CHIEF COMPLAINT: hand weakness

PRESENT ILLNESS: 62-year-old woman who presents with cervical spondylitic
myelopathy.  She reports difficulty with buttoning her blouse
and repeatedly dropping things.  This has become progressively
more severe over the last several months, but dates back at
least a year or more.  She has paravertebral spasm, which
migrates to the shoulders, but to no real radiculopathy.  She
denies difficulty with bowel, bladder, or gait.

MEDICAL HISTORY: hypertension

MEDICATION ON ADMISSION: albuterol,esidrix 12.5, lipitor80, toprol XL 50,lisinopril
10,MVI, NTG prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On examination, her motor strength is [**6-11**] in the deltoid,
biceps, triceps, and hand intrinsics bilaterally.  There may
have been some mild weakness of the triceps and deltoid on the
left, but this may have been effort dependent as well.  The
lower extremity strength is normal.  She is able to stand out of
a chair without using her arms.  Her sensory examination showed
a decreased appreciation of light touch in the hands
bilaterally. It does not follow a dermatomal pattern.  Her hand
intrinsics were diminished and graded [**5-12**] bilaterally.  There
was no clonus. Lhermitte's phenomenon was absent.  Hoffmann's
reflex was absent.

FAMILY HISTORY: nc

SOCIAL HISTORY: She smokes approximately a third of a pack per day.
Cervical spondylosis with myelopathy,Quadriplegia, unspecified,Vascular myelopathies,Accidental puncture or laceration of dura during a procedure,Ventilator associated pneumonia,Candidiasis of mouth,Acute venous embolism and thrombosis of axillary veins,Delirium due to conditions classified elsewhere,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Percutaneous transluminal coronary angioplasty status,Tobacco use disorder,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified adjustment reaction,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Cerv spondyl w myelopath,Quadriplegia, unspecifd,Vascular myelopathies,Accid punc/op lac dura,Ventltr assoc pneumonia,Thrush,Ac emblsm axillary veins,Delirium d/t other cond,Acc cut/hem in surgery,Hypertension NOS,DMII wo cmp nt st uncntr,Status-post ptca,Tobacco use disorder,MRSA elsewhere/NOS,Abn react-procedure NEC,Adjustment reaction NOS,Abn react-artif implant
Admission Date:  [**2167-4-30**]              Discharge Date:   [**2167-5-29**]

Date of Birth:  [**2105-6-17**]             Sex:   F

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
hand weakness

Major Surgical or Invasive Procedure:
C6 corpectomy and ACDF C7T1 with allograft and plate
tracheostomy
PEG
lumbar drain placements


History of Present Illness:
62-year-old woman who presents with cervical spondylitic
myelopathy.  She reports difficulty with buttoning her blouse
and repeatedly dropping things.  This has become progressively
more severe over the last several months, but dates back at
least a year or more.  She has paravertebral spasm, which
migrates to the shoulders, but to no real radiculopathy.  She
denies difficulty with bowel, bladder, or gait.

Past Medical History:
hypertension

Social History:
She smokes approximately a third of a pack per day.

Family History:
nc

Physical Exam:
On examination, her motor strength is [**6-11**] in the deltoid,
biceps, triceps, and hand intrinsics bilaterally.  There may
have been some mild weakness of the triceps and deltoid on the
left, but this may have been effort dependent as well.  The
lower extremity strength is normal.  She is able to stand out of
a chair without using her arms.  Her sensory examination showed
a decreased appreciation of light touch in the hands
bilaterally. It does not follow a dermatomal pattern.  Her hand
intrinsics were diminished and graded [**5-12**] bilaterally.  There
was no clonus. Lhermitte's phenomenon was absent.  Hoffmann's
reflex was absent.

Exam on discharge: Awake and alert. Follows commands. Moving L
bicep and deltoid with 5-/5 strength. Moves R bicep 4-/5 and R
deltoid 5-/5. No movement in lower extremities.


Pertinent Results:
An MRI of the cervical spine on [**2166-12-5**] demonstrated normal
alignment.  There were degenerative changes throughout with
significant compression at both C5-6 and C6-7 and compression
behind the body of C6 as well.  There
was less severe, but still significant compression at the C7-T1
disc.

MRI C SPINE [**4-30**]
The patient is status post C6 corpectomy and partial resection
of a heavily
calcified PLL. There is extensive signal intensity abnormality
in the spinal cord, new since the study of [**2166-12-5**]. The
spinal cord is poorly defined at the level of surgery, which may
reflect, singly or in combination, contusion,infarction, or
direct mechanical injury. There appears to be intramedullary
hemorrhage inferior to the surgical site, again difficult to
characterize

Chest X ray [**5-6**]
Left lower lobe retrocardiac opacity has improved consistent
with improving atelectasis. Right middle lobe consolidation is
unchanged. There is evidence of loss of volume in the right
chest with tenting of the hemidiaphragm. This loss of volume is
most likely due to atelectasis in the right middle lobe.  There
is no pneumothorax or large pleural effusion. Left PICC remains
in place. NG tube tip is out of view below the diaphragm. ET
tube is seen in standard position.

