CHIEF COMPLAINT: back pain

PRESENT ILLNESS: 57-year-old gentleman who underwent a nephrectomy in [**2172**] for
renal cell cancer.  He was discovered with metastasis to the
right ninth and tenth ribs
in [**2181**].  That has been treated with CyberKnife in [**2184-4-8**].  He
has had previous CyberKnife treatment as well as
interleukin-2therapy.  He has been on Avastin.  He had been
followed by Dr. [**Last Name (STitle) 548**] and had been asympomatic but then began to
have back pain and surgery was agreed upon.

MEDICAL HISTORY: His past medical and past surgical history are significant for
the renal cell cancer as mentioned above.

MEDICATION ON ADMISSION: Duragesic patch (Fetanyl transdermal)(12 mcg hourly)
Ibuprofen [Motrin, Advil] (400 mg prnstopped)
Lisinopril (10 mg daily)
Neurontin(600 mg TID)
Olmesartan (30 mg daily)
Warfarin [Coumadin] (daily- last dose [**2185-3-3**])
Other (pamidronate monthly- next infusion [**2185-3-4**])
OTCs Co Q10

ALLERGIES: Morphine

PHYSICAL EXAM: General WD, WN man in NAD
Mental/Psychological cooperative, anxious
Airway Mallampati [Class IV]
Mouth Opening [Adequate (> 3 cm)]
Thyromental Distance [>6 cm]
Hyomental Distance [>3 cm]
Dental Good
Head/Neck Range of Motion Free Range of Motion
Heart RRR
Lungs Clear to Auscultation
Abdomen soft, nontender, no bruits
Extremities no edema, skin warm and dry, palp PT's B
Other R side lower rib swelling with skin
discoloration.
On  neuro logic examination, his motor strength was normal in
the upper and
lower extremities.  His sensory examination showed a decreased
appreciation in the right posterior and lateral chest wall, but
otherwise was intact.  His reflexes were normal and
symmetric.There was no point tenderness anywhere along the
thoracolumbarjunction.  There was no clonus, and Hoffmann reflex
was absent.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: He does not smoke.
Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of kidney, except pelvis,Acute posthemorrhagic anemia,Unspecified essential hypertension
Secondary malig neo bone,Malig neopl kidney,Ac posthemorrhag anemia,Hypertension NOS
Admission Date:  [**2185-3-9**]              Discharge Date:   [**2185-3-13**]

Date of Birth:  [**2126-10-11**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Morphine

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

Major Surgical or Invasive Procedure:
LECA T8-9 vertebrectomies and fusion T5-11


History of Present Illness:
57-year-old gentleman who underwent a nephrectomy in [**2172**] for
renal cell cancer.  He was discovered with metastasis to the
right ninth and tenth ribs
in [**2181**].  That has been treated with CyberKnife in [**2184-4-8**].  He
has had previous CyberKnife treatment as well as
interleukin-2therapy.  He has been on Avastin.  He had been
followed by Dr. [**Last Name (STitle) 548**] and had been asympomatic but then began to
have back pain and surgery was agreed upon.

Past Medical History:
His past medical and past surgical history are significant for
the renal cell cancer as mentioned above.

Social History:
He does not smoke.

Family History:
non contributory

Physical Exam:
General WD, WN man in NAD
Mental/Psychological cooperative, anxious
Airway Mallampati [Class IV]
Mouth Opening [Adequate (> 3 cm)]
Thyromental Distance [>6 cm]
Hyomental Distance [>3 cm]
Dental Good
Head/Neck Range of Motion Free Range of Motion
Heart RRR
Lungs Clear to Auscultation
Abdomen soft, nontender, no bruits
Extremities no edema, skin warm and dry, palp PT's B
Other R side lower rib swelling with skin
discoloration.
On  neuro logic examination, his motor strength was normal in
the upper and
lower extremities.  His sensory examination showed a decreased
appreciation in the right posterior and lateral chest wall, but
otherwise was intact.  His reflexes were normal and
symmetric.There was no point tenderness anywhere along the
thoracolumbarjunction.  There was no clonus, and Hoffmann reflex
was absent.


