CHIEF COMPLAINT: lower extremity weakness

PRESENT ILLNESS: 75 yo W PMH recent diagnosis of necrotic RUL mass concerning for
malignancy, CRI (Cr 3.7), lumbar stenosis s/p partial R
laminectomy, h/o b/l DVTs and PVD who was transferred from OSH
with bilateral LE weakness since Saturday x3 days. Patient
reports last walking on Saturday morning going about her usual
am routine and then sat down in a chair. She was unable to get
up after that and required use of a wheelchair since then. VNA
saw her today and noted that she was unable to bear weight and
recommended emergent evaluation. She was initially taken to an
OSH where she was evaluated by a neurologist there who
recommended transfer to [**Hospital1 18**]. At baseline, walks with a walker
especially at home and uses a wheelchair when she goes outside."
Images from OSH L-spine MRI and CT-chest obtained.  In total
CTL-Spine MRI all unrevealing. Exam fluctuates. Was dramatically
improved on the morning of [**2124-9-26**] with 4-5/5 strength in the
lower extremities. When rounding with the attending in the
afternoon of the same day she was able to move the legs, but was
weaker with left worse than right. It is not clear at this time
what might cause such a rapidly fluctuating physical exam.
EMG Fellow - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] - has been curbsided regarding the
possibility of this being [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Location (un) **] Myasthenic syndrome.
She is discussing the utility of EMG/NCS with her colleagues.
An MRI of the pelvis was ordered to look for ancillary mass
compressing the lumbosacral plexus.
CT-chest at OSH and X-ray show large cavitary lesion in the
right chest. Per the patient's PCP the CT was read as worrysome
for bronchogenic carcinoma. A BAL was negative for AFB and was
culture negative. It was also negative for malignant cytology.
T/SICU team is helping by consulting thoracic surgery.

MEDICAL HISTORY: # bronchoscopy & biopsy of necrotic lung mass in RUL [**2124-9-12**]
(?)dx
of lung ca. Scheduled for outpt PET scan in am and CT needle
biopsy [**9-28**].
# uterine ca s/p resection c/b chronic urine/stool incontinence

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER FROM OSH:
Acetaminophen 325-650 mg PO Q6H:PRN pain or fever >101.4
Paricalcitol 1 mcg IV DAILY
Nephrocaps 1 CAP PO DAILY
Sodium Bicarbonate 650 mg PO BID
Potassium Chloride 20 mEq PO DAILY
Ferrous Sulfate 325 mg PO TID
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID:PRN constipation
Furosemide 20 mg PO DAILY
Loperamide 2 mg PO DAILY:PRN
Epoetin Alfa 8000 UNIT SC QMOWEFR
Lovenox 40mg SC QD
.

ALLERGIES: Keflex / Percocet

PHYSICAL EXAM: VS: 97.4 94/50 86 20 94%RA
Gen: Alter, oriented, loquacious
HEENT: NCAT, no LAD
NECK: No JVP noted
CV: RRR s1, s2, no M/G/R noted
LUNGS: CTA b/l
ABD: soft, NT/ND, no masses
EXT: dark discoloratoins bilaterally, trace edema
NEURO: decreased strength of lower extremities, L >> R. Able to
lift right leg [**4-13**] against gravity and wekanly against my hand.
Left unable to lift against gravity.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: NC

SOCIAL HISTORY: Former smoker (40 yrs ago). No current tobacco or ETOH.
Lives in nursing home.
Other musculoskeletal symptoms referable to limbs,Acute kidney failure with lesion of tubular necrosis,Hypovolemia,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Malignant neoplasm of upper lobe, bronchus or lung,Pressure ulcer, lower back,Spinal stenosis, lumbar region, without neurogenic claudication,Anemia of other chronic disease,Esophageal reflux,Personal history of malignant neoplasm of other parts of uterus,Osteoporosis, unspecified
Muscskel sympt limb NEC,Ac kidny fail, tubr necr,Hypovolemia,Urin tract infection NOS,Chronic kidney dis NOS,Mal neo upper lobe lung,Pressure ulcer, low back,Spin sten,lumbr wo claud,Anemia-other chronic dis,Esophageal reflux,Hx-uterus malignancy NEC,Osteoporosis NOS
Admission Date:  [**2124-9-25**]              Discharge Date:   [**2124-9-28**]

