CHIEF COMPLAINT: status post fall, dizziness

PRESENT ILLNESS: 83 yo female with h/o breast CA s/p mastectomy and chemo and h/o
syncope vs seizure event in [**2108**] who is transferred with a left
cerebellar ICH.

MEDICAL HISTORY: -Breast CA s/p mastectomy and chemo.  Right mastectomy 6 yrs
ago,
followed by chemo and tamoxifen.  She had recurrence in LNs and
was treated with 16 months chemo ~1 yr ago.  She was off for
several months, then got new LNs, so started XRT and got 37
treatments which finished 6 weeks ago.  She also gets frequent
PRBCs.  Onc is Dr [**Last Name (STitle) 6099**] at N-W (part of Farber)
-h/o possible seizure in [**2108**] (MRI at that time with age related
change only by report)
-GERD
-Anemia

MEDICATION ON ADMISSION: Medications:
1. Ketoprofen 50 daily
2. Detrol LA 4 mg
3. Pravachol 20
4. Tramadol 50 prn
5. Omeprazole

ALLERGIES: Caffeine

PHYSICAL EXAM: On admission:
Vitals:98.1, 96, 160/124->142/94, 16, 98% on RA
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: RRR, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema

FAMILY HISTORY: No strokes. Sister and mother with HTN.

SOCIAL HISTORY: Lives alone with cat. Son [**Name (NI) **] involved in care. No smoking.
EtOH socially.
Cerebral thrombosis with cerebral infarction,Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified,Secondary hypercoagulable state,Anemia in neoplastic disease,Esophageal reflux,Personal history of malignant neoplasm of breast
Crbl thrmbs w infrct,Mal neo lymph node NOS,Sec hypercoagulable st,Anemia in neoplastic dis,Esophageal reflux,Hx of breast malignancy
Admission Date:  [**2111-5-7**]              Discharge Date:   [**2111-5-13**]


Service: NEUROLOGY

Allergies:
Caffeine

Attending:[**First Name3 (LF) 5018**]
Chief Complaint:
status post fall, dizziness

Major Surgical or Invasive Procedure:
TEE
MR CERVICAL SPINE W/O C
CT CHEST W/CONTRAST
CTA HEAD & NECK W&W/O C & RECO
C-SPINE, TRAUMA
MR HEAD W & W/O CONTRAS
TTE
CT HEAD W/O CONTRAST


History of Present Illness:
83 yo female with h/o breast CA s/p mastectomy and chemo and h/o
syncope vs seizure event in [**2108**] who is transferred with a left
cerebellar ICH.

She was feeling fine the morning of presentation and got into a
shower.  She then felt LH and increased the hot water. She still
felt LH, leaned forward to grab something and her "head swam"
and she felt strange. She then went down to her knees and
realized she was going to faint. She reports hitting her
shoulder, but she does not think she hit her head(she is not
sure though).  She was apparently in the tub for some time
unable to get up(possibly hours) before her son found her and
called EMS. She went to [**Location (un) 620**] and had a head CT which showed a
left cerebellar hemisphere hemorrhage with some edema, but no
obstruction of the 4th ventricle. She was given mannitol 25g and
transferred here.

She has been mildly confused; per her son, this started about 3
weeks prior to presentation, fairly acutely. For example, she
has been calling the cat the wrong name, went out on the balcony
not fully dressed, and thought it was the fourth of [**Month (only) 205**] last
week. She is usually fully functional at home, living just with
her cat, so this was a significant change from her baseline.

She also has a positive troponin, but had no CP or ECG changes
and no ASA was given due to the hemorrhage.

ROS: Patient denies any fever, chills, nausea, vomiting,
headache, dysarthria, dysphagia, neck pain, weakness, numbness,
tingling, visual changes, diplopia, hearing changes, chest pain,
shortness of breath, or bowel/bladder problems.

Past Medical History:
-Breast CA s/p mastectomy and chemo.  Right mastectomy 6 yrs
ago,
followed by chemo and tamoxifen.  She had recurrence in LNs and
was treated with 16 months chemo ~1 yr ago.  She was off for
several months, then got new LNs, so started XRT and got 37
treatments which finished 6 weeks ago.  She also gets frequent
PRBCs.  Onc is Dr [**Last Name (STitle) 6099**] at N-W (part of Farber)
-h/o possible seizure in [**2108**] (MRI at that time with age related
change only by report)
-GERD
-Anemia


Social History:
Lives alone with cat. Son [**Name (NI) **] involved in care. No smoking.
EtOH socially.


