CHIEF COMPLAINT: back pain

PRESENT ILLNESS: 47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], who is admitted
for pain control.  He was doing well after completion of
radiotherapy but within a few weeks developed severe left leg
pain as well as muscular spasms and areas of numbness.  Since
this weekend, he has developed severe left leg and back pain.
However, he denied fecal or urinary incontinence and focalized
weakness.

MEDICAL HISTORY: - Renal Cell Carcinoma (please see below)

MEDICATION ON ADMISSION: Transfer meds:
Duragesic patch 400mcg Q3 days
Lidoderm patch for 12 hours
ativan 1mg daily
Miralax 17g daily
Dilaudid 2-3 mg Q 2hours PRN
Flexeril 5mg tid
Ativan 1mg QHS
Zofran 2mg IV Q 6hours PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA
GEN: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, tender in his right flank and RUQ area, +BS. no
rebound/guarding. neg HSM. neg [**Doctor Last Name **] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.

FAMILY HISTORY: Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."

SOCIAL HISTORY: Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug
use. Not currently emplyed, but worked as an electrician. 2
Healthy children.
Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of lung,Myelopathy in other diseases classified elsewhere,Acute posthemorrhagic anemia,Other nervous system complications,Leukocytosis, unspecified,Neoplasm related pain (acute) (chronic),Hypopotassemia,Other constipation,Personal history of venous thrombosis and embolism,Personal history of malignant neoplasm of bladder,Arthrodesis status,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of large intestine,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Secondary malig neo bone,Secondary malig neo lung,Myelopathy in oth dis,Ac posthemorrhag anemia,Surg comp nerv systm NEC,Leukocytosis NOS,Neoplasm related pain,Hypopotassemia,Constipation NEC,Hx-ven thrombosis/embols,Hx of bladder malignancy,Arthrodesis status,Hx antineoplastic chemo,Hx of irradiation,Acquire absnce intestine,Hx of colonic malignancy,Abn react-artif implant
Name:  [**Known lastname 12204**],[**Known firstname **]                Unit No:   [**Numeric Identifier 12205**]

Admission Date:  [**2111-10-1**]              Discharge Date:   [**2111-10-19**]

Date of Birth:  [**2064-2-2**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 12206**]
Addendum:
Allergies
Patient recorded as having No Known Allergies to Drugs
Attending
[**Last Name (LF) **],[**First Name3 (LF) **] M.F.
Service
MEDICINE
Chief Complaint
back pain




Major Surgical or Invasive Procedure
T12 transpedicular decompression and posterior instrumented


fusion T10 to L2




History of Present Illness
47 yo male with renal cell cancer with intrahepatic and


paraspinal metastasis treated with stereotactic body


radiotherapy, completed on [**2111-8-5**], who is admitted


for pain control.  He was doing well after completion of


radiotherapy but within a few weeks developed severe left leg


pain as well as muscular spasms and areas of numbness.  Since


this weekend, he has developed severe left leg and back pain.


However, he denied fecal or urinary incontinence and focalized


weakness.




Because of the pain, on [**2111-9-28**], pt was admitted to local


hospital where he received pain medications and MRI under


anesthesia because of inability to lie flat.  The MRI revealed "





a large mass over the right renal fossa extending to the


paraspinal muscle and also there was a tumor involving the


thoracic 11 and thoracic 12 vertebral body extending into the


spinal canal, cord compression, and also a tumor involving the


paraspinous muscle.  Possible metastatic lesion of cervical 2


vertebral body with possible cord compression.




After discussing with his own [**Date Range 12207**] in [**Hospital1 8**], he was


transferred to here for further management.


.


Review of Systems:


(+) Per HPI


(-) Denies fever, chills, night sweats, recent weight loss or


gain. Denies headache, sinus tenderness, rhinorrhea or


congestion. Denies chest pain or tightness, palpitations. Denies





cough, shortness of breath, or wheezes. Denies nausea, vomiting,





diarrhea, constipation. He admitted right side abd pain.  No


recent change in bowel or bladder habits. No dysuria. Denies


arthralgias or myalgias. Denies rashes or skin breakdown. No


numbness/tingling in extremities. No feelings of depression or


anxiety. All other review of systems negative.




Past Medical History
ONCOLOGIC HISTORY:


1. Partial right nephrectomy in [**1-/2107**] after the patient


presented with hematuria and flank pain to [**Hospital1 **]


Hospital and was found on CT scan to have a 5.1 x 5.8 right


renal mass.


2. Resection of recurrent renal cell carcinoma in the right


subcostal region and rib in 11/[**2106**]. The pathology of the


resected tumor was consistent with the previously resected clear



cell primary.


3. Posterior cervical fusion, occiput to C5 and left-sided C2


laminectomy and decompression in [**4-/2108**] because of the finding


on MRI of a 2.5 x 3.2 cm destructive soft tissue mass. This mass



had replaced the left side of the C2 vertebral body and extended



into the pedicle and neural foramen on the left at the C2-C3


level.


4. Postoperative radiation therapy to the cervical spine.


5. One cycle of IL-2 as part of the IL-2 select trial in


08/[**2107**].


6. Hospitalization in [**9-/2108**] for hypercalcemia.


7. Enrolled in sorafenib/bevacizumab phase II trial on


[**2108-11-14**] - discontinued as of [**2109-1-4**] with development of


colonic perforation.


8. Readmitted to [**2109-1-10**] with contrast nephropathy. Status


post diverting ileostomy on [**2108-1-17**].


