CHIEF COMPLAINT: Syncope

PRESENT ILLNESS: [**Known firstname **] [**First Name8 (NamePattern2) 7635**] [**Known lastname 54865**] is a 54-year-old woman with breast
cancer and extensive metastasess (liver, lung, [**Last Name (LF) 500**], [**First Name3 (LF) **],
leptomeningeal), s/p lumpectomy, chemoterhapy and radiation
therapy with intrathecal liposomal cytarabine, and CyberKnife
radiosurgery treatment.  Her current chemotherapy regimen
includes intrathecal liposomal cytarabine, zoledronic acid,
paclitaxel, and bevacixumab.  Patient presents after having
episode of loss of consciousness.  She was at home in New
[**Location (un) **] when she felt a headache and dizziness.  She decided
to lay down in bed and her husband then heard a bang and found
her on the floor, she was confused for 3 to 4 minutes and had
two episodes of vomiting and then recovered.  Patient has been
having severe headaches over the past 1-2 months that are
thought to be due in part to bevacizumab, liposomal cytarabine,
or both.  The headaches originally came on with changes in
position, however over the past two days they have come on every
30 minutes and last 2-5 minutes.  They were associated with
changes in peripheral vision, and posterior occipital pain and
neck pain with left sided trigeminal pain and tingling.

MEDICAL HISTORY: Oncologic History (include past therapies, surgeries,
etc):(1) [**12/2090**] Diagnosed with Breast Cancer on left breast and
had a lumpectomy and pathology showed ER+, Progesterone neg,
HER2/Neu and treated with Adriamycin, Cytoxan and Taxol followed
by radiation and tamoxifen,
(2) [**2098**] Diagnosed with metastatic breast cancer to the lungs,
liver, [**Year (4 digits) 500**] and rib and started on Taxol, bevacizumab, Xeloda
and Lupron,
(3) [**5-/2104**] Had an MI and bevacizumab was stopped.
(4) [**5-/2104**] Developed left hip pain
(5) [**2105-2-16**] Pelvic and lumbar MRI showed possible
leptomeningeal disease manifesting as thickened cauda equina,
(6) lumbar puncture on [**2105-2-20**] that showed positive cytology
for malignant cells,
(7) head MRI on [**2105-2-23**] that was normal,
(8) MRI of the cervical and thoracic spine showing
leptomeningeal metastasis at T1-2 level,
(9) started external beam irradiation to C1-T2 and T12-sacrum
on [**2105-2-26**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**],
(10) lumbar puncture on [**2105-2-20**] showed 8 WBC, 215 RBC, 119
protein, 35 glucose, and postive cytology for malignant cells,
and
(11) placement of Ommaya reservoir on [**2105-3-18**] by Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **]
(12) MRI of the brain on [**2105-4-27**] showed a mass at the right
Meckel's cave and this would explain the numbness and pain at
the V2 and V3 distribution of her trigeminal nerve on the right
side of her face.  Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] did CyberKnife radiosurgery
procedure on [**2105-5-6**] to [**2105-5-8**].
(12) Cardiac: [**2104-6-14**] had a mid-LAD MI.  She underwent cardiac
catheterization on [**2105-6-16**] that revealed 2 vessel CAD; a stent
to one vessel and medications adjusted.
CURRENT TREATMENT PLAN:Taxol D1, D15, Avastin D1 and D15, lupron
D15, faslodex D15, Depocyt (liposomal cytarabine) every two
weeks, Xeloda 2 weeks with 1 week off, and zometa every 9 weeks.

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Clopidogrel 75 mg PO DAILY
2. Cyclobenzaprine 10 mg PO BID:PRN pain
3. Gabapentin 600 mg PO TID
4. Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Monday, Wednesday,
Friday
5. traZODONE 50 mg PO HS:PRN insomnia
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Excedrin Migraine *NF* (aspirin-acetaminophen-caffeine)
250-250-65 mg Oral [**Hospital1 **]
8. calcium *NF* unknown  Oral daily
9. Dexamethasone 2 mg PO DAILY Duration: 3 Days Start: In am
2 mg on [**2105-8-12**]
1 mg on [**2105-8-13**]
0.5 mg on [**2105-8-14**] then STOP
Tapered dose - DOWN

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAMINATION:
Vital Signs: T 98.0 F, HR 93, BP 146/84, and O2 saturation 99%
in room air
General:  Alert, oriented, no acute distress
HEENT:  Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck:  Supple, JVP not elevated, no LAD
Cardiovascular:  Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs:  Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen:  Soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: Mother- lung cancer. Father- prostate and [**Name2 (NI) 499**] cancer. Paternal
GM- breast cancer. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.