Family History:
No strokes. Sister and mother with HTN.

Physical Exam:
On admission:
Vitals:98.1, 96, 160/124->142/94, 16, 98% on RA
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: RRR, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema

Neurologic examination:
Mental status: Awake and alert, cooperative with exam
Orientation: Oriented to person, [**Location (un) 620**], and [**4-/2027**]
Attention: Able to do DOWF not B
Language: Fluent with good comprehension and repetition. Naming
intact. No dysarthria or paraphasic errors
No apraxia, no neglect. ? ext to DSS on right
[**Location (un) **] intact
Calculation poor. $1.50=8

Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to finger movement.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements

Motor:
Normal bulk and tone bilaterally
Postural tremor in L>R UE. No resting tremor
       D T B WE FiF [**Last Name (un) **] IP Q H DF PF TE([**Last Name (un) 938**])
Right  * 5 5 5  5   5   5  5 5  5  5  5
Left   5 5 5 5  5   5   5  5 5  5  5  5
No pronator drift

Sensation: Intact to light touch, pinprick, temperature (cold),
vibration throughout all extremities.

Reflexes: B T Br Pa Ankle
Right     2 t  t 1   0
Left      2 t  t 1   0

Toes were downgoing bilaterally

Coordination: Normal on finger-nose-finger, rapid alternating
movements normal, FFM normal.

Gait: Not tested

Pertinent Results:
Labs at OSH:
Chem:138/3.2/100/25/27/1/88
Ca=9.7, Alb=4.2, ALT=37, AST=54
CK=552, MB=12, trop=0.128
CBC:12.6/34.7\106 92% polys
INR=1, PTT=33.3

On admission:
CBC: WBC-11.6* RBC-3.31* Hgb-11.5* Hct-31.8* MCV-96 MCH-34.9*
MCHC-36.3* RDW-17.5* Plt Ct-100*
Coags: PT-13.8* PTT-32.3 INR(PT)-1.2*
Chem10: Glucose-109* UreaN-26* Creat-1.0 Na-139 K-3.3 Cl-105
HCO3-22 Calcium-9.5 Phos-4.0 Mg-2.2
FLP: Cholest-163 Triglyc-90 HDL-46 CHOL/HD-3.5 LDLcalc-99
CEs: CK(CPK)-690* CK-MB-16* MB Indx-2.3 cTropnT-0.16*
CK(CPK)-624* CK-MB-13* MB Indx-2.1 cTropnT-0.18*
CK-MB-9 cTropnT-0.20*
%HbA1c-PND

Imaging:
HCT [**5-7**]: 1. Small hyperdense focus in the left cerebellum
likely represents subarachnoid hemorrhage. Mild surrounding
edema, but no significant mass effect on the fourth ventricle.
2. Chronic small vessel ischemic disease, with additional area
of hypodensity in the right parietal lobe that may represent an
area of subacute infarction. If there is clinical concern, MRI
would be more sensitive for evaluation of acute brain ischemia.

MRI [**5-8**]: Multiple infarcts involving several vascular
territories, the largest area involving the right temporal and
parietal regions, which appear acute and subacute. The areas of
enhancement could certainly represent some of the more acute
foci of infarction. Blood products in both the right parietal
region as well as the left cerebellum.
These multiple findings can be unified with the diagnosis of
emboli. Please consider a cardiac echo to evaluate for thrombus
and defects such as a PFO or ASD. Follow up examination in a few
days may help to differentiate multiple emboli from the
possibility of metastatic disease given the patient's history of
breast cancer.

C-spine x-ray: 1. Limited study as described above. The cervical
spine cannot be fully evaluated on these views; however, there
are no signs for acute injury. If there is high clinical
concern, cross-sectional imaging with CT scan can be performed.
2. Extensive degenerative change of the cervical spine. There is
also retrolisthesis of C3 over C4 and anterolisthesis of C4 over
C5.

CTA Head & Neck w/Contrast: 1. 3mm left supraclinoid internal
carotid artery aneurysm.  2. Fusiform aneurysm or pseudoaneurysm
in the V3 segment of the right vertebral artery.  3. Right upper
lobe peripheral consolidation could represent areas of
infection/neoplasm or pulmonary infarct from emboli.