9. Begin Sutent 37.5 mg on [**2109-3-31**]. Stopped Sutent on [**1-/2110**]



(tired of taking it).


10. Consideration for the RAD-001 biomarker trial.  The patient,


however, had a nondiagnostic tumor biopsy, and was therefore


ineligible.


11. Resection of right retroperitoneal tumor, right colectomy,


partial liver resection, and ileal transverse colostomy


anastomosis on [**2110-11-14**] for recurrent renal cell carcinoma in


previous right nephrectomy bed with involvement of the liver,


right colon and right psoas muscle.


12. [**2111-4-20**] started PKI-587 (PI3K/mTOR inhibitor) on protocol


09-215


13. [**2111-6-15**] taken off protocol 09-215 because of disease


progression including T11-T12 paraspinal lesion invading spinal


canal


14. [**2111-7-2**] last zometa


15. [**Date range (3) 12208**] SRS to right infrahepatic metastasis;


[**Date range (2) 12209**] SRS to paraspinal metastasis




PAST MEDICAL HISTORY:


- Renal Cell Carcinoma (please see below)


- h/o RLE DVT [**8-/2107**]


- Colonic perforation


- Hyponatremia


- Anemia


- Cervical surgery with rod-placement due to C2 met


-[**2110-11-14**] Right colectomy, Segment VI partial liver


resection, resection of retroperitoneal tumor mass; ileal


transverse colostomy anastomosis (side to side).




Social History
Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug


use. Not currently emplyed, but worked as an electrician. 2


Healthy children.




Family History
Mother died of a brain tumor. Father diagnosed with prostate


cancer in his 70s and is still living. He has 3 siblings and 2


children without medical concerns. Maternal aunt with lymphoma.


Father and sister have had h/o "blood clots."


Physical Exam
VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA


GEN: AOx3, NAD


HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.


Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.


Pulm: No dullness to percussion, CTAB no crackles or wheezes


Abd: soft, tender in his right flank and RUQ area, +BS. no


rebound/guarding. neg HSM. neg [**Doctor Last Name **] sign.


Extremities: wwp, no edema. DPs, PTs 2+.


Skin: no rashes or bruising


Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.





DTRs 2+ BL.  sensation intact to LT, cerebellar fxn intact (FTN,





HTS). gait WNL.




Upon discharge:


T 97.8 120/70 75 16 96RA


GEN: NAD,


HEENT:  sclera anicteric.  no oral lesions.


Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.


Pulm: CTAB


Abd: soft, NT, +BS. no rebound/guarding.


Extremities: no edema


Neuro: A&Ox3, 5/5 strength in lower extremities


Back: clean dressing in place, staples, non erythematous




Pertinent Results
CT of abd ([**2111-9-22**])




1. The paraspinal mass which originates at the lytic lesion of


right 12th


rib, invades into the spinal canal, is more prominent as


compared to the prior studies. Spinal cord compression at the


level of D12, D11, and D10, mostly from the right side but


crossing anteriorly to the left at the level of D11. Findings


are consistent with spinal cord compression and can be further


evaluated by MRI.


2. The overall size of the paraspinal lesion is mildly


increased, as compared to the prior study.


3. The mass in the right lateral posterior abdominal wall


adjacent to the


liver now demonstrates small amount of air in it with possible


tract into


adjacent small bowel loop, suggesting a fistula.


4. Increase in size and number of numerous bilateral pulmonary


metastases and  one of them in the right middle lobe with a


cavitation.


5. New small right pleural effusion.




CT L spine [**10-16**]:


IMPRESSION:


1. Extensive fluid surrounding the surgical bed, without


definite


organization or rim to suggest abscess formation.


2. Large, peripherally enhancing fluid collection centered in


the right


paraspinal location near the level of the liver. This is


concerning for a


paraspinal abscess. However, given the presence of a lesion near





this


location on a previous MRI, it is unclear if there is also a


component of


necrotic neoplastic disease. Correlation to prior studies, if


available,


would be helpful.


3. Small, rim-enhancing collection in the left paraspinal


musculature on the


left, also concerning for a paraspinal abscess.


4. Numerous pulmonary nodules, the largest of which are


described above.


.




[**2111-10-19**] 06:45AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-26.7*


MCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* Plt Ct-388


[**2111-10-2**] 05:15AM BLOOD WBC-5.8 RBC-4.08* Hgb-10.5* Hct-33.4*


MCV-82 MCH-25.7* MCHC-31.3 RDW-15.2 Plt Ct-281


[**2111-10-19**] 06:45AM BLOOD Neuts-87.5* Lymphs-6.0* Monos-4.7 Eos-1.6





Baso-0.3


[**2111-10-2**] 05:15AM BLOOD Neuts-74.7* Lymphs-12.5* Monos-9.6


Eos-2.8 Baso-0.2


[**2111-10-13**] 03:50AM BLOOD PT-14.1* PTT-25.5 INR(PT)-1.2*


[**2111-10-2**] 05:15AM BLOOD PT-13.0 PTT-25.2 INR(PT)-1.1


[**2111-10-18**] 06:10AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-143


K-5.7* Cl-103 HCO3-32 AnGap-14


[**2111-10-2**] 05:15AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-136


K-4.8 Cl-101 HCO3-31 AnGap-9


[**2111-10-11**] 01:03AM BLOOD ALT-10 AST-14 AlkPhos-94 Amylase-27


TotBili-0.3


[**2111-10-2**] 05:15AM BLOOD ALT-16 AST-19 AlkPhos-109 TotBili-0.3


[**2111-10-18**] 06:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2


[**2111-10-2**] 05:15AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.5 Mg-2.2




Brief Hospital Course
47 yo male with renal cell cancer with intrahepatic and


paraspinal metastasis treated with stereotactic body


radiotherapy, completed on [**2111-8-5**], admitted for pain control


s/p T10-L2 fusion and removal of 12th vertebrae.