SOCIAL HISTORY: -Tobacco history: None
-ETOH: None
-Illicit drugs: None
-Married with 4 children, husband (lawyer) is HCP
-Architect by trade
Other alteration of consciousness,Secondary malignant neoplasm of other parts of nervous system,Secondary malignant neoplasm of lung,Retention of urine, unspecified,Headache,Hyperpotassemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Antineoplastic chemotherapy induced anemia,Old myocardial infarction,Personal history of malignant neoplasm of breast,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Percutaneous transluminal coronary angioplasty status,Thoracic or lumbosacral neuritis or radiculitis, unspecified
Other alter consciousnes,Sec malig neo nerve NEC,Secondary malig neo lung,Retention urine NOS,Headache,Hyperpotassemia,Hypertension NOS,Crnry athrscl natve vssl,Hyperlipidemia NEC/NOS,Anemia d/t antineo chemo,Old myocardial infarct,Hx of breast malignancy,Hx antineoplastic chemo,Hx of irradiation,Status-post ptca,Lumbosacral neuritis NOS
Admission Date:  [**2105-8-10**]              Discharge Date:   [**2105-8-14**]

Date of Birth:  [**2051-8-1**]             Sex:   F

Service: NEUROLOGY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 8850**]
Chief Complaint:
Syncope

Major Surgical or Invasive Procedure:
Lumbar puncture on [**2105-8-10**]

History of Present Illness:
[**Known firstname **] [**First Name8 (NamePattern2) 7635**] [**Known lastname 54865**] is a 54-year-old woman with breast
cancer and extensive metastasess (liver, lung, [**Last Name (LF) 500**], [**First Name3 (LF) **],
leptomeningeal), s/p lumpectomy, chemoterhapy and radiation
therapy with intrathecal liposomal cytarabine, and CyberKnife
radiosurgery treatment.  Her current chemotherapy regimen
includes intrathecal liposomal cytarabine, zoledronic acid,
paclitaxel, and bevacixumab.  Patient presents after having
episode of loss of consciousness.  She was at home in New
[**Location (un) **] when she felt a headache and dizziness.  She decided
to lay down in bed and her husband then heard a bang and found
her on the floor, she was confused for 3 to 4 minutes and had
two episodes of vomiting and then recovered.  Patient has been
having severe headaches over the past 1-2 months that are
thought to be due in part to bevacizumab, liposomal cytarabine,
or both.  The headaches originally came on with changes in
position, however over the past two days they have come on every
30 minutes and last 2-5 minutes.  They were associated with
changes in peripheral vision, and posterior occipital pain and
neck pain with left sided trigeminal pain and tingling.

The patient denies any fever, chills, nightsweat, diarrhea,
chest pain, palpitations, cough, dyspnea, frequency, urinary
urgency, or sick contacts.

In the ED, initial vital signs were: T 97.8 F, HR 86, BP 121/69,
RR 14, and oxygen saturation 99% in room air.  She had another
episode in the ED where she was unresponsive briefly and then
recovered.  Laboratory data were notable for WBC 65, lactate
1.3, unremarkable CSF profile, and normal urinalysis.  Head CT
preliminary reported no acute intracranial hemorrhage, edema,
mass, mass effect, or large vascular territorial infarction.
Chest X-ray did not have any acute processes or changes.

On arrival to the MICU, patient's vital signs were T 98.0 F, HR
93, BP 146/84, and oxygen saturation 99% in room air.

Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain.  Denies headache, sinus tenderness, rhinorrhea or
congestion.  Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools.  Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias.  Denies rashes or skin changes.