Date of Birth:  [**2049-9-2**]             Sex:   F

Service: MEDICINE

Allergies:
Keflex / Percocet

Attending:[**First Name3 (LF) 898**]
Chief Complaint:
lower extremity weakness

Major Surgical or Invasive Procedure:
none


History of Present Illness:
75 yo W PMH recent diagnosis of necrotic RUL mass concerning for
malignancy, CRI (Cr 3.7), lumbar stenosis s/p partial R
laminectomy, h/o b/l DVTs and PVD who was transferred from OSH
with bilateral LE weakness since Saturday x3 days. Patient
reports last walking on Saturday morning going about her usual
am routine and then sat down in a chair. She was unable to get
up after that and required use of a wheelchair since then. VNA
saw her today and noted that she was unable to bear weight and
recommended emergent evaluation. She was initially taken to an
OSH where she was evaluated by a neurologist there who
recommended transfer to [**Hospital1 18**]. At baseline, walks with a walker
especially at home and uses a wheelchair when she goes outside."
Images from OSH L-spine MRI and CT-chest obtained.  In total
CTL-Spine MRI all unrevealing. Exam fluctuates. Was dramatically
improved on the morning of [**2124-9-26**] with 4-5/5 strength in the
lower extremities. When rounding with the attending in the
afternoon of the same day she was able to move the legs, but was
weaker with left worse than right. It is not clear at this time
what might cause such a rapidly fluctuating physical exam.
EMG Fellow - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] - has been curbsided regarding the
possibility of this being [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Location (un) **] Myasthenic syndrome.
She is discussing the utility of EMG/NCS with her colleagues.
An MRI of the pelvis was ordered to look for ancillary mass
compressing the lumbosacral plexus.
CT-chest at OSH and X-ray show large cavitary lesion in the
right chest. Per the patient's PCP the CT was read as worrysome
for bronchogenic carcinoma. A BAL was negative for AFB and was
culture negative. It was also negative for malignant cytology.
T/SICU team is helping by consulting thoracic surgery.


Past Medical History:
# bronchoscopy & biopsy of necrotic lung mass in RUL [**2124-9-12**]
(?)dx
of lung ca. Scheduled for outpt PET scan in am and CT needle
biopsy [**9-28**].
# uterine ca s/p resection c/b chronic urine/stool incontinence

# s/p partial right L4 laminectomy
# chronic renal insufficency (patient reports congenital small
kidney)
# osteoarthritis/osteoporosis
# h/o bilateral deep vein thrombosis
# pernicious anemia
# h/o c difficile
# gastroesophageal reflux disease
# h/o peripheral vascular disease


Social History:
Former smoker (40 yrs ago). No current tobacco or ETOH.
Lives in nursing home.


Family History:
NC

Physical Exam:
VS: 97.4 94/50 86 20 94%RA
Gen: Alter, oriented, loquacious
HEENT: NCAT, no LAD
NECK: No JVP noted
CV: RRR s1, s2, no M/G/R noted
LUNGS: CTA b/l
ABD: soft, NT/ND, no masses
EXT: dark discoloratoins bilaterally, trace edema
NEURO: decreased strength of lower extremities, L >> R. Able to
lift right leg [**4-13**] against gravity and wekanly against my hand.
Left unable to lift against gravity.
PSYCH: Listens and responds to questions appropriately, pleasant



Pertinent Results:
[**2124-9-26**] 04:34AM BLOOD WBC-7.8# RBC-3.10* Hgb-7.9* Hct-24.8*
MCV-80*# MCH-25.4*# MCHC-31.8 RDW-19.4* Plt Ct-267
[**2124-9-27**] 02:05AM BLOOD Neuts-86* Bands-2 Lymphs-7* Monos-2 Eos-0
Baso-0 Atyps-2* Metas-1* Myelos-0 NRBC-2*
[**2124-9-27**] 02:05AM BLOOD Hypochr-3+ Anisocy-2+ Poiklo-1+
Macrocy-1+ Microcy-2+ Polychr-1+ Ovalocy-1+ Target-1+ Burr-1+
[**2124-9-26**] 04:34AM BLOOD PT-14.2* PTT-27.7 INR(PT)-1.3*
[**2124-9-26**] 04:34AM BLOOD Glucose-140* UreaN-53* Creat-3.5*# Na-138
K-4.4 Cl-103 HCO3-21* AnGap-18
[**2124-9-28**] 01:00AM BLOOD Calcium-8.3* Phos-1.8* Mg-1.8
[**2124-9-27**] 02:05PM BLOOD COPPER (SERUM)-PND
[**2124-9-26**] 04:34AM BLOOD VitB12-GREATER TH Folate-GREATER TH
.
Blood cx pending
.
Urine cx: URINE CULTURE (Final [**2124-9-28**]):
      ESCHERICHIA COLI.    PRESUMPTIVE IDENTIFICATION.
         >100,000 ORGANISMS/ML..
         Trimethoprim/Sulfa sensitivity testing confirmed by
[**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**].

