CHIEF COMPLAINT: back pain, leg weakness

PRESENT ILLNESS: HPI: Pt is a 55 yo male w/ PMHx sig for metastatic renal cancer
to the thoracic spine, rheumatoid arthritis who presents as a
transfer from an OSH for leg weakness.  The patient was found to
have a renal tumor in [**2190**] s/p resection.  In [**6-21**] the patient
was found to have an extradural mass at T5 that was felt to be
metastases.  The patient is also known to have a kyphotic
collapse at T10.  The patient was seen in Dr.[**Name (NI) 2845**] office
several days ago where it was felt that the patient would need
surgical instrumentation of the thoracic spine for
stabilization.
This was scheduled for the future.  In the last couple of days,
the patient has had increased difficulty walking and numbness in
his legs.  He was seen at an OSH and then transferred to [**Hospital1 18**]
for further evaluation.

MEDICAL HISTORY: Past Medical History: rheumatoid arthritis x 20 years, renal ca
s/p nephrectomy, metastatic spine disease

MEDICATION ON ADMISSION: Medications: Celexa 20 mg PO DAILY, Methadone 50 mg/50 mg/20 mg,
Cyclobenzaprine, Dilaudid 4 mg PO DAILY.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: radial deviation of MCP joints of both hands.

FAMILY HISTORY: Family History: father deceased at 63 yo of heart disease.

SOCIAL HISTORY: Social History:  Lives with a friend and his wife.  2 ppd x
30-40
years.  Recovering alcoholic.  Past history of drug abuse, clean
for last two years.
Secondary malignant neoplasm of bone and bone marrow,Pneumonia, organism unspecified,Myelopathy in other diseases classified elsewhere,Pathologic fracture of vertebrae,Opioid type dependence, continuous,Personal history of malignant neoplasm of kidney,Rheumatoid arthritis,Chronic hepatitis C without mention of hepatic coma,Kyphosis (acquired) (postural)
Secondary malig neo bone,Pneumonia, organism NOS,Myelopathy in oth dis,Path fx vertebrae,Opioid dependence-contin,Hx of kidney malignancy,Rheumatoid arthritis,Chrnc hpt C wo hpat coma,Kyphosis NOS
Admission Date:  [**2194-1-23**]              Discharge Date:   [**2194-2-5**]

Date of Birth:  [**2138-6-4**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back pain, leg weakness

Major Surgical or Invasive Procedure:
Thoracic instrumented fusion T1-12


History of Present Illness:
HPI: Pt is a 55 yo male w/ PMHx sig for metastatic renal cancer
to the thoracic spine, rheumatoid arthritis who presents as a
transfer from an OSH for leg weakness.  The patient was found to
have a renal tumor in [**2190**] s/p resection.  In [**6-21**] the patient
was found to have an extradural mass at T5 that was felt to be
metastases.  The patient is also known to have a kyphotic
collapse at T10.  The patient was seen in Dr.[**Name (NI) 2845**] office
several days ago where it was felt that the patient would need
surgical instrumentation of the thoracic spine for
stabilization.
This was scheduled for the future.  In the last couple of days,
the patient has had increased difficulty walking and numbness in
his legs.  He was seen at an OSH and then transferred to [**Hospital1 18**]
for further evaluation.

Pt denies headache, vertigo, tinnitus, hearing loss, dysarthria,
dysphagia, visual changes, shortness of breath, chest pain,
abdominal pain, joint pain, bleeding, nausea, vomiting, fevers,
chills, night sweats, bowel/bladder incontinence, rash
: deferred

Past Medical History:
Past Medical History: rheumatoid arthritis x 20 years, renal ca
s/p nephrectomy, metastatic spine disease

Social History:
Social History:  Lives with a friend and his wife.  2 ppd x
30-40
years.  Recovering alcoholic.  Past history of drug abuse, clean
for last two years.

Family History:
Family History: father deceased at 63 yo of heart disease.


Physical Exam:
General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: radial deviation of MCP joints of both hands.

Neurological Exam:
Mental status: A & O x3, relays coherent history.  Fluent speech
with no paraphasic or phonemic errors.  Adequate comprehension.
Follows simple and multi-step commands.  Repetition intact (no
ifs, ands or buts).  Able to name low and high frequency
objects.