.


#Back/leg pain secondary to known spinal mets and cord


compression seen on imaging without neurological deficits:


 Radiation oncology and Neurosurgery were consulted and decided


that a


surgical approach was best for his management.  Pain was


controlled prior to surgery with fentanyl patch 400 mcg/hr,


hydromorphone 1-3 mg every 2-3 hrs IV prn, and gabapentin 300 mg





q8.  Patient underwent surgical decompression on [**10-8**]-> he


underwent T12 transpedicular decompression and posterior fusion


T10 to L2 under general anesthesia.  Had 1500cc EBL. During


procedure he was transfused with 2 units of PRBC and his POD#1


hematocrit was 32.  Went to SICU post op and remained intubated


overnight as he required nasal intubation. He was extubated


POD#1 without difficulty.  Given his long history of chronic


pain, the pain managment team was consulted and recommended a


ketamine drip for pain control and dilaudid IV as needed. They


continued to follow him post operatively and his ketamine drip


was dc'd on POD#4. His JP drain drain was DC'd on POD#4 without


difficulties.  His HCT continued to trend down and on [**2111-10-12**] he





received 2 units of PRBC's for a HCT of 21.7. His hematocrits


remained stable for the rest of his hospital course.  He was


transferred to the floor in stable condition although he


suffered [**2111-4-9**] back pain and intense headache.  The pain team


continued to follow him on the floor and his pain regimen was


optimized.  The IV dilaudid was changed to PO dilaudid and


slowly decreased as tolerated.  He was started on methadone 5 mg





[**Hospital1 **] which was decreased to 2.5 mg [**Hospital1 **].  He was given IV caffeine





and benadryl for his headache with minimal improvement.


Indomethacin 25 mg tid in combination with the methadone seemed


to help his headache tremendously and he denied headache on day


of discharge.  He will be discharged on fentanyl patch 400


mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid,


tylenol 1000mg tid, methadone 2.5 mg [**Hospital1 **], and prn dilaudid [**3-23**]


mg po as needed for breakthrough pain.  He should f/u with his


PCP, [**Name10 (NameIs) 12207**], and neurosurgery, and his pain regimen should


be adjusted and decreased as tolerated.  Of note, a CT L-spine


[**10-16**] was read as concerning for possible paraspinal abscess.


This was not clinically correlated as the patient was afebrile


without leukocytosis.  The neurosurgery team reviewed the CT


films and reported that the changes seen were most consistent


with post-op surgical changes rather than infection.  He will be





seen as an outpatient by neurosurgery to follow-up.


.


#asymptomatic elevated TSH: elevated at 5.5.  No symptoms.  [**Month (only) 412**]


be elevated due to


general illness/hospital stay.  Will not pursue further workup


at this time.  Consider outpatient work-up after discharge.




Medications on Admission
Transfer meds:


Duragesic patch 400mcg Q3 days


Lidoderm patch for 12 hours


ativan 1mg daily


Miralax 17g daily


Dilaudid 2-3 mg Q 2hours PRN


Flexeril 5mg tid


Ativan 1mg QHS


Zofran 2mg IV Q 6hours PRN




Home meds:


ativan prn


fentanyl for pain




Discharge Medications
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)


as needed for insomnia.


2. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO


TID (3 times a day) as needed for fever or pain: Please do not


exceed 4 g in 24 hours.


Disp:*60 solution* Refills:*2*


3. gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg


PO Q8H (every 8 hours).


Disp:*100 ml* Refills:*2*


4. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3


times a day).


Disp:*90 Capsule(s)* Refills:*2*


5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr


Transdermal Q72H (every 72 hours): Please do not combine with


alcohol or drive while taking this medication.


Disp:*40 Patch 72 hr(s)* Refills:*2*


6. hydromorphone 4 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3


hours) as needed for pain: Please do not combine with alcohol or



drive while taking this medication.


Disp:*30 Tablet(s)* Refills:*2*


7. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):



Please do not combine with alcohol or drive while taking this


medication.


Disp:*30 Tablet(s)* Refills:*2*




Discharge Disposition
Home with Service


Discharge Diagnosis
T 12 Spinal metastasis


epidural spinal cord compression seen on imaging with no


neurological deficits


metastatic renal cell carcinoma, mets to spine, liver, and with


pulmonary nodules


back/leg pain


elevated TSH, asymptomatic


Discharge Condition
Mental Status: Clear and coherent.


Level of Consciousness: Alert and interactive.


Activity Status: Ambulatory - Independent.




Discharge Instructions
Dear Mr. [**Known lastname **],


It was a pleasure participating in your health care.  You were


admitted to [**Hospital1 536**] for pain


control.  Your pain was managed with a fentanyl patch,


intravenous dilaudid, and gabapentin prior to your operation.


After surgery, your pain was controlled with a fentanyl patch,


oral dilaudid, gabapentin, indomethacin, tylenol, and methadone.




