at an outside facility and presented with films
indicating an approximately 2 x 2.5 cm contrast enhancing
lesion, most consistent with a tentorial notch meningioma. Since
the patient is significantly symptomatic from this lesion, the
patient is also in need of a histopathological diagnosis to
further decide on treatment and management

Past Medical History:
s/p hysterectomy
Cerebal Palsy

Social History:
Married, resides at home with husband in [**Name (NI) 14663**]. No history
of tobacco or illicit substances.

Family History:
Non-contributory

Physical Exam:
On Admission:
Patient is alert, oriented to person; place; date. Mildly
depressed affect, but pleasant. Full motor strength throughout
upper and lower extremities.

On Discharge:

Afebrile. Alert and oriented x3. Following all commands. PERRLA
3.0mm to 2.5mm. speech is clear. CN II-XII intact. EOM's full
with conjugate gaze. No diplopia or nystagmus. No pronator
drift. Surgical suture line is clean, dry and intact. There is
no edema, erythema or eccymosis. There is no drainage present.
The patient has been out of bed and ambulating. She has been
cleared by PT for d/c to home.


Pertinent Results:
Labs on Admission;
[**2152-6-15**] 08:31PM BLOOD WBC-14.5*# RBC-4.42 Hgb-12.5 Hct-35.5*
MCV-80* MCH-28.3 MCHC-35.2* RDW-14.0 Plt Ct-279
[**2152-6-15**] 08:31PM BLOOD PT-13.5* PTT-19.7* INR(PT)-1.2*
[**2152-6-15**] 08:31PM BLOOD Glucose-209* UreaN-12 Creat-1.0 Na-143
K-3.6 Cl-107 HCO3-16* AnGap-24*
[**2152-6-15**] 08:31PM BLOOD Calcium-9.1 Phos-4.1 Mg-1.7

Imaging:
MRI Head w/Contrast [**6-16**]: FINDINGS: Patient is status post left
suboccipital craniotomy, with expected
post-operative changes. There are a few, approximately 4- mm
sized punctate foci of T1- hyperintensity (4:12, 4:11, 4:10) in
the surgical resection bed, which have corresponding
susceptibility artifact on gradient- recalled echo sequence, and
likely represent small residual foci of post- operative
hemorrhage. On T1W post- gadolinium sequences, there is more
planar or sheet like enhancement along the [**Last Name (un) 46280**] aspect of
the tentorium which likely relates to operative manipulation. On
T1W MP-RAGE and SE post- gadolinium sequences, there are several
small enhancing vessels seen along the posterior aspect of the
surgical resection bed, seen on the pre-operative study, which
likely represent normal vessels at the margin of the surgical
resection bed. Allowing for the above, no definitive evidence
for residual tumor is seen. The ventricles and sulci are normal
in size and in contour. There is no shift of normally-midline
structures. No new enhancing mass is identified. No foci
concerning for infarction seen on diffusion- weighted imaging.

[**2152-6-19**] 05:45AM BLOOD WBC-11.2* RBC-4.52 Hgb-12.8 Hct-35.7*
MCV-79* MCH-28.3 MCHC-35.9* RDW-13.7 Plt Ct-307
[**2152-6-19**] 05:45AM BLOOD Plt Ct-307
[**2152-6-19**] 05:45AM BLOOD Plt Ct-307

Brief Hospital Course:
Patient was electively admitted on [**6-15**] for suboccipital
craniotomy for cerebellar mass resection. Intraoperatively, she
diureised nearly seven liters of urine, which was treated with
albumin and crystalloid IV fluids. Due to the excessive urine
output, and elecated lactate in this setting, she was kept
intubated overnight in the ICU for concerns of potential airway
compromise.

On POD#1, DVT prophylaxsis was started, and MRI of the head was
performed to evaluate for residual tumor burden.  Post operative
MR imaging was obtained routinely. She has been followed by
Neuro-oncology, social service, PT and OT while inpt. She has
progressed as expected in the immediate post op course with no
perioperative complications. She is tolerating all p.o. food and
fluid well. She will follow up as outlined in the Neurosurgery
and Brain tumor clinics.

Medications on Admission:
Antivert

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for .
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for .

3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day) as needed for htn.
Disp:*60 Tablet(s)* Refills:*2*
6. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day) x3 days then taper to 2mg [**Hospital1 **] for three days.
Disp:*90 Tablet(s)* Refills:*2*
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).


Discharge Disposition:
Home

Discharge Diagnosis:
Cerebellar Mass


Discharge Condition:
Neurologically Stable


Discharge Instructions:
General Instructions/Information

??????	Have a friend/family member check your incision daily for
signs of infection.
??????	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	You may wash your hair only after sutures have been removed.
??????	You may shower before this time using a shower cap to cover
your head.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, and
Ibuprofen etc.
??????	You are being sent home on steroid medication, make sure you
are taking a medication to protect your stomach (Prilosec,
Protonix, or Pepcid), as these medications can cause stomach
irritation.  Make sure to take your steroid medication with
meals, or a glass of milk.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	Any signs of infection at the wound site: increasing redness,
increased swelling, increased tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Follow-Up Appointment Instructions

??????Please return to the office in [**8-4**] days (from your date of
surgery) for removal of your sutures and a wound check. This
appointment can be made with the Nurse Practitioner.  Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????You have an appointment in the Brain [**Hospital 341**] Clinic on [**7-10**] @
2:00pm with Dr. [**Last Name (STitle) 4253**]. The Brain [**Hospital 341**] Clinic is located on
the [**Hospital Ward Name 516**] of [**Hospital1 18**], in the [**Hospital Ward Name 23**] Building. Their phone
number is [**Telephone/Fax (1) 44**]. Please call if you need to change your
appointment, or require additional directions.
??????You will not need an MRI of the brain as this was completed
during you acute hospitalization



Completed by:[**2152-6-19**]
{'Hemangioma of intracranial structures'}


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: Cerebellar Brain Mass/Vertigo

PRESENT ILLNESS: 49-year-old female who was recently seen in outpatient clinic,
having been referred for a newly diagnosed intracranial lesion.
The patient was
worked up at an outside facility and presented with films
indicating an approximately 2 x 2.5 cm contrast enhancing
lesion, most consistent with a tentorial notch meningioma. Since
the patient is significantly symptomatic from this lesion, the
patient is also in need of a histopathological diagnosis to
further decide on treatment and management

MEDICAL HISTORY: s/p hysterectomy
Cerebal Palsy

MEDICATION ON ADMISSION: Antivert

ALLERGIES: Pollen Extracts

PHYSICAL EXAM: On Admission:
Patient is alert, oriented to person; place; date. Mildly
depressed affect, but pleasant. Full motor strength throughout
upper and lower extremities.

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Married, resides at home with husband in [**Name (NI) 14663**]. No history
of tobacco or illicit substances. 

### Response:
{'Hemangioma of intracranial structures'}