Cranial Nerves:
I: Not tested
II: PERRL, 4-->2mm with light. VFF.
III, IV, VI: EOMI. no nystagmus.
V, VII: facial sensation intact, facial strength
VIII: hearing intact b/l to finger rubbing.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: SCM [**5-19**]
XII: Tongue midline without fasciculations.

Motor: Normal bulk. Normal tone. No pronator drift.

     Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham   DF PF [**Last Name (un) 938**] EDB
     C5   C7  C6          C8 L2 L3 L4-S1 L4    L5  L5
RT:   5    5  5   5 5  5  5  3  5  3-    4  5  4    4
LEFT: 5    5  5   5 5  5  5  4+ 5  4+    5  5  4+   5

Sensation: Decreased pinprick from ~ T10 to R thigh but intact
to
pinprick on left.  Impaired proprioception large movements at
the
ankle, decreased vibration in toes.

Reflexes: Bic T Br Pa Ac
Right      2  2 2  2  2
Left       2  2 2  2  2
Toes upgoing bilaterally.

Coordination: FNF intact.

Gait: deferred

Pertinent Results:
[**2194-1-24**] 07:00AM BLOOD WBC-8.0 RBC-4.64 Hgb-11.2* Hct-34.0*
MCV-73* MCH-24.2* MCHC-33.1 RDW-13.8 Plt Ct-296
[**2194-2-3**] 05:35AM BLOOD Hct-26.1*
[**2194-2-1**] 08:49AM BLOOD PT-13.5* PTT-45.8* INR(PT)-1.2*
[**2194-2-1**] 02:04AM BLOOD Glucose-146* UreaN-27* Creat-0.7 Na-131*
K-4.5 Cl-101 HCO3-26 AnGap-9
[**2194-2-1**] 02:04AM BLOOD Calcium-7.7* Phos-2.1* Mg-1.9

CT [**2194-1-22**]: IMPRESSION: Enhancing lytic mass involving the left
posterior elements of T5 with left lateral epidural extension
and near complete extension into the left T4/5 foramen.

Severe destructive changes of the T9 vertebral body and the T10
vertebral body with focal kyphosis measuring approximately 50
degrees. Approximately 2-cm anterior spondylolisthesis of T8 on
T10. This is causing severe canal stenosis and likely
compression of the cord.

High-density material seen within and around the destroyed T9
vertebral body and right posterior elements with some
well-circumscribed bony defects of the T9 body on the left.
These findings likely represent prior corpectomy with graft
material or polymethylmethacrylate placement. The lytic lesions
causing the bony destructive changes at these levels likely
represent metastases given the prior right nephrectomy.
Differential diagnostic possibility would also include myeloma.

Mild anterior wedge deformity of the T11 vertebral body.

Brief Hospital Course:
Pt was admitted to the hospital for increasing leg weakness and
pain.  He had pain management and was readied for the OR. On
[**2194-1-28**] he went to Or where under general anesthesia he
underwent thoracic instrumented fusion T1-12.  H etolerated this
procedure well, was kept intubated and transferred to ICU post
op for close monitoring. He was extubated on POD#1.  He required
PCA pain management.  He had 2 JP drains placed intraop and
output was followed closely along with hematocrit. The first
drain was removed [**2194-1-31**] and second [**2194-2-1**] without any
difficulties. He was then transferred to the floor. Diet and
activity were advanced.  he pain was well controlled. His leg
strength improved.  He was evaluated by PT. On discharge he was
noted to have some serosangous drainage from his wound no
redness, fluid collection or edema.  His staples should stay in
an additional 7 days.

Medications on Admission:
Medications: Celexa 20 mg PO DAILY, Methadone 50 mg/50 mg/20 mg,
Cyclobenzaprine, Dilaudid 4 mg PO DAILY.