Pertinent Results:
CT of the thoracic spine obtained on [**2184-6-21**] demonstratesa
right-sided metastatic lesion that has involved the T9-T10 rib.
It is extending into the lateral one-third of the vertebral
body.  An MRI obtained on [**2184-3-1**] demonstrates that same
mass.  There does seem to have been some progression between
those two studies, although it is difficult to compare MRI to
CT.

[**2185-3-9**] 10:47AM   PO2-235* PCO2-29* PH-7.52* TOTAL CO2-24 BASE
XS-2
[**2185-3-9**] 10:47AM   GLUCOSE-105 LACTATE-1.1 NA+-139 K+-3.7
CL--105
[**2185-3-9**] 10:47AM   HGB-12.5* calcHCT-38
[**2185-3-9**] 09:51PM   GLUCOSE-143* UREA N-16 CREAT-0.9 SODIUM-142
POTASSIUM-4.9 CHLORIDE-112* TOTAL CO2-23 ANION GAP-12
[**2185-3-9**] 09:51PM   CALCIUM-7.7* PHOSPHATE-4.2 MAGNESIUM-1.6
[**2185-3-9**] 09:51PM   WBC-3.7* RBC-3.63* HGB-11.1* HCT-31.4* MCV-86
MCH-30.6 MCHC-35.4* RDW-15.2
[**2185-3-9**] 09:51PM   PLT COUNT-194
[**2185-3-9**] 06:25PM   TYPE-ART PO2-197* PCO2-41 PH-7.35 TOTAL
CO2-24 BASE XS--2
[**2185-3-9**] 06:25PM   GLUCOSE-121* LACTATE-1.1 NA+-138 K+-4.2
CL--109
[**2185-3-9**] 06:25PM   HGB-11.0* calcHCT-33
[**2185-3-9**] 06:25PM   freeCa-1.03*
[**2185-3-9**] 04:12PM   TYPE-ART PO2-189* PCO2-43 PH-7.38 TOTAL
CO2-26 BASE XS-0
[**2185-3-9**] 04:12PM   GLUCOSE-124* LACTATE-1.0 NA+-140 K+-4.2
CL--106
[**2185-3-9**] 04:12PM   HGB-12.1* calcHCT-36
[**2185-3-9**] 04:12PM   freeCa-1.11*
[**2185-3-9**] 01:44PM   PO2-186* PCO2-43 PH-7.39 TOTAL CO2-27 BASE
XS-1
[**2185-3-9**] 01:44PM   GLUCOSE-116* LACTATE-1.5 NA+-139 K+-4.6
CL--103
[**2185-3-9**] 01:44PM   HGB-12.6* calcHCT-38
[**2185-3-9**] 01:44PM   freeCa-1.11*
[**2185-3-9**] 10:47AM   PO2-235* PCO2-29* PH-7.52* TOTAL CO2-24 BASE
XS-2
[**2185-3-9**] 10:47AM   GLUCOSE-105 LACTATE-1.1 NA+-139 K+-3.7
CL--105
[**2185-3-9**] 10:47AM   HGB-12.5* calcHCT-38
[**2185-3-9**] 10:47AM   freeCa-1.12

SPECIMEN SUBMITTED: T8-T9 renal cell metastasis plus FS; T8-T9
renal metastasis (2 jars).
Procedure date     Tissue received     Report Date    Diagnosed
by
[**2185-3-9**] [**2185-3-9**] [**2185-3-14**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]-[**Doctor Last Name **]/bef??????
Previous biopsies:    [**-3/4527**]  Consult slides referred to Dr.
[**Last Name (STitle) **].
DIAGNOSIS:
1.     Bone and soft tissue, "T8-T9" (FS, A-E):

Metastatic carcinoma with clear cell features compatible with
renal cell carcinoma (see comment).
2.     Bone and soft tissue, "T8-T9" (F-H):

Metastatic carcinoma with clear cell features compatible with
renal cell carcinoma (see comment).
Comment. Both specimens contain metastatic carcinoma as well as
fragments of bone, fibroadipose tissue and skeletal muscle,
showing reactive changes. The tumor cells are predominantly
clear and the morphologic appearances are compatible with
metastatic renal cell carcinoma (conventional type). No
sarcomatoid component is identified. Slides F, G and H have been
reviewed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **].
Clinical: 58 year old man, metastatic renal cell carcinoma to
T8-T9.
Gross:

The specimens are received fresh in two containers, each labeled
with the patient's name, "[**Known lastname **], [**Known firstname **]" and his medical
record number.