Please make the following changes to your medications:


STOP flexeril 5mg three times daily


START Fentanyl patch 400 mcg/hr every 72 hours


START Gabapentin 300 mg every 8 hours


START Indomethacin 25 mg three times a day


START Methadone 2.5 m twice a day


START HYDROmorphone (Dilaudid) 4-8 mg every 3 hours as needed


for uncontrolled pain.


START Acetaminophen (Tylenol) 1000 mg three times a day




Please work with your physician to reduce the amount of pain


medications that you are taking as your pain improves.




Please continue your other home medications.




In addition, please follow the instructions below:


??????        Do not smoke


??????        Keep wound clean / No tub baths or pools until seen in


follow up/ begin daily showers [**2111-10-12**]


??????        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 above;


??????        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


Followup Instructions
The following appointments have been made for you:




Department: HEMATOLOGY/ONCOLOGY


When: WEDNESDAY [**2111-10-14**] at 4:00 PM


With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5637**], MD [**Telephone/Fax (1) 1578**]


Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]


Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage




Department: HEMATOLOGY/ONCOLOGY


When: WEDNESDAY [**2111-10-14**] at 4:00 PM


With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12210**], MD [**Telephone/Fax (1) 1578**]


Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]


Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage




* PLEASE RETURN TO Dr[**Name (NI) 12211**] OFFICE IN [**4-13**] DAYS FOR REMOVAL OF



YOUR STAPLES/SUTURE(CLINIC DAYS TUES OR FRI).  PLEASE CALL


[**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT.





* PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.


[**Doctor Last Name **] TO BE SEEN IN 6 WEEKS.YOU WILL NEED XRAYS PRIOR TO THIS


APPOINTMENT




* Please arrange an appointment with your primary care physician



[**Doctor Last Name **] [**Last Name (NamePattern4) 12212**],MD for 2-3 weeks after discharge.  Please call


[**Telephone/Fax (1) 12213**] to arrange an appointment.




Chief Complaint:
back pain


Major Surgical or Invasive Procedure:
T12 transpedicular decompression and posterior instrumented
fusion T10 to L2


History of Present Illness:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], who is admitted
for pain control.  He was doing well after completion of
radiotherapy but within a few weeks developed severe left leg
pain as well as muscular spasms and areas of numbness.  Since
this weekend, he has developed severe left leg and back pain.
However, he denied fecal or urinary incontinence and focalized
weakness.

Because of the pain, on [**2111-9-28**], pt was admitted to local
hospital where he received pain medications and MRI under
anesthesia because of inability to lie flat.  The MRI revealed "

a large mass over the right renal fossa extending to the
paraspinal muscle and also there was a tumor involving the
thoracic 11 and thoracic 12 vertebral body extending into the
spinal canal, cord compression, and also a tumor involving the
paraspinous muscle.  Possible metastatic lesion of cervical 2
vertebral body with possible cord compression.

After discussing with his own [**Date Range 12207**] in [**Hospital1 8**], he was
transferred to here for further management.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies

cough, shortness of breath, or wheezes. Denies nausea, vomiting,

diarrhea, constipation. He admitted right side abd pain.  No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.


Past Medical History:
ONCOLOGIC HISTORY:
1. Partial right nephrectomy in [**1-/2107**] after the patient
presented with hematuria and flank pain to [**Hospital1 12214**] and was found on CT scan to have a 5.1 x 5.8 right
renal mass.
2. Resection of recurrent renal cell carcinoma in the right
subcostal region and rib in 11/[**2106**]. The pathology of the
resected tumor was consistent with the previously resected clear
cell primary.
3. Posterior cervical fusion, occiput to C5 and left-sided C2
laminectomy and decompression in [**4-/2108**] because of the finding
on MRI of a 2.5 x 3.2 cm destructive soft tissue mass. This mass
had replaced the left side of the C2 vertebral body and extended
into the pedicle and neural foramen on the left at the C2-C3
level.
4. Postoperative radiation therapy to the cervical spine.
5. One cycle of IL-2 as part of the IL-2 select trial in
08/[**2107**].
6. Hospitalization in [**9-/2108**] for hypercalcemia.
7. Enrolled in sorafenib/bevacizumab phase II trial on
[**2108-11-14**] - discontinued as of [**2109-1-4**] with development of
colonic perforation.
8. Readmitted to [**2109-1-10**] with contrast nephropathy. Status
post diverting ileostomy on [**2108-1-17**].
9. Begin Sutent 37.5 mg on [**2109-3-31**]. Stopped Sutent on [**1-/2110**]
(tired of taking it).
10. Consideration for the RAD-001 biomarker trial.  The patient,
however, had a nondiagnostic tumor biopsy, and was therefore
ineligible.
11. Resection of right retroperitoneal tumor, right colectomy,
partial liver resection, and ileal transverse colostomy
anastomosis on [**2110-11-14**] for recurrent renal cell carcinoma in
previous right nephrectomy bed with involvement of the liver,
right colon and right psoas muscle.
12. [**2111-4-20**] started PKI-587 (PI3K/mTOR inhibitor) on protocol
09-215
13. [**2111-6-15**] taken off protocol 09-215 because of disease
progression including T11-T12 paraspinal lesion invading spinal
canal
14. [**2111-7-2**] last zometa
15. [**Date range (3) 12208**] SRS to right infrahepatic metastasis;
[**Date range (2) 12209**] SRS to paraspinal metastasis

PAST MEDICAL HISTORY:
- Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver
resection, resection of retroperitoneal tumor mass; ileal
transverse colostomy anastomosis (side to side).


Social History:
Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug
use. Not currently emplyed, but worked as an electrician. 2
Healthy children.