Discharge Medications:
1. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

2. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed.
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
6. Methadone 10 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
7. Methadone 10 mg Tablet Sig: Five (5) Tablet PO Q 6 AM AND Q 6
PM ().
8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
11. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
12. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
13. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
14. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q8H (every 8
hours) for 2 days.
15. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12
hours) for 2 days.
16. Dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily)
for 2 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Renal cell carcinoma metastatic to thoracic spine


Discharge Condition:
Neurologically improved


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES



??????        Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up/ change dressing daily / take daily showers
??????        No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
??????        Limit your use of stairs to 2-3 times per day
??????        Have a family member check your incision daily for
signs of infection
??????        Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake for morning stiffness
and before bed for sleeping discomfort
??????        Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc.
??????        Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
??????        Clearance to drive and return to work will be addressed
at your post-operative office visit

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????        Pain that is continually increasing or not relieved by
pain medicine
??????        Any weakness, numbness, tingling in your extremities
??????        Any signs of infection at the wound site: redness,
swelling, tenderness, drainage
??????        Fever greater than or equal to 101?????? F
??????        Any change in your bowel or bladder habits

Followup Instructions:
Have your staples removed at rehab on [**2194-2-12**].

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT



Completed by:[**2194-2-5**]

Name:  [**Known lastname 1799**],[**Known firstname 63**]                Unit No:   [**Numeric Identifier 12405**]

Admission Date:  [**2194-1-23**]              Discharge Date:   [**2194-2-5**]

Date of Birth:  [**2138-6-4**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2427**]
Addendum:
Mr. [**Known lastname **] had radiologic evidence of pneumonia on studies
done just prior to admission.  Treatment was begun during his
hospital stay here.

Major Surgical or Invasive Procedure:
Thoracic instrumented fusion T1-12


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1174**] [**Hospital **] Hospital - [**Location (un) **]

Discharge Diagnosis:
Renal cell carcinoma metastatic to thoracic spine
community acquired pneumonia


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]

Completed by:[**2194-2-14**]
{'Secondary malignant neoplasm of bone and bone marrow,Pneumonia, organism unspecified,Myelopathy in other diseases classified elsewhere,Pathologic fracture of vertebrae,Opioid type dependence, continuous,Personal history of malignant neoplasm of kidney,Rheumatoid arthritis,Chronic hepatitis C without mention of hepatic coma,Kyphosis (acquired) (postural)'}


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: back pain, leg weakness

PRESENT ILLNESS: HPI: Pt is a 55 yo male w/ PMHx sig for metastatic renal cancer
to the thoracic spine, rheumatoid arthritis who presents as a
transfer from an OSH for leg weakness.  The patient was found to
have a renal tumor in [**2190**] s/p resection.  In [**6-21**] the patient
was found to have an extradural mass at T5 that was felt to be
metastases.  The patient is also known to have a kyphotic
collapse at T10.  The patient was seen in Dr.[**Name (NI) 2845**] office
several days ago where it was felt that the patient would need
surgical instrumentation of the thoracic spine for
stabilization.
This was scheduled for the future.  In the last couple of days,
the patient has had increased difficulty walking and numbness in
his legs.  He was seen at an OSH and then transferred to [**Hospital1 18**]
for further evaluation.

MEDICAL HISTORY: Past Medical History: rheumatoid arthritis x 20 years, renal ca
s/p nephrectomy, metastatic spine disease

MEDICATION ON ADMISSION: Medications: Celexa 20 mg PO DAILY, Methadone 50 mg/50 mg/20 mg,
Cyclobenzaprine, Dilaudid 4 mg PO DAILY.

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: General: lying in bed NAD
HEENT: NCAT, moist mucous membranes
Neck: supple
Pulmonary: CTA b/l
Cardiac: regular rate and rhythm, with no m/r/g
Carotids: no blood flow murmur
Abdomen: soft, nontender, non distended, normal bowel sounds
Extremities: radial deviation of MCP joints of both hands.

FAMILY HISTORY: Family History: father deceased at 63 yo of heart disease.

SOCIAL HISTORY: Social History:  Lives with a friend and his wife.  2 ppd x
30-40
years.  Recovering alcoholic.  Past history of drug abuse, clean
for last two years. 

### Response:
{'Secondary malignant neoplasm of bone and bone marrow,Pneumonia, organism unspecified,Myelopathy in other diseases classified elsewhere,Pathologic fracture of vertebrae,Opioid type dependence, continuous,Personal history of malignant neoplasm of kidney,Rheumatoid arthritis,Chronic hepatitis C without mention of hepatic coma,Kyphosis (acquired) (postural)'}