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ESCHERICHIA COLI
                             |
AMPICILLIN------------   <=2 S
AMPICILLIN/SULBACTAM--   <=2 S
CEFAZOLIN-------------   <=4 S
CEFEPIME--------------   <=1 S
CEFTAZIDIME-----------   <=1 S
CEFTRIAXONE-----------   <=1 S
CEFUROXIME------------     4 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------   <=1 S
IMIPENEM--------------   <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN--------  <=16 S
PIPERACILLIN----------   <=4 S
PIPERACILLIN/TAZO-----   <=4 S
TOBRAMYCIN------------   <=1 S
TRIMETHOPRIM/SULFA----   <=1 S
.
Studies:
.
Renal U/S: Evaluation of the kidneys is limited due to difficult
beam
penetration. The left kideny measures 9.2 cm. The right kidney
is small
measuring 6.8 cm. No hydronephrosis, stone, or renal masses
identified.
IMPRESSION: Asymmetrically small right kidney which is
consistent with
provided history of congenitally small kidney.  No
hydronephrosis.
.
EKG: Sinus rhythm. Low voltage. Since tracing of [**2122-12-28**] the
voltage has
decreased.
.
CXR: Cardiac and mediastinal contours appear grossly
unremarkable.  Large likely
cavitary lesion seen in the right lung, measuring upwards of 12
cm in greatest
dimension.  No focal consolidations or definite pleural
effusions. Surgical
clips are seen overlying the abdomen.
IMPRESSION:  Large cavitary lesion within the right lung,
concerning for
neoplasm.  CT would be helpful for further evaluation.
.
MRI Spine:
CERVICAL SPINE:  Normal cervical lordosis is preserved.  The
alignment of the vertebral bodies is normal.  There is no
abnormal signal in the vertebral bodies, spinal cord, or dural
space.
The limited assessment of posterior fossa is unremarkable.
Cervicomedullary junction is normal.  At C3-4 level, there is a
posterior osteophyte disc bulge, leading to right neural foramen
narrowing.  There is no significant central canal narrowing.
At C4-5, there is a posterior central disc bulge, leading to
anterior thecal sac deformity, as well as bilateral neural
foraminal narrowing.  There is no significant central canal
stenosis at this level.
At C5-6 level, there is a posterior disc bulge as well as
osteophytes, leading to left greater than right neural foramen
narrowing.  There is no significant spinal canal stenosis.
At C6-7 level, there is mild spondylosis, without evidence of
neural foraminal or central canal narrowing.
THORACIC SPINE:  Axial images of T1 through T8 presented.
There is accentuation of thoracic kyphosis.  There are no signal
intensity
abnormalities in the vertebral bodies, spinal cord or within the
dural space.
At T5-6 level, there is a posterior disc bulge, without
significant neural
foraminal narrowing or central canal stenosis.
At T7-8 level, there is a central disc protrusion, leading to
anterior thecal
sac deformity without significant central canal stenosis.
At T10-11 level, there is minimal posterior disc bulge, without
significant neural foraminal narrowing or central canal
stenosis.  No significant abnormalities are reviewed atT11-L2
levels.
Note made of a large cavitary right lung mass.
IMPRESSION:
1.  Multilevel spondylosis, without evidence of central canal
stenosis or
spinal cord compression.
2.  Large cavitary lung lesion.  Differential diagnosis is
broad.  If not
already obtained, dedicated chest CT is recommended for further
evaluation of this finding.