Past Medical History:
Oncologic History (include past therapies, surgeries,
etc):(1) [**12/2090**] Diagnosed with Breast Cancer on left breast and
had a lumpectomy and pathology showed ER+, Progesterone neg,
HER2/Neu and treated with Adriamycin, Cytoxan and Taxol followed
by radiation and tamoxifen,
(2) [**2098**] Diagnosed with metastatic breast cancer to the lungs,
liver, [**Year (4 digits) 500**] and rib and started on Taxol, bevacizumab, Xeloda
and Lupron,
(3) [**5-/2104**] Had an MI and bevacizumab was stopped.
(4) [**5-/2104**] Developed left hip pain
(5) [**2105-2-16**] Pelvic and lumbar MRI showed possible
leptomeningeal disease manifesting as thickened cauda equina,
(6) lumbar puncture on [**2105-2-20**] that showed positive cytology
for malignant cells,
(7) head MRI on [**2105-2-23**] that was normal,
(8) MRI of the cervical and thoracic spine showing
leptomeningeal metastasis at T1-2 level,
(9) started external beam irradiation to C1-T2 and T12-sacrum
on [**2105-2-26**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**],
(10) lumbar puncture on [**2105-2-20**] showed 8 WBC, 215 RBC, 119
protein, 35 glucose, and postive cytology for malignant cells,
and
(11) placement of Ommaya reservoir on [**2105-3-18**] by Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **]
(12) MRI of the brain on [**2105-4-27**] showed a mass at the right
Meckel's cave and this would explain the numbness and pain at
the V2 and V3 distribution of her trigeminal nerve on the right
side of her face.  Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] did CyberKnife radiosurgery
procedure on [**2105-5-6**] to [**2105-5-8**].
(12) Cardiac: [**2104-6-14**] had a mid-LAD MI.  She underwent cardiac
catheterization on [**2105-6-16**] that revealed 2 vessel CAD; a stent
to one vessel and medications adjusted.
CURRENT TREATMENT PLAN:Taxol D1, D15, Avastin D1 and D15, lupron
D15, faslodex D15, Depocyt (liposomal cytarabine) every two
weeks, Xeloda 2 weeks with 1 week off, and zometa every 9 weeks.

Past Medical History:
Recurrent UTI's
Hypertension
Proteinuria (d/t Avastin)
Immunocompromised state
Coronary artery disease, s/p BMS to LCx
Hyperlipidemia
Headaches

Social History:
-Tobacco history: None
-ETOH: None
-Illicit drugs: None
-Married with 4 children, husband (lawyer) is HCP
-Architect by trade

Family History:
Mother- lung cancer. Father- prostate and [**Name2 (NI) 499**] cancer. Paternal
GM- breast cancer. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.

Physical Exam:
ADMISSION EXAMINATION:
Vital Signs: T 98.0 F, HR 93, BP 146/84, and O2 saturation 99%
in room air
General:  Alert, oriented, no acute distress
HEENT:  Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck:  Supple, JVP not elevated, no LAD
Cardiovascular:  Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs:  Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen:  Soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

Genitourinary:  No foley
Extremities:  Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema

Neurological Examination:  Her Karnofsky Performance Score is
60.  She is awake, alert, and oriented times 3.  She is able to
respond to questions appropriately.  Her language is fluent with
good comprehension.  Her recent recall is good.  Cranial Nerve
Examination:  Her pupils are equal and reactive to light, 4 mm
to 2 mm on the right and 3 mm to 2 mm on the left.  Extraocular
movements are full; there is a few beats of possibly physiologic
nystagmus on right gaze.  Visual fields are full to
confrontation.  She has a slight increasein right palpebral
fissure and closure of her left eyelid is slightly weaker than
the right.  Facial sensation is intact bilaterally.  Her hearing
is intact bilaterally.  Her tongue is midline.  Palate goes up
in the midline.  Sternocleidomastoids and upper trapezius are
strong.  Motor Examination:  She does not have a drift.  Her
muscle strengths are [**4-18**] at all muscle groups, except for
weakness in the flexor digitorum of the right foot at 4/5.  Her
muscle tone is normal.  Her reflexes are absent throughout.  Her
ankle jerks are absent.  Her right toe is down while the left is
up.  Sensory examination is intact to touch and proprioception;
there is no glove-stocking or radicular pattern of sensation
loss.  Coordination examination does not reveal appendicular
dysmetria.  Gait and stance are deferred.