Family History:
Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."

Physical Exam:
VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA
GEN: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, tender in his right flank and RUQ area, +BS. no
rebound/guarding. neg HSM. neg [**Doctor Last Name **] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.

DTRs 2+ BL.  sensation intact to LT, cerebellar fxn intact (FTN,

HTS). gait WNL.

Upon discharge:
T 97.8 120/70 75 16 96RA
GEN: NAD,
HEENT:  sclera anicteric.  no oral lesions.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no rebound/guarding.
Extremities: no edema
Neuro: A&Ox3, 5/5 strength in lower extremities
Back: clean dressing in place, staples, non erythematous


Pertinent Results:
CT of abd ([**2111-9-22**])

1. The paraspinal mass which originates at the lytic lesion of
right 12th
rib, invades into the spinal canal, is more prominent as
compared to the prior studies. Spinal cord compression at the
level of D12, D11, and D10, mostly from the right side but
crossing anteriorly to the left at the level of D11. Findings
are consistent with spinal cord compression and can be further
evaluated by MRI.
2. The overall size of the paraspinal lesion is mildly
increased, as compared to the prior study.
3. The mass in the right lateral posterior abdominal wall
adjacent to the
liver now demonstrates small amount of air in it with possible
tract into
adjacent small bowel loop, suggesting a fistula.
4. Increase in size and number of numerous bilateral pulmonary
metastases and  one of them in the right middle lobe with a
cavitation.
5. New small right pleural effusion.

CT L spine [**10-16**]:
IMPRESSION:
1. Extensive fluid surrounding the surgical bed, without
definite
organization or rim to suggest abscess formation.
2. Large, peripherally enhancing fluid collection centered in
the right
paraspinal location near the level of the liver. This is
concerning for a
paraspinal abscess. However, given the presence of a lesion near

this
location on a previous MRI, it is unclear if there is also a
component of
necrotic neoplastic disease. Correlation to prior studies, if
available,
would be helpful.
3. Small, rim-enhancing collection in the left paraspinal
musculature on the
left, also concerning for a paraspinal abscess.
4. Numerous pulmonary nodules, the largest of which are
described above.
.

[**2111-10-19**] 06:45AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-26.7*
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* Plt Ct-388
[**2111-10-2**] 05:15AM BLOOD WBC-5.8 RBC-4.08* Hgb-10.5* Hct-33.4*
MCV-82 MCH-25.7* MCHC-31.3 RDW-15.2 Plt Ct-281
[**2111-10-19**] 06:45AM BLOOD Neuts-87.5* Lymphs-6.0* Monos-4.7 Eos-1.6

Baso-0.3
[**2111-10-2**] 05:15AM BLOOD Neuts-74.7* Lymphs-12.5* Monos-9.6
Eos-2.8 Baso-0.2
[**2111-10-13**] 03:50AM BLOOD PT-14.1* PTT-25.5 INR(PT)-1.2*
[**2111-10-2**] 05:15AM BLOOD PT-13.0 PTT-25.2 INR(PT)-1.1
[**2111-10-18**] 06:10AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-143
K-5.7* Cl-103 HCO3-32 AnGap-14
[**2111-10-2**] 05:15AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-136
K-4.8 Cl-101 HCO3-31 AnGap-9
[**2111-10-11**] 01:03AM BLOOD ALT-10 AST-14 AlkPhos-94 Amylase-27
TotBili-0.3
[**2111-10-2**] 05:15AM BLOOD ALT-16 AST-19 AlkPhos-109 TotBili-0.3
[**2111-10-18**] 06:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2
[**2111-10-2**] 05:15AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.5 Mg-2.2


Brief Hospital Course:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], admitted for pain control
s/p T10-L2 fusion and removal of 12th vertebrae.
.
#Back/leg pain secondary to known spinal mets and cord
compression seen on imaging without neurological deficits:
 Radiation oncology and Neurosurgery were consulted and decided
that a
surgical approach was best for his management.  Pain was
controlled prior to surgery with fentanyl patch 400 mcg/hr,
hydromorphone 1-3 mg every 2-3 hrs IV prn, and gabapentin 300 mg

q8.  Patient underwent surgical decompression on [**10-8**]-> he
underwent T12 transpedicular decompression and posterior fusion
T10 to L2 under general anesthesia.  Had 1500cc EBL. During
procedure he was transfused with 2 units of PRBC and his POD#1
hematocrit was 32.  Went to SICU post op and remained intubated
overnight as he required nasal intubation. He was extubated
POD#1 without difficulty.  Given his long history of chronic
pain, the pain managment team was consulted and recommended a
ketamine drip for pain control and dilaudid IV as needed. They
continued to follow him post operatively and his ketamine drip
was dc'd on POD#4. His JP drain drain was DC'd on POD#4 without
difficulties.  His HCT continued to trend down and on [**2111-10-12**] he

received 2 units of PRBC's for a HCT of 21.7. His hematocrits
remained stable for the rest of his hospital course.  He was
transferred to the floor in stable condition although he
suffered [**2111-4-9**] back pain and intense headache.  The pain team
continued to follow him on the floor and his pain regimen was
optimized.  The IV dilaudid was changed to PO dilaudid and
slowly decreased as tolerated.  He was started on methadone 5 mg