Chest CT w/Contrast: 1. Air bronchogram containing right upper
lobe opacity is likely infectious with malignant etiologies
including a slow growing bronchoalveolar carcinoma felt less
likely. Slightly prominent peripheral interstitial markings more
inferiorly is also likely infectious however underlying
lymphangitic spread of tumor cannot be excluded. Recommend
appropriate treatment and repeat CT examination in three months
to assess for change.
2. Small pericardial effusion. Small right renal hypoattenuating
lesion, likley benign but too small to characterize.
3. Moderate hiatal hernia.
4. Moderate atherosclerotic vascular disease.

TEE [**2111-5-11**]: The left atrium is mildly dilated. No spontaneous
echo contrast or thrombus is seen in the body of the left
atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. No atrial septal defect or patent
foramen ovale is seen by 2D, color Doppler or saline contrast at
rest x 2 (unable to cooperate with maneuvers). There are simple
atheroma in the aortic arch and descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Trace aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild to moderate
([**12-9**]+) mitral regurgitation is seen. There is no pericardial
effusion.
IMPRESSION: Simple atheroma in the aortic arch and descending
thoracic aorta.  Mild-moderate mitral regurgitation.


Brief Hospital Course:
Patient is an 83 yo female with h/o breast CA s/p mastectomy and
chemo and history of syncope vs seizure event in [**2108**], confusion
x 3 weeks, who is transferred with a left cerebellar ICH. On
MRI, found to have multiple infarcts, likely embolic as there is
a large right temporoparietal infarct and multiple other small
infarcts in anterior and posterior circulations bilaterally.
.
1. Neurology: Initial and repeat head CT stable.  MRI showed
right temporoparietal infarct, several other small right and
left infarcts, c/w embolic source or prothrombotic state.  It
was felt that she was prothrombotic and hypercoaguable due to
her malignancy.  We did not start anticoagulation because of the
presence of a large hemorrhagic transformation in the
cerebellum.  Started ASA 325.  Lipid panel was total 163/HDL
46/triglycerides 99/LDL 90, increased Pravastatin to 40.
Hemoglobin A1C was 4.7.  Plan to Repeat MRI with contrast in one
month and follow-up in [**Hospital 4038**] clinic at that time to readdress
starting anti-coagulation such as Lovenox.  Plan discussed with
patient and son who understand the risks of bleeding on
anti-coagulation soon after the stroke and of subsequent strokes
from prothrombotic state due to her underlying metastatic breast
cancer.

2. She had a right upper lobe peripheral consolidation seen on
CXR, which could represent areas of infection/neoplasm or
pulmonary infarct from emboli.  She will need follow up CXR or
CT scan, as an outpatient to further assess the nature of this
finding.  Her PCP was notified.

3. Status post fall:  CT c-spine done at [**Hospital3 4527**]
Hospital, report no fracture but positive for retrolisthesis.
MRI C-spine without ligamentous injury.
.
4. Cards:  Monitored on telemetry without events.  Patient had
elevated tropT (peak 0.20) with normal MB index.  TTE with
normal EF, agitated saline contrast study revealed late bubbles
which may reflect pulmonary A-V shunting but cannot exclude
intracardiac shunt.  TEE negative for valvular vegetations,
clot, large atheromas or ASD/PFO.  TSH and LFTs normal
.
5. ID:  CT chest performed showed air bronchogram containing
right upper lobe opacity, likely infectious with malignant
etiologies including a slow growing bronchoalveolar carcinoma
felt less likely.  Slightly prominent peripheral interstitial
markings more inferiorly is also likely infectious however
underlying lymphangitic spread of tumor cannot be excluded.
Recommend appropriate treatment and repeat CT examination in
three months to assess for change.  Started on Cipro for
treatment of community acquired pneumonia for 7 day course.
.
6. GU:  Continued her home Detrol.
.
7. Heme:  Iron studies consistent with anemia of chronic
disease.  Per her son, she has been intermittently anemia since
start chemotherapy and has required blood transfusions in the
past. She drifted down to a nadir of 22.5 and was transfused two
units of packed red cells on [**2111-5-12**] with an appropriate bump in
her hct to 30.9.  She will need intermittent checks of her hct
and should be tranfused for hct<25.  Her stools were guaiac'd
and were negative.
.
8. PPx:  PPI, RISS, Tylenol
.
9. Other:  PT/OT evaluated patient and recommended discharge to
rehab.