DISCHARGE EXAMINATION:
Vital Signs:  Tm 97.6 F, BP 136/76, HR 82, RR 20, O2 saturation
100% in room air
General:  NAD, resting comfortably in bed
Skin:  Warm and well perfused, no excoriations or lesions, no
rashes
HEENT:  AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
Cardiovascular:  RRR, S1/S2, no murmers, gallops, or rubs
Lungs:  CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
Abdomen:  Non-distended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Extremities:  Moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
Pulses:  2+ DP pulses bilaterally

Neurological Examination:  CN II-XII intact, sensation decreased
in lower extremity b/l, 5/5 strength in upper and lower
extremity

Pertinent Results:
ADMISSION LABS:
[**2105-8-10**] 04:50PM BLOOD WBC-67.0*# RBC-3.11* Hgb-11.4* Hct-33.2*
MCV-107* MCH-36.8* MCHC-34.5 RDW-17.4* Plt Ct-142*
[**2105-8-10**] 04:50PM BLOOD Neuts-95* Bands-5 Lymphs-0* Monos-0 Eos-0
Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-1*
[**2105-8-10**] 04:50PM BLOOD PT-11.3 PTT-27.1 INR(PT)-1.0
[**2105-8-10**] 04:50PM BLOOD Glucose-104* UreaN-14 Creat-0.5 Na-133
K-5.5* Cl-99 HCO3-21* AnGap-19
[**2105-8-10**] 04:50PM BLOOD Prolact-7.7
[**2105-8-10**] 08:12PM BLOOD Lactate-1.3
[**2105-8-10**] 04:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014
[**2105-8-10**] 04:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
[**2105-8-10**] 04:35PM URINE UCG-NEGATIVE
[**2105-8-10**] 08:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-2* Polys-10
Lymphs-90 Monos-0
[**2105-8-10**] 08:00PM CEREBROSPINAL FLUID (CSF) TotProt-70*
Glucose-61

MICROBIOLOGY:
Blood cultures [**2105-8-10**]:
Urine culture [**2105-8-10**]:
CSF culture [**2105-8-10**]: pending, gram stain negative

IMAGING:
CT Head w/o contrast [**2105-8-10**]:
1.  No acute intracranial process.
2.  Unchanged mild left mastoid air cell opacification.

Chest X-Ray [**2105-8-10**]:
No acute intrathoracic process.

Other labs:
[**2105-8-11**] 04:30AM BLOOD WBC-56.5* RBC-3.17* Hgb-11.3* Hct-33.1*
MCV-105* MCH-35.7* MCHC-34.1 RDW-17.4* Plt Ct-155
[**2105-8-12**] 06:00AM BLOOD WBC-20.9*# RBC-3.06* Hgb-11.0* Hct-34.0*
MCV-111* MCH-35.8* MCHC-32.2 RDW-17.0* Plt Ct-160
[**2105-8-13**] 07:00AM BLOOD WBC-12.0* RBC-2.96* Hgb-10.6* Hct-31.4*
MCV-106* MCH-35.6* MCHC-33.7 RDW-17.4* Plt Ct-191
[**2105-8-14**] 05:20AM BLOOD WBC-17.9* RBC-2.95* Hgb-10.4* Hct-31.2*
MCV-106* MCH-35.2* MCHC-33.2 RDW-17.3* Plt Ct-193
[**2105-8-12**] 06:00AM BLOOD Neuts-94.1* Lymphs-3.0* Monos-2.1 Eos-0.5
Baso-0.3

Brief Hospital Course:
[**Known firstname **] [**First Name8 (NamePattern2) 7635**] [**Known lastname 54865**] is a 54-year-old woman with breast
cancer and extensive mets  s/p lumpectomy, chemoterhapy and
radiation therapy with intrathecal liposomal cytarabine and
CyberKnife radiosurgery treatment for leptomeningeal disease
admitted after loss of consciousness concerning for seizure.

(1) Syncope:  Patient presented s/p LOC with fall.  Differential
diagnosis includes seizure, syncope, infection, intracranial
mass.  Description of episode, LOC without immediate recovery is
more consistent with seizure than syncope.  Pertinent negatives
include normal CSF, CT scan unchanged without any acute bleed or
midline shift. Episode seems less likely to be syncope given
association with headache, however she was placed on telemetry.
No events were found.  She had orthostatics which showed an
18mmg difference between systolic blood pressures standing and
sitting, and was given a fluid bolus of 1L.  EEG for 20 minute
showed short runs of sharp waves concerning for seizure
activity, and so 24-hour EEG was recommended.  Urine and blood
cultures were sent. The 24 hour EEG study was undertaken and no
seizure activity was noted.  Patient denied any seizure activity
or loss of consciousness.  She was started on valproic Acid to
prevent further seizures which she will take once discharged.