Brief Hospital Course:
The patient was initially admitted to the Neuro-ICU and
evaluated by neurology. CTL-Spine MRI was performed and found to
be unrevealing. Her physical exam seemed to fluctuate widely day
to day, but her lower extremitiy exam was dramatically improved
on the morning of [**2124-9-26**] with 4-5/5 strength in the lower
extremities. She was weaker on the left side, especially with
hip flexion but states that she has had that problem for 5
years. Upon discharge her exam was similar with good strength in
her upper extremities and R lower extremity and mild defects in
the left as described above. The neuromuscular team was
consulted and had discussed the possibility of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]/[**Location (un) **]
myasthenia in the setting of a possible pulomary malignancy. An
MRI of the pelvis was ordered to look for ancillary mass
compressing the lumbosacral plexus.  She was evaluated by
physical therapy on the day of discharge, but exam was limited
by patient cooperation, however she was able to stand and
shuffle a short distance with a walker.
In regards to her lung lesion, CT-chest at OSH and X-ray show
large cavitary lesion in the right chest. Per the patient's PCP
the CT was read as worrysome for bronchogenic carcinoma. A BAL
was negative for AFB and was culture negative. It was also
negative for malignant cytology.  Thoracic surgery was consulted
at [**Hospital1 18**], but at that point the patient wished to pursue her
care at [**Hospital3 4107**] and with her outpatient pulmonologist.
The patient was also found to be in acute on chronic renal
failure upon admission with a creatinine of 3.5. The renal team
saw her and felt this might have been due to
hypotension/hypovolemia.  Her renal function improved with
gentle hydration. Renal U/S showed no cause for acute renal
failure, no hydronephrosis.  She was also found to have a
urinary tract infection (E.coli) for which she was started on
ciprofloxacin on [**9-27**].

Medications on Admission:
MEDICATIONS ON TRANSFER FROM OSH:
Acetaminophen 325-650 mg PO Q6H:PRN pain or fever >101.4
Paricalcitol 1 mcg IV DAILY
Nephrocaps 1 CAP PO DAILY
Sodium Bicarbonate 650 mg PO BID
Potassium Chloride 20 mEq PO DAILY
Ferrous Sulfate 325 mg PO TID
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID:PRN constipation
Furosemide 20 mg PO DAILY
Loperamide 2 mg PO DAILY:PRN
Epoetin Alfa 8000 UNIT SC QMOWEFR
Lovenox 40mg SC QD
.


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain or fever >101.4.
2. Sodium Bicarbonate 650 mg Tablet Sig: 1-2 Tablets PO BID (2
times a day): as instructed.
3. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
4. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID
(3 times a day) as needed.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
6. Epoetin Alfa 20,000 unit/2 mL Solution Sig: One (1) injection
Injection once a week: Monday.
7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
8. Loperamide 2 mg Capsule Sig: One (1) Capsule PO three times a
day as needed.
9. Cyanocobalamin 1,000 mcg/mL Solution Sig: One (1) injection
Injection once a month.
10. Hexavitamin     Tablet Sig: One (1) Cap PO DAILY (Daily).
11. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 7 days.
12. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) units
Subcutaneous every twelve (12) hours.
13. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection subQ Injection four times a day as needed: Please
follow insulin sliding scale, starting at blood glucose 151 give
4units, then per increase 50 in BG advance insulin dose by 2
units.
14. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6
hours) as needed.
15. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) as needed.
16. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day.
17. Zemplar 1 mcg Capsule Sig: One (1) Capsule PO once a day.
18. Renal Caps 1 mg Capsule Sig: One (1) Capsule PO once a day.



Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hosp

Discharge Diagnosis:
Primary:
1.) Lower extremity weakness
2.) Right lung mass
3.) Urinary tract infection
Secondary:
3.) Chronic renal failure


Discharge Condition:
good


Discharge Instructions:
You were transferred to [**Hospital1 18**] because of lower extremity
weakness.  You were evaluated by the neurology servive and
underwent imaging studies of your spine which showed no
abnormalities. You were scheduled for an MRI of the pelvis which
may be done at [**Hospital3 4107**].
.
You should continue to take all medications as instructed and
keep all health care appointments when you are discharged.
.
If you have worsening leg weakness, shortness of breath, chest
pain, numbness, trouble speaking, or if your condition worsens
in any way contact your physician or seek medical attention.