MRI brain [**2167-5-8**]
No acute intracranial abnormality. Paranasal sinus mucosal
reaction with fluid-fluid levels in the sphenoidal sinuses and
mastoid
opacification. This may be secondary to intubation.

MR [**Name13 (STitle) 2853**] [**2167-5-8**]

LUE Doppler [**2167-5-8**]
Non-occlusive DVT extending from the left axillary vein to the
subclavian vein. Complete thrombosis of the left basilic vein.

Chest X ray [**5-14**]

Unchanged moderate cardiomegaly with areas of atelectasis at
both the right and the left lung base. No newly appeared focal
parenchymal opacities. No larger pleural effusions. No
pneumothorax.

Echo [**5-18**]

The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The estimated pulmonary artery systolic pressure is high normal.
There is an anterior space which most likely represents a
prominent fat pad.


Brief Hospital Course:
Pt was admitted electively to hospital, went to OR where under
general anesthesia underwent C6 corpectomy and C7T1 ACDF with
plate.  She tolerated the procedure well, was extubated, and
post op was found to have poor motor exam.  She underwent
emergent MRI which showed no hematoma or cord compression.  She
was monitored in ICU with MAP>80 to promote cord perfusion.  She
was also started on high dose steroids.  She had slight
improvement in UE strength in morning but still no movement of
lower extremities. She was maintained at flat bedrest for dural
leak from OR but then activity liberalized [**2167-5-2**]. Steroids
were slowly tapered. She had slight improvement in UE motor
function.  On [**5-4**] early morning she required intubation for
respiratory decline. She had a bronchoscopy that revealed
copious clear secreation. Repeat bronchoscopy was performed the
same day and more secretions were suctioned and the airway was
mildly erythematous.

On [**2167-5-5**] an additional repeat bronchoscopy was performed with
brochoalveleolar lavage of the left lower lobe. She continued to
require pressors to maintain a MAP above 80. Aterial line
placement for blood pressure monitoring failed. She also spiked
a fever to 102.8 and a fever workup was sent.

On [**5-6**] goal MAP of greater than 80 was deemed no longer
necessary, though the patient could not be weaned off pressurs.
Given the patients tenous respiratory status, secretion
production, and fevers, therapy for ventilator associated
pneumonia was initiated with vancomycin/cefepime/ciprofloxacin.
The BAL samples speciated to H.influenzae.

On [**5-7**] she continued to be febrile and a planned trach/PEG was
delayed. She remained consistently febrile overnight and on [**5-8**]
a.m she was transistioned to high dose ceftriaxone for better
coverage of H. Flu in her sputum. An MRI of the cervical spine
was ordered as part of fever workup and this showed an increase
in pseudomeningoceal but cord comprssion was not suspected. She
was febrile on [**5-9**] and antibiotic dosing was increased per ID.
She was found to have a DVT at her Left PICC site and a Heparin
drip was started when cleared by Neurosurgery.

[**Date range (1) 105207**] Heparin drip remained on with a goal PTT of 45-60 for
the treatment of her DVT. She remained febrile with a rising WBC
count and ID changed her abx regimen to ceftriaxone and
linezolid. On [**5-12**] a tracheostomy was attempted but was aborted
when a CSF collection was encountered. A JP drain was placed at
the site of the fluid collection and she was transferred back to
the ICU. CSF was sent for culture at that time. The JP drain
continued with drainage of CSF and on [**5-14**] she underwent
uncomplicated placement of lumbar drain, her JP drain was
removed and a stitch was placed on the site.

[**5-15**]- Pt underwent tracheostomy and PEG tube placement. Her
lumbar drain continued to drain and her neck remained soft
without any palpable fluid collection. Her JP site had no active
drainage. Her abx continued per ID recs.

[**Date range (1) 52620**]- Her WBC count continued to trend down over the weeknd
and she remained on abx treatment for hospital aquired PNA with
H.Flu and MRSA. Her lumbar drain stopped functioning on [**5-17**] and
it was pulled without complication. Her Heparin GTT was held
overnight in preparation for lumbar drain placement on [**5-18**].

[**5-18**]- Pt underwent placement of two lumbar drains and tolerated
this procedure very well. Both drains were functioning well and
she was draining a total of 15-20cc of CSF per hour.

[**5-19**]- Pt had small amount of serosanguinous drainage at the
lumbar drain sites that was insignificant. Her glycopyrolate was
increased. On physical examination it was noted she had some
thrush and fluconazole was started. She was weaned off of neo.

[**5-20**]: She was switched to cefazolin Q8H for drain prophylaxis
after finishing her course of antibiotics for ventilator
associated pneumonia. She was switched hydrocortisone from to
prednisone to further wean off of steroids.