(2) Headache:  Patient with 1-2 months of headaches that are
increasing in frequency and now associated with loss of
consciousness and vomiting.  Etiology unclear.  Differential
includes metastatic disease, migraine, tension, post LP,
medication side effect.  Patient has a history of migraine
headaches prior to diagnosis of breast cancer.  CT scan ruled
out acute bleed or midline shift.  CSF with no evidence of
infection. She was started on morphine 2-5 mg q 4hrs prn pain
with continuation of gabapentin prn and cyclobenzaprine as
needed.  Pain service was consulted who recommended no blood
patch as was considered a possibility as an outpatient.  They
did recommend IV caffeine, however, this is not available
currently, as well as continuing morphine and encouraging good
fluid intake, which minimalization of position changes.  Pt was
transitioned from Morphine IV to Morphine Sulfate IR 15-30 mg PO
Q4H in preparation for discharge. This oral morphine seemed to
control her pain well and pt was satisfied with pain control
regimen.

(3) Leukocytosis:  Patient received neulasta [**8-8**]. Likely
secondary to this.  No evidence of infection (unchanged chest
X-ray, normal CSF, normal urinalysis, denies fever, chills, or
nightsweat).  Patient's oncologist informed who believes this is
most likely secondary to Neulasta and dexamethasone.  This was
trended.

(4) Metastatic Breast Cancer:  Patient is s/p lumpectomy with
chemo and radiation therapy.  Metastatic disease to lung, [**Month/Year (2) 500**],
brain, leptomeningeal disease.  Current chemo regimen includes
intrathecal cytarabine, zoledronic acid, paclitaxel,
bevacixumab.  Outpatient oncologist was informed.  Dexamethasone
taper from CyberKnife to cerebellar lesions was continued; this
should be 2mg [**2105-8-12**], 1mg [**2105-8-13**], 0.5mg [**2105-8-14**], then stop.
 Chemotherapeutic regimen was held while hospitalized which she
will resume as directed by primary oncologist.

(5) CAD s/p MI with Stent:
- continued ASA, crestor
- Plavix on hold for possible blood patch, this was restarted as
the pain service does not want to pursue a blood patch.

Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Clopidogrel 75 mg PO DAILY
2. Cyclobenzaprine 10 mg PO BID:PRN pain
3. Gabapentin 600 mg PO TID
4. Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Monday, Wednesday,
Friday
5. traZODONE 50 mg PO HS:PRN insomnia
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Excedrin Migraine *NF* (aspirin-acetaminophen-caffeine)
250-250-65 mg Oral [**Hospital1 **]
8. calcium *NF* unknown  Oral daily
9. Dexamethasone 2 mg PO DAILY Duration: 3 Days Start: In am
2 mg on [**2105-8-12**]
1 mg on [**2105-8-13**]
0.5 mg on [**2105-8-14**] then STOP
Tapered dose - DOWN

Discharge Medications:
1. Cyclobenzaprine 10 mg PO BID:PRN pain
2. Dexamethasone 4 mg PO BID please give at 0800 and 1400
RX *dexamethasone 4 mg 1 (One) tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
3. Gabapentin 600 mg PO TID
4. Rosuvastatin Calcium 20 mg PO DAILY
5. Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Monday, Wednesday,
Friday
6. traZODONE 50 mg PO HS:PRN insomnia
7. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace]
100 mg 1 (One) capsule(s) by mouth Twice daily Disp #*60 Capsule
Refills:*0
8. Famotidine 20 mg PO Q12H RX *famotidine 20 mg 1 (One)
tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0
9. Ondansetron 4 mg PO Q8H:PRN nausea RX *ondansetron 4 mg 1
(One) tablet(s) by mouth every eight hours Disp #*90 Tablet
Refills:*0
10. Senna 1 TAB PO BID:PRN constipation RX *sennosides [senna]
8.6 mg 1 (One) tablet by mouth twice daily Disp #*60 Capsule
Refills:*0
11. Valproic Acid 250 mg PO Q8H RX *valproic acid (as sodium
salt) 250 mg/5 mL (5 mL) 5 Milliliter by mouth every eight hours
Disp #*450 Milliliter Refills:*0
12. Clopidogrel 75 mg PO DAILY
13. Excedrin Migraine *NF* (aspirin-acetaminophen-caffeine) 250
mg ORAL [**Hospital1 **]
14. calcium *NF* 0 unknown ORAL DAILY
15. Aspirin 81 mg PO DAILY
16. Morphine Sulfate IR 15-30 mg PO Q4H:PRN pain RX *morphine 15
mg [**12-15**] tablet(s) by mouth every 4 hours Disp #*270 Tablet
Refills:*0