Followup Instructions:
Please follow-up as instructed by Dr. [**Last Name (STitle) 11510**] or the physician
at [**Hospital3 **].
{'Other musculoskeletal symptoms referable to limbs,Acute kidney failure with lesion of tubular necrosis,Hypovolemia,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Malignant neoplasm of upper lobe, bronchus or lung,Pressure ulcer, lower back,Spinal stenosis, lumbar region, without neurogenic claudication,Anemia of other chronic disease,Esophageal reflux,Personal history of malignant neoplasm of other parts of uterus,Osteoporosis, 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: lower extremity weakness

PRESENT ILLNESS: 75 yo W PMH recent diagnosis of necrotic RUL mass concerning for
malignancy, CRI (Cr 3.7), lumbar stenosis s/p partial R
laminectomy, h/o b/l DVTs and PVD who was transferred from OSH
with bilateral LE weakness since Saturday x3 days. Patient
reports last walking on Saturday morning going about her usual
am routine and then sat down in a chair. She was unable to get
up after that and required use of a wheelchair since then. VNA
saw her today and noted that she was unable to bear weight and
recommended emergent evaluation. She was initially taken to an
OSH where she was evaluated by a neurologist there who
recommended transfer to [**Hospital1 18**]. At baseline, walks with a walker
especially at home and uses a wheelchair when she goes outside."
Images from OSH L-spine MRI and CT-chest obtained.  In total
CTL-Spine MRI all unrevealing. Exam fluctuates. Was dramatically
improved on the morning of [**2124-9-26**] with 4-5/5 strength in the
lower extremities. When rounding with the attending in the
afternoon of the same day she was able to move the legs, but was
weaker with left worse than right. It is not clear at this time
what might cause such a rapidly fluctuating physical exam.
EMG Fellow - [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7673**] - has been curbsided regarding the
possibility of this being [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-[**Location (un) **] Myasthenic syndrome.
She is discussing the utility of EMG/NCS with her colleagues.
An MRI of the pelvis was ordered to look for ancillary mass
compressing the lumbosacral plexus.
CT-chest at OSH and X-ray show large cavitary lesion in the
right chest. Per the patient's PCP the CT was read as worrysome
for bronchogenic carcinoma. A BAL was negative for AFB and was
culture negative. It was also negative for malignant cytology.
T/SICU team is helping by consulting thoracic surgery.

MEDICAL HISTORY: # bronchoscopy & biopsy of necrotic lung mass in RUL [**2124-9-12**]
(?)dx
of lung ca. Scheduled for outpt PET scan in am and CT needle
biopsy [**9-28**].
# uterine ca s/p resection c/b chronic urine/stool incontinence

MEDICATION ON ADMISSION: MEDICATIONS ON TRANSFER FROM OSH:
Acetaminophen 325-650 mg PO Q6H:PRN pain or fever >101.4
Paricalcitol 1 mcg IV DAILY
Nephrocaps 1 CAP PO DAILY
Sodium Bicarbonate 650 mg PO BID
Potassium Chloride 20 mEq PO DAILY
Ferrous Sulfate 325 mg PO TID
Pantoprazole 40 mg PO Q24H
Docusate Sodium 100 mg PO BID:PRN constipation
Furosemide 20 mg PO DAILY
Loperamide 2 mg PO DAILY:PRN
Epoetin Alfa 8000 UNIT SC QMOWEFR
Lovenox 40mg SC QD
.

ALLERGIES: Keflex / Percocet

PHYSICAL EXAM: VS: 97.4 94/50 86 20 94%RA
Gen: Alter, oriented, loquacious
HEENT: NCAT, no LAD
NECK: No JVP noted
CV: RRR s1, s2, no M/G/R noted
LUNGS: CTA b/l
ABD: soft, NT/ND, no masses
EXT: dark discoloratoins bilaterally, trace edema
NEURO: decreased strength of lower extremities, L >> R. Able to
lift right leg [**4-13**] against gravity and wekanly against my hand.
Left unable to lift against gravity.
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: NC

SOCIAL HISTORY: Former smoker (40 yrs ago). No current tobacco or ETOH.
Lives in nursing home. 

### Response:
{'Other musculoskeletal symptoms referable to limbs,Acute kidney failure with lesion of tubular necrosis,Hypovolemia,Urinary tract infection, site not specified,Chronic kidney disease, unspecified,Malignant neoplasm of upper lobe, bronchus or lung,Pressure ulcer, lower back,Spinal stenosis, lumbar region, without neurogenic claudication,Anemia of other chronic disease,Esophageal reflux,Personal history of malignant neoplasm of other parts of uterus,Osteoporosis, unspecified'}