Part 1 is additionally labeled "T8-T9 renal cell metastasis". It
consists of multiple tissue fragments which measure 8.5 x 6.4 x
3.2 cm in aggregate. An intraoperative consult was obtained. A
frozen section is performed on the specimen. Intraoperative
diagnosis by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) 4223**] reads: "Epithelioid neoplasm with
clear cell features compatible with renal cell carcinoma". The
specimen is represented in cassettes as follows: A=frozen
section remnant", B-E= representative portions of tissue. The
specimen is decalcified prior to specimen processing.
Part 2 is additionally labeled "T8 - T9 renal metastases,
permanent." It consists of multiple tissue and bone fragments
measuring 5 x 5 x 3 cm in aggregate. The specimen is serially
sectioned and represented in cassettes F-H.  The specimen is
decalcified prior to specimen processing.

Radiology Report T-SPINE Study Date of [**2185-3-11**] 10:34 AM
Final Report
INDICATION: 58-year-old man status post thoracic vertebrectomy
of T8 and 9 with fusion of T5 through 11.
COMPARISON: PA and lateral VIEWS OF THE THORACIC SPINE:

FINDINGS: The patient is status post placement of posterior
spinal rods and pedicle screws within T5-T6, T7, T10, and T11.
Intervertebral disc spacers are noted at T7-8 and T9-10. Stable
loss of height of vertebral body at T8 is again demonstrated. No
hardware complications are noted. At least two drains are noted
posteriorly. Multiple surgical clips are seen overlying the
posterior aspect of the spine.

IMPRESSION: Satisfactory postoperative appearance.

Cardiology Report ECG Study Date of [**2185-3-10**]  10:42:30 AM
Sinus rhythm
Modest nonspecific low amplitude inferolateral lead T wave
changes
Since previous tracing of [**2185-3-3**], modest T wave changes now
present  Intervals Axes
Rate PR QRS QT/QTc P QRS T
76 174 96 372/400 31 -12 -3

Radiology Report CHEST (PORTABLE AP) Study Date of [**2185-3-9**]
10:33 PM
Final Report
PORTABLE AP CHEST

INDICATION: Thoracic fusion and ET tube placement.

FINDINGS: Comparison is made with prior radiograph from [**2184-4-10**], prior CT from [**2184-8-23**], and MR of the thoracic
spine from [**2185-3-3**]. The ET tube is 6.8 cm from the
carina. The numerous right-sided nodules are minimally larger.
Several left-sided pulmonary nodules are also noted. The vague
opacity in the right lower lung is likely the posterior chest
wall mass seen on the prior CT scan. Surgical clips and fiducial
markers are seen throughout the right hemithorax. The
cardiomediastinal silhouette is normal. There has been interval
thoracic spinal fusion.

IMPRESSION: No pneumothorax. Minimal size increase in the
diffuse pulmonary nodules, some of which correlate to known
chest wall masses





Brief Hospital Course:
Pt was admitted electively and brought to the OR where under
general anestheisa he underwent a LATERAL EXTRACAVITARY T8-T9
FUSION T5-T11 without complications. Post operatively he went to
the ICU for close neurological observation and he was intubated.
Immediately post operatively he was moving all extremeties
symmetrically and full strength. His dressing was dry and his
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] drains were putting out serosanguous fluid. He was
extubated on post operative day 1 and transferred to the
surgical floor. His diet and activity were increased.  JP drains
were removed POD#2. Incision was clean and dry.  Foley was dc'd.
Pt was out of bed to chair. He was transitioned to PO pain
medication. Post op xrays were done and showed good hardware
alignment. His motor exam continued to be full strength. He was
high risk for clotting with h/o PE and after speaking with his
hematologist it was decided to resume lovenox bridge to
therapeutic coumadin. PT evaluated him and cleared him for
discharge to home. On the day of his discharge [**2185-3-13**] he was
neurologically intact with some mild decreased sensation over
his right posterior and lateral chest wall, but otherwise was
intact.  His reflexes were normal and symmetric.There was no
clonus.  His strength was full. He was ambulating in the hallway
without difficulty.