Discharge Disposition:
Home

Discharge Diagnosis:
Primary diagnosis:
Loss of consciousness

Secondary diagnosis:
Metastatic breast cancer
Headaches

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

Discharge Instructions:
Ms. [**Known lastname 54865**],

It has been a pleasure taking care of you here at [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1675**]
[**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **].

You were admitted because of loss of consciousness.  You
received many tests and the good news is that you had no
documented seizure activity.

You will require close follow up with your primary care
physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 84166**] to refill the presciption on oral
morphine, the pain medication started during this admission.  Do
not drink alcohol with this medication.  Do not operate heavy
machinary or drive while taking this medication.  You will also
have follow-up with your oncologists, Dr. [**Last Name (STitle) 724**] and Dr. [**First Name (STitle) **].
Please see below for appointments that have already been made
for you.

Medication changes have been made during this admission.  Please
see the accompanying chart regarding medication changes.

Followup Instructions:
Department: Primary Care
Name: Dr. [**First Name4 (NamePattern1) 6382**] [**Last Name (NamePattern1) 84166**]
When: Thursday [**2105-8-20**] at 10:00 AM
Address: [**Apartment Address(1) 107061**], [**Hospital1 **],[**Numeric Identifier 4293**]
Phone: [**Telephone/Fax (1) 26774**]

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2105-8-21**] at 11:00 AM
With: PADDY [**Name8 (MD) **], RN [**Telephone/Fax (1) 9644**]
Building: [**Hospital6 29**] [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: HEMATOLOGY/ONCOLOGY
When: FRIDAY [**2105-8-21**] at 11:00 AM
With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 22**]
Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage

Department: [**Hospital1 **] MRI (MOBILE)
When: MONDAY [**2105-8-31**] at 11:55 AM
With: MRI [**Telephone/Fax (1) 590**]
Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: HEMATOLOGY/ONCOLOGY-SC
When: [**2105-9-4**] at 10:30a
With: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]
Building:  SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **]
Campus: EAST     Best Parking: [**Hospital Ward Name 23**] Garage
{'Other alteration of consciousness,Secondary malignant neoplasm of other parts of nervous system,Secondary malignant neoplasm of lung,Retention of urine, unspecified,Headache,Hyperpotassemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Antineoplastic chemotherapy induced anemia,Old myocardial infarction,Personal history of malignant neoplasm of breast,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Percutaneous transluminal coronary angioplasty status,Thoracic or lumbosacral neuritis or radiculitis, 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: Syncope

PRESENT ILLNESS: [**Known firstname **] [**First Name8 (NamePattern2) 7635**] [**Known lastname 54865**] is a 54-year-old woman with breast
cancer and extensive metastasess (liver, lung, [**Last Name (LF) 500**], [**First Name3 (LF) **],
leptomeningeal), s/p lumpectomy, chemoterhapy and radiation
therapy with intrathecal liposomal cytarabine, and CyberKnife
radiosurgery treatment.  Her current chemotherapy regimen
includes intrathecal liposomal cytarabine, zoledronic acid,
paclitaxel, and bevacixumab.  Patient presents after having
episode of loss of consciousness.  She was at home in New
[**Location (un) **] when she felt a headache and dizziness.  She decided
to lay down in bed and her husband then heard a bang and found
her on the floor, she was confused for 3 to 4 minutes and had
two episodes of vomiting and then recovered.  Patient has been
having severe headaches over the past 1-2 months that are
thought to be due in part to bevacizumab, liposomal cytarabine,
or both.  The headaches originally came on with changes in
position, however over the past two days they have come on every
30 minutes and last 2-5 minutes.  They were associated with
changes in peripheral vision, and posterior occipital pain and
neck pain with left sided trigeminal pain and tingling.