[**Hospital1 **] which was decreased to 2.5 mg [**Hospital1 **].  He was given IV caffeine

and benadryl for his headache with minimal improvement.
Indomethacin 25 mg tid in combination with the methadone seemed
to help his headache tremendously and he denied headache on day
of discharge.  He will be discharged on fentanyl patch 400
mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid,
tylenol 1000mg tid, methadone 2.5 mg [**Hospital1 **], and prn dilaudid [**3-23**]
mg po as needed for breakthrough pain.  He should f/u with his
PCP, [**Name10 (NameIs) 12207**], and neurosurgery, and his pain regimen should
be adjusted and decreased as tolerated.  Of note, a CT L-spine
[**10-16**] was read as concerning for possible paraspinal abscess.
This was not clinically correlated as the patient was afebrile
without leukocytosis.  The neurosurgery team reviewed the CT
films and reported that the changes seen were most consistent
with post-op surgical changes rather than infection.  He will be

seen as an outpatient by neurosurgery to follow-up.
.
#asymptomatic elevated TSH: elevated at 5.5.  No symptoms.  [**Month (only) 412**]
be elevated due to
general illness/hospital stay.  Will not pursue further workup
at this time.  Consider outpatient work-up after discharge.


Medications on Admission:
Transfer meds:
Duragesic patch 400mcg Q3 days
Lidoderm patch for 12 hours
ativan 1mg daily
Miralax 17g daily
Dilaudid 2-3 mg Q 2hours PRN
Flexeril 5mg tid
Ativan 1mg QHS
Zofran 2mg IV Q 6hours PRN

Home meds:
ativan prn
fentanyl for pain


Discharge Medications:
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
TID (3 times a day) as needed for fever or pain: Please do not
exceed 4 g in 24 hours.
Disp:*60 solution* Refills:*2*
3. gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q8H (every 8 hours).
Disp:*100 ml* Refills:*2*
4. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr
Transdermal Q72H (every 72 hours): Please do not combine with
alcohol or drive while taking this medication.
Disp:*40 Patch 72 hr(s)* Refills:*2*
6. hydromorphone 4 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3
hours) as needed for pain: Please do not combine with alcohol or
drive while taking this medication.
Disp:*30 Tablet(s)* Refills:*2*
7. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):
Please do not combine with alcohol or drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] VNA, [**University/College 12215**]

Discharge Diagnosis:
T 12 Spinal metastasis
epidural spinal cord compression seen on imaging with no
neurological deficits
metastatic renal cell carcinoma, mets to spine, liver, and with
pulmonary nodules
back/leg pain
elevated TSH, asymptomatic

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


Discharge Instructions:
Dear Mr. [**Known lastname **],
It was a pleasure participating in your health care.  You were
admitted to [**Hospital1 536**] for pain
control.  Your pain was managed with a fentanyl patch,
intravenous dilaudid, and gabapentin prior to your operation.
After surgery, your pain was controlled with a fentanyl patch,
oral dilaudid, gabapentin, indomethacin, tylenol, and methadone.

Please make the following changes to your medications:
STOP flexeril 5mg three times daily
START Fentanyl patch 400 mcg/hr every 72 hours
START Gabapentin 300 mg every 8 hours
START Indomethacin 25 mg three times a day
START Methadone 2.5 m twice a day
START HYDROmorphone (Dilaudid) 4-8 mg every 3 hours as needed
for uncontrolled pain.
START Acetaminophen (Tylenol) 1000 mg three times a day

Please work with your physician to reduce the amount of pain
medications that you are taking as your pain improves.

Please continue your other home medications.

In addition, please follow the instructions below:
??????        Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2111-10-12**]
??????        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 above;
??????        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

Followup Instructions:
The following appointments have been made for you:

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5637**], MD [**Telephone/Fax (1) 1578**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 12210**], MD [**Telephone/Fax (1) 1578**]
Building: SC [**Hospital Ward Name **] Clinical Ctr [**Location (un) 1579**]
Campus: EAST     Best Parking: [**Hospital Ward Name **] Garage

* PLEASE RETURN TO Dr[**Name (NI) 12211**] OFFICE IN [**4-13**] DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURE(CLINIC DAYS TUES OR FRI).  PLEASE CALL
[**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT.

* 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 THIS
APPOINTMENT

* Please arrange an appointment with your primary care physician
[**Name9 (PRE) **] [**Last Name (NamePattern4) 12212**],MD for 2-3 weeks after discharge.  Please call
[**Telephone/Fax (1) 12213**] to arrange an appointment.


                             [**Doctor First Name **] [**Last Name (NamePattern5) 12216**] MD [**MD Number(2) 12217**]

Completed by:[**2111-10-21**]

Admission Date:  [**2111-10-1**]              Discharge Date:   [**2111-10-19**]

Date of Birth:  [**2064-2-2**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4282**]
Chief Complaint:
back pain

Major Surgical or Invasive Procedure:
T12 transpedicular decompression and posterior instrumented
fusion T10 to L2


History of Present Illness:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], who is admitted
for pain control.  He was doing well after completion of
radiotherapy but within a few weeks developed severe left leg
pain as well as muscular spasms and areas of numbness.  Since
this weekend, he has developed severe left leg and back pain.
However, he denied fecal or urinary incontinence and focalized
weakness.

Because of the pain, on [**2111-9-28**], pt was admitted to local
hospital where he received pain medications and MRI under
anesthesia because of inability to lie flat.  The MRI revealed "
a large mass over the right renal fossa extending to the
paraspinal muscle and also there was a tumor involving the
thoracic 11 and thoracic 12 vertebral body extending into the
spinal canal, cord compression, and also a tumor involving the
paraspinous muscle.  Possible metastatic lesion of cervical 2
vertebral body with possible cord compression.