Medications on Admission:
Duragesic patch (Fetanyl transdermal)(12 mcg hourly)
Ibuprofen [Motrin, Advil] (400 mg prnstopped)
Lisinopril (10 mg daily)
Neurontin(600 mg TID)
Olmesartan (30 mg daily)
Warfarin [Coumadin] (daily- last dose [**2185-3-3**])
Other (pamidronate monthly- next infusion [**2185-3-4**])
OTCs Co Q10

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

3. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
4. Fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
5. Olmesartan 20 mg Tablet Sig: One (1) Tablet PO daily ().
6. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO every twelve
(12) hours as needed for muscle spasm.
Disp:*60 Tablet(s)* Refills:*0*
7. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours) for 5 days.
Disp:*11 * Refills:*0*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as
needed for pain for 1 weeks: hold for lethargy, decreased
respiratory rate < 12 in one hour.
Disp:*60 Tablet(s)* Refills:*0*
9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day for 1
weeks: hold for loose stools.
Disp:*14 Tablet(s)* Refills:*0*
10. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO Mon, Wed, Fri:
please take your regularly scheduled home dose of Coumadin as
directed by your oncologist/primary care, as discussed with Dr
[**Last Name (STitle) 548**].-please start [**3-14**] am.


Discharge Disposition:
Home

Discharge Diagnosis:
Renal metastasis to thoracic spine
post op anemia


Discharge Condition:
Neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES

??????        Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up begin daily showers [**2185-3-13**]
??????        You have steri-strips in place ?????? keep dry x 72 hours.
Do not pull them off. They will fall off on their own or be
taken off in the office
??????        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. for 3 months.
??????        Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
-CONTINUE LOVENOX AND COUMADIN AND FOLLOW UP WITH PCP/ONCOLOGIST
FOR BLOODWORK AND DOSAGE CHANGES THIS WEEK


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:
PLEASE RETURN TO THE OFFICE IN [**9-21**] DAYS FOR REMOVAL OF YOUR
SUTURES OR HAVE THEM REMOVED BY PCP CLOSER TO HOME
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:[**2185-3-18**]
{'Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of kidney, except pelvis,Acute posthemorrhagic anemia,Unspecified essential hypertension'}


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

PRESENT ILLNESS: 57-year-old gentleman who underwent a nephrectomy in [**2172**] for
renal cell cancer.  He was discovered with metastasis to the
right ninth and tenth ribs
in [**2181**].  That has been treated with CyberKnife in [**2184-4-8**].  He
has had previous CyberKnife treatment as well as
interleukin-2therapy.  He has been on Avastin.  He had been
followed by Dr. [**Last Name (STitle) 548**] and had been asympomatic but then began to
have back pain and surgery was agreed upon.

MEDICAL HISTORY: His past medical and past surgical history are significant for
the renal cell cancer as mentioned above.

MEDICATION ON ADMISSION: Duragesic patch (Fetanyl transdermal)(12 mcg hourly)
Ibuprofen [Motrin, Advil] (400 mg prnstopped)
Lisinopril (10 mg daily)
Neurontin(600 mg TID)
Olmesartan (30 mg daily)
Warfarin [Coumadin] (daily- last dose [**2185-3-3**])
Other (pamidronate monthly- next infusion [**2185-3-4**])
OTCs Co Q10

ALLERGIES: Morphine

PHYSICAL EXAM: General WD, WN man in NAD
Mental/Psychological cooperative, anxious
Airway Mallampati [Class IV]
Mouth Opening [Adequate (> 3 cm)]
Thyromental Distance [>6 cm]
Hyomental Distance [>3 cm]
Dental Good
Head/Neck Range of Motion Free Range of Motion
Heart RRR
Lungs Clear to Auscultation
Abdomen soft, nontender, no bruits
Extremities no edema, skin warm and dry, palp PT's B
Other R side lower rib swelling with skin
discoloration.
On  neuro logic examination, his motor strength was normal in
the upper and
lower extremities.  His sensory examination showed a decreased
appreciation in the right posterior and lateral chest wall, but
otherwise was intact.  His reflexes were normal and
symmetric.There was no point tenderness anywhere along the
thoracolumbarjunction.  There was no clonus, and Hoffmann reflex
was absent.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: He does not smoke. 

### Response:
{'Secondary malignant neoplasm of bone and bone marrow,Malignant neoplasm of kidney, except pelvis,Acute posthemorrhagic anemia,Unspecified essential hypertension'}