MEDICAL HISTORY: Oncologic History (include past therapies, surgeries,
etc):(1) [**12/2090**] Diagnosed with Breast Cancer on left breast and
had a lumpectomy and pathology showed ER+, Progesterone neg,
HER2/Neu and treated with Adriamycin, Cytoxan and Taxol followed
by radiation and tamoxifen,
(2) [**2098**] Diagnosed with metastatic breast cancer to the lungs,
liver, [**Year (4 digits) 500**] and rib and started on Taxol, bevacizumab, Xeloda
and Lupron,
(3) [**5-/2104**] Had an MI and bevacizumab was stopped.
(4) [**5-/2104**] Developed left hip pain
(5) [**2105-2-16**] Pelvic and lumbar MRI showed possible
leptomeningeal disease manifesting as thickened cauda equina,
(6) lumbar puncture on [**2105-2-20**] that showed positive cytology
for malignant cells,
(7) head MRI on [**2105-2-23**] that was normal,
(8) MRI of the cervical and thoracic spine showing
leptomeningeal metastasis at T1-2 level,
(9) started external beam irradiation to C1-T2 and T12-sacrum
on [**2105-2-26**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**],
(10) lumbar puncture on [**2105-2-20**] showed 8 WBC, 215 RBC, 119
protein, 35 glucose, and postive cytology for malignant cells,
and
(11) placement of Ommaya reservoir on [**2105-3-18**] by Dr. [**First Name8 (NamePattern2) **]
[**Name (STitle) **]
(12) MRI of the brain on [**2105-4-27**] showed a mass at the right
Meckel's cave and this would explain the numbness and pain at
the V2 and V3 distribution of her trigeminal nerve on the right
side of her face.  Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] did CyberKnife radiosurgery
procedure on [**2105-5-6**] to [**2105-5-8**].
(12) Cardiac: [**2104-6-14**] had a mid-LAD MI.  She underwent cardiac
catheterization on [**2105-6-16**] that revealed 2 vessel CAD; a stent
to one vessel and medications adjusted.
CURRENT TREATMENT PLAN:Taxol D1, D15, Avastin D1 and D15, lupron
D15, faslodex D15, Depocyt (liposomal cytarabine) every two
weeks, Xeloda 2 weeks with 1 week off, and zometa every 9 weeks.

MEDICATION ON ADMISSION: Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Clopidogrel 75 mg PO DAILY
2. Cyclobenzaprine 10 mg PO BID:PRN pain
3. Gabapentin 600 mg PO TID
4. Sulfameth/Trimethoprim DS 1 TAB PO QMOWEFR Monday, Wednesday,
Friday
5. traZODONE 50 mg PO HS:PRN insomnia
6. Rosuvastatin Calcium 20 mg PO DAILY
7. Excedrin Migraine *NF* (aspirin-acetaminophen-caffeine)
250-250-65 mg Oral [**Hospital1 **]
8. calcium *NF* unknown  Oral daily
9. Dexamethasone 2 mg PO DAILY Duration: 3 Days Start: In am
2 mg on [**2105-8-12**]
1 mg on [**2105-8-13**]
0.5 mg on [**2105-8-14**] then STOP
Tapered dose - DOWN

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAMINATION:
Vital Signs: T 98.0 F, HR 93, BP 146/84, and O2 saturation 99%
in room air
General:  Alert, oriented, no acute distress
HEENT:  Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck:  Supple, JVP not elevated, no LAD
Cardiovascular:  Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs:  Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen:  Soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding

FAMILY HISTORY: Mother- lung cancer. Father- prostate and [**Name2 (NI) 499**] cancer. Paternal
GM- breast cancer. No family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.

SOCIAL HISTORY: -Tobacco history: None
-ETOH: None
-Illicit drugs: None
-Married with 4 children, husband (lawyer) is HCP
-Architect by trade 

### Response:
{'Other alteration of consciousness,Secondary malignant neoplasm of other parts of nervous system,Secondary malignant neoplasm of lung,Retention of urine, unspecified,Headache,Hyperpotassemia,Unspecified essential hypertension,Coronary atherosclerosis of native coronary artery,Other and unspecified hyperlipidemia,Antineoplastic chemotherapy induced anemia,Old myocardial infarction,Personal history of malignant neoplasm of breast,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Percutaneous transluminal coronary angioplasty status,Thoracic or lumbosacral neuritis or radiculitis, unspecified'}