After discussing with his own [**Date Range 5564**] in [**Hospital1 18**], he was
transferred to here for further management.
.
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough, shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea, constipation. He admitted right side abd pain.  No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rashes or skin breakdown. No
numbness/tingling in extremities. No feelings of depression or
anxiety. All other review of systems negative.


Past Medical History:
ONCOLOGIC HISTORY:
1. Partial right nephrectomy in [**1-/2107**] after the patient
presented with hematuria and flank pain to [**Hospital1 14579**] and was found on CT scan to have a 5.1 x 5.8 right
renal mass.
2. Resection of recurrent renal cell carcinoma in the right
subcostal region and rib in 11/[**2106**]. The pathology of the
resected tumor was consistent with the previously resected clear
cell primary.
3. Posterior cervical fusion, occiput to C5 and left-sided C2
laminectomy and decompression in [**4-/2108**] because of the finding
on MRI of a 2.5 x 3.2 cm destructive soft tissue mass. This mass
had replaced the left side of the C2 vertebral body and extended
into the pedicle and neural foramen on the left at the C2-C3
level.
4. Postoperative radiation therapy to the cervical spine.
5. One cycle of IL-2 as part of the IL-2 select trial in
08/[**2107**].
6. Hospitalization in [**9-/2108**] for hypercalcemia.
7. Enrolled in sorafenib/bevacizumab phase II trial on
[**2108-11-14**] - discontinued as of [**2109-1-4**] with development of
colonic perforation.
8. Readmitted to [**2109-1-10**] with contrast nephropathy. Status
post diverting ileostomy on [**2108-1-17**].
9. Begin Sutent 37.5 mg on [**2109-3-31**]. Stopped Sutent on [**1-/2110**]
(tired of taking it).
10. Consideration for the RAD-001 biomarker trial.  The patient,
however, had a nondiagnostic tumor biopsy, and was therefore
ineligible.
11. Resection of right retroperitoneal tumor, right colectomy,
partial liver resection, and ileal transverse colostomy
anastomosis on [**2110-11-14**] for recurrent renal cell carcinoma in
previous right nephrectomy bed with involvement of the liver,
right colon and right psoas muscle.
12. [**2111-4-20**] started PKI-587 (PI3K/mTOR inhibitor) on protocol
09-215
13. [**2111-6-15**] taken off protocol 09-215 because of disease
progression including T11-T12 paraspinal lesion invading spinal
canal
14. [**2111-7-2**] last zometa
15. [**Date range (3) 64795**] SRS to right infrahepatic metastasis;
[**Date range (2) 73646**] SRS to paraspinal metastasis

PAST MEDICAL HISTORY:
- Renal Cell Carcinoma (please see below)
- h/o RLE DVT [**8-/2107**]
- Colonic perforation
- Hyponatremia
- Anemia
- Cervical surgery with rod-placement due to C2 met
-[**2110-11-14**] Right colectomy, Segment VI partial liver
resection, resection of retroperitoneal tumor mass; ileal
transverse colostomy anastomosis (side to side).


Social History:
Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug
use. Not currently emplyed, but worked as an electrician. 2
Healthy children.


Family History:
Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."

Physical Exam:
VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA
GEN: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, tender in his right flank and RUQ area, +BS. no
rebound/guarding. neg HSM. neg [**Doctor Last Name 515**] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
DTRs 2+ BL.  sensation intact to LT, cerebellar fxn intact (FTN,
HTS). gait WNL.

Upon discharge:
T 97.8 120/70 75 16 96RA
GEN: NAD,
HEENT:  sclera anicteric.  no oral lesions.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTAB
Abd: soft, NT, +BS. no rebound/guarding.
Extremities: no edema
Neuro: A&Ox3, 5/5 strength in lower extremities
Back: clean dressing in place, staples, non erythematous


Pertinent Results:
CT of abd ([**2111-9-22**])

1. The paraspinal mass which originates at the lytic lesion of
right 12th
rib, invades into the spinal canal, is more prominent as
compared to the prior studies. Spinal cord compression at the
level of D12, D11, and D10, mostly from the right side but
crossing anteriorly to the left at the level of D11. Findings
are consistent with spinal cord compression and can be further
evaluated by MRI.
2. The overall size of the paraspinal lesion is mildly
increased, as compared to the prior study.
3. The mass in the right lateral posterior abdominal wall
adjacent to the
liver now demonstrates small amount of air in it with possible
tract into
adjacent small bowel loop, suggesting a fistula.
4. Increase in size and number of numerous bilateral pulmonary
metastases and  one of them in the right middle lobe with a
cavitation.
5. New small right pleural effusion.

CT L spine [**10-16**]:
IMPRESSION:
1. Extensive fluid surrounding the surgical bed, without
definite
organization or rim to suggest abscess formation.
2. Large, peripherally enhancing fluid collection centered in
the right
paraspinal location near the level of the liver. This is
concerning for a
paraspinal abscess. However, given the presence of a lesion near
this
location on a previous MRI, it is unclear if there is also a
component of
necrotic neoplastic disease. Correlation to prior studies, if
available,
would be helpful.
3. Small, rim-enhancing collection in the left paraspinal
musculature on the
left, also concerning for a paraspinal abscess.
4. Numerous pulmonary nodules, the largest of which are
described above.
.