Medications on Admission:
Medications:
1. Ketoprofen 50 daily
2. Detrol LA 4 mg
3. Pravachol 20
4. Tramadol 50 prn
5. Omeprazole


Discharge Medications:
1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
3. Insulin Regular Human 100 unit/mL Solution Sig: PER SLIDING
SCALE UNITS Injection ASDIR (AS DIRECTED).
4. Tolterodine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000)
UNITS Injection TID (3 times a day).
7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
10. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
11. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): Until [**5-16**].
12. Heparin Lock Flush (Porcine) 10 unit/mL Solution Sig: Five
(5) ML Intravenous DAILY (Daily) as needed: 10 ml NS followed by
5 ml of 10 Units/ml heparin (50 units heparin) each lumen Daily
and PRN. Inspect site every shift. .
13. Metaxalone 800 mg Tablet Sig: One (1) Tablet PO at bedtime
as needed for muscle spasm.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 11851**] Healthcare - [**Location (un) 620**]

Discharge Diagnosis:
Primary diagnosis:
- Left cerebellar abd Right parietal infarcts with hemorrhagic
conversion

Secondary diagnosis:
- Metastatic breast CA
- Gastroesophageal reflux
- Anemia


Discharge Condition:
Good. Alert and oriented x2, not to date. Cranial nerves intact.
Right postural tremor. Left finger curl. Left upper motor neuron
pattern arm weakness (dist>prox).


Discharge Instructions:
You have embolic strokes to your brain.  You will need to
follow-up with the stroke neurologist and get a repeat MRI brain
with contrast (see below).

You will need your red blood cell count checked by your primary
care physician one week after discharge.

Please take medications as prescribed and keep your follow-up
appointments.  If you have any weakness, numbness/tingling,
difficulty speaking, sudden vision or hearing changes or any
other worrying symptoms, please call your primary care physician
or return to the emergency department.

Followup Instructions:
PCP: [**Name10 (NameIs) 34556**] [**Name11 (NameIs) 11302**], MD Phone: [**Telephone/Fax (1) 29110**] Date/Time:[**2111-5-25**]
11:30

Stroke neurologist: [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 657**]
Date/Time:[**2111-6-16**] 3:00

Repeat MRI brain with contrast in one month.  Please call
[**Telephone/Fax (1) 327**](#1)

Repeat Chest CT with contrast in 3 months.  Please call
[**Telephone/Fax (1) 327**](#1)


                             [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]
{'Cerebral thrombosis with cerebral infarction,Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified,Secondary hypercoagulable state,Anemia in neoplastic disease,Esophageal reflux,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: status post fall, dizziness

PRESENT ILLNESS: 83 yo female with h/o breast CA s/p mastectomy and chemo and h/o
syncope vs seizure event in [**2108**] who is transferred with a left
cerebellar ICH.

MEDICAL HISTORY: -Breast CA s/p mastectomy and chemo.  Right mastectomy 6 yrs
ago,
followed by chemo and tamoxifen.  She had recurrence in LNs and
was treated with 16 months chemo ~1 yr ago.  She was off for
several months, then got new LNs, so started XRT and got 37
treatments which finished 6 weeks ago.  She also gets frequent
PRBCs.  Onc is Dr [**Last Name (STitle) 6099**] at N-W (part of Farber)
-h/o possible seizure in [**2108**] (MRI at that time with age related
change only by report)
-GERD
-Anemia

MEDICATION ON ADMISSION: Medications:
1. Ketoprofen 50 daily
2. Detrol LA 4 mg
3. Pravachol 20
4. Tramadol 50 prn
5. Omeprazole

ALLERGIES: Caffeine

PHYSICAL EXAM: On admission:
Vitals:98.1, 96, 160/124->142/94, 16, 98% on RA
Gen:NAD.
HEENT:MMM. Sclera clear. OP clear
Neck: No Carotid bruits
CV: RRR, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema

FAMILY HISTORY: No strokes. Sister and mother with HTN.

SOCIAL HISTORY: Lives alone with cat. Son [**Name (NI) **] involved in care. No smoking.
EtOH socially. 

### Response:
{'Cerebral thrombosis with cerebral infarction,Secondary and unspecified malignant neoplasm of lymph nodes, site unspecified,Secondary hypercoagulable state,Anemia in neoplastic disease,Esophageal reflux,Personal history of malignant neoplasm of breast'}