She continued to have lumbar drain in place. CSF was cultured
for surveillance which revealed no growth.  She continued to
have hypotension but remained aymptomatic.  She was started on
Glycopyrrolate to improved her pressures on [**5-21**]. On Sunday,
[**5-24**], her LD was removed and sutures were placed which should be
removed 7-10 days. On [**5-25**], patient was stable on examination.
No drainage was observed at the trach site or around lumbar
drain sites. Her PTT was at goal and coumadin 5mg QD was started
and was therapeutic at INR 2.4 [**2167-5-26**] and heparin drip was
discontinued.  She will need to remain on coumadin for [**4-12**]
months for treatment of left arm DVT. Her exam remained stable
with trapezious full, deltoid/bicep 5-/4+ and no
triceps/grip/LE.  Wound clean and dry.

Medications on Admission:
albuterol,esidrix 12.5, lipitor80, toprol XL 50,lisinopril
10,MVI, NTG prn

Discharge Medications:
1. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
6-8 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing.

3. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
4. glycopyrrolate 1 mg Tablet Sig: Two (2) Tablet PO QID (4
times a day).
5. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
6. ipratropium bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig:
Six (6) Puff Inhalation Q4H (every 4 hours) as needed for
wheezing.
7. docusate sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg
PO BID (2 times a day).
8. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
9. oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO Q4H (every 4
hours) as needed for pain.
10. midodrine 2.5 mg Tablet Sig: 1.5 Tablets PO Q6H (every 6
hours).
11. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
goal INR 2.5 - 3.0.
12. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y
(650) mg PO Q6H (every 6 hours) as needed for pain/fever.
13. acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs
Miscellaneous Q6H (every 6 hours) as needed for thick
secretions.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
cervical spondylotic myelopathy
Hospital aquired pneumonia
quadraplegia
Pseudomeningocele
Upper extremity DVT
CSF leak
Sepsis
Pneumonia
MRSA
Respiratory failure
Post-op Fever
Delirium
dysphagia
Transient transaminitis
Adjustment disorder


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
??????        Keep wound clean
??????        Take medication as instructed.
??????        Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months to promote
bony fusion. Please use bone stimulator per instructions from
vendor.
**Remove lumbar drain sutures [**2167-6-3**]***

Followup Instructions:
YOUR SUTURES ARE UNDER THE SKIN YOU WILL NOT NEED TO BE SEEN
UNTIL THE FOLLOW UP APPOINTMENT
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED AP AND LATERAL C SPINE XRAYS PRIOR TO YOUR
APPOINTMENT



Completed by:[**2167-5-28**]
{'Cervical spondylosis with myelopathy,Quadriplegia, unspecified,Vascular myelopathies,Accidental puncture or laceration of dura during a procedure,Ventilator associated pneumonia,Candidiasis of mouth,Acute venous embolism and thrombosis of axillary veins,Delirium due to conditions classified elsewhere,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Percutaneous transluminal coronary angioplasty status,Tobacco use disorder,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified adjustment reaction,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}


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: hand weakness

PRESENT ILLNESS: 62-year-old woman who presents with cervical spondylitic
myelopathy.  She reports difficulty with buttoning her blouse
and repeatedly dropping things.  This has become progressively
more severe over the last several months, but dates back at
least a year or more.  She has paravertebral spasm, which
migrates to the shoulders, but to no real radiculopathy.  She
denies difficulty with bowel, bladder, or gait.

MEDICAL HISTORY: hypertension

MEDICATION ON ADMISSION: albuterol,esidrix 12.5, lipitor80, toprol XL 50,lisinopril
10,MVI, NTG prn

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On examination, her motor strength is [**6-11**] in the deltoid,
biceps, triceps, and hand intrinsics bilaterally.  There may
have been some mild weakness of the triceps and deltoid on the
left, but this may have been effort dependent as well.  The
lower extremity strength is normal.  She is able to stand out of
a chair without using her arms.  Her sensory examination showed
a decreased appreciation of light touch in the hands
bilaterally. It does not follow a dermatomal pattern.  Her hand
intrinsics were diminished and graded [**5-12**] bilaterally.  There
was no clonus. Lhermitte's phenomenon was absent.  Hoffmann's
reflex was absent.

FAMILY HISTORY: nc

SOCIAL HISTORY: She smokes approximately a third of a pack per day. 

### Response:
{'Cervical spondylosis with myelopathy,Quadriplegia, unspecified,Vascular myelopathies,Accidental puncture or laceration of dura during a procedure,Ventilator associated pneumonia,Candidiasis of mouth,Acute venous embolism and thrombosis of axillary veins,Delirium due to conditions classified elsewhere,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Unspecified essential hypertension,Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled,Percutaneous transluminal coronary angioplasty status,Tobacco use disorder,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Unspecified adjustment reaction,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