[**2111-10-19**] 06:45AM BLOOD WBC-10.6 RBC-3.03* Hgb-8.5* Hct-26.7*
MCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* Plt Ct-388
[**2111-10-2**] 05:15AM BLOOD WBC-5.8 RBC-4.08* Hgb-10.5* Hct-33.4*
MCV-82 MCH-25.7* MCHC-31.3 RDW-15.2 Plt Ct-281
[**2111-10-19**] 06:45AM BLOOD Neuts-87.5* Lymphs-6.0* Monos-4.7 Eos-1.6
Baso-0.3
[**2111-10-2**] 05:15AM BLOOD Neuts-74.7* Lymphs-12.5* Monos-9.6
Eos-2.8 Baso-0.2
[**2111-10-13**] 03:50AM BLOOD PT-14.1* PTT-25.5 INR(PT)-1.2*
[**2111-10-2**] 05:15AM BLOOD PT-13.0 PTT-25.2 INR(PT)-1.1
[**2111-10-18**] 06:10AM BLOOD Glucose-100 UreaN-10 Creat-0.9 Na-143
K-5.7* Cl-103 HCO3-32 AnGap-14
[**2111-10-2**] 05:15AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-136
K-4.8 Cl-101 HCO3-31 AnGap-9
[**2111-10-11**] 01:03AM BLOOD ALT-10 AST-14 AlkPhos-94 Amylase-27
TotBili-0.3
[**2111-10-2**] 05:15AM BLOOD ALT-16 AST-19 AlkPhos-109 TotBili-0.3
[**2111-10-18**] 06:10AM BLOOD Calcium-9.6 Phos-4.3 Mg-2.2
[**2111-10-2**] 05:15AM BLOOD Albumin-3.5 Calcium-9.7 Phos-3.5 Mg-2.2

Brief Hospital Course:
47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], admitted for pain control
s/p T10-L2 fusion and removal of 12th vertebrae.
.
#Back/leg pain: Secondary to known spinal mets. Radiation
oncology and Neurosurgery were consulted and decided that a
surgical approach was best for his management.  Pain was
controlled prior to surgery with fentanyl patch 400 mcg/hr,
hydromorphone 1-3 mg every 2-3 hrs IV prn, and gabapentin 300 mg
q8.  Patient underwent surgical decompression on [**10-8**]-> he
underwent T12 transpedicular decompression and posterior fusion
T10 to L2 under general anesthesia.  Had 1500cc EBL. During
procedure he was transfused with 2 units of PRBC and his POD#1
hematocrit was 32.  Went to SICU post op and remained intubated
overnight as he required nasal intubation. He was extubated
POD#1 without difficulty.  Given his long history of chronic
pain, the pain managment team was consulted and recommended a
ketamine drip for pain control and dilaudid IV as needed. They
continued to follow him post operatively and his ketamine drip
was dc'd on POD#4. His JP drain drain was DC'd on POD#4 without
difficulties.  His HCT continued to trend down and on [**2111-10-12**] he
received 2 units of PRBC's for a HCT of 21.7. His hematocrits
remained stable for the rest of his hospital course.  He was
transferred to the floor in stable condition although he
suffered [**2111-4-9**] back pain and intense headache.  The pain team
continued to follow him on the floor and his pain regimen was
optimized.  The IV dilaudid was changed to PO dilaudid and
slowly decreased as tolerated.  He was started on methadone 5 mg
[**Hospital1 **] which was decreased to 2.5 mg [**Hospital1 **].  He was given IV caffeine
and benadryl for his headache with minimal improvement.
Indomethacin 25 mg tid in combination with the methadone seemed
to help his headache tremendously and he denied headache on day
of discharge.  He will be discharged on fentanyl patch 400
mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid,
tylenol 1000mg tid, methadone 2.5 mg [**Hospital1 **], and prn dilaudid [**3-23**]
mg po as needed for breakthrough pain.  He should f/u with his
PCP, [**Name10 (NameIs) 5564**], and neurosurgery, and his pain regimen should
be adjusted and decreased as tolerated.  Of note, a CT L-spine
[**10-16**] was read as concerning for possible paraspinal abscess.
This was not clinically correlated as the patient was afebrile
without leukocytosis.  The neurosurgery team reviewed the CT
films and reported that the changes seen were most consistent
with post-op surgical changes rather than infection.  He will be
seen as an outpatient by neurosurgery to follow-up.
.
#TSH: elevated at 5.5.  No symptoms.  [**Month (only) 116**] be elevated due to
general illness/hospital stay.  Will not pursue further workup
at this time.  Consider outpatient work-up after discharge.


Medications on Admission:
Transfer meds:
Duragesic patch 400mcg Q3 days
Lidoderm patch for 12 hours
ativan 1mg daily
Miralax 17g daily
Dilaudid 2-3 mg Q 2hours PRN
Flexeril 5mg tid
Ativan 1mg QHS
Zofran 2mg IV Q 6hours PRN

Home meds:
ativan prn
fentanyl for pain

Discharge Medications:
1. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
2. acetaminophen 650 mg/20.3 mL Solution Sig: 1000 (1000) mg PO
TID (3 times a day) as needed for fever or pain: Please do not
exceed 4 g in 24 hours.
Disp:*60 solution* Refills:*2*
3. gabapentin 250 mg/5 mL Solution Sig: Three Hundred (300) mg
PO Q8H (every 8 hours).
Disp:*100 ml* Refills:*2*
4. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
5. fentanyl 100 mcg/hr Patch 72 hr Sig: Four (4) Patch 72 hr
Transdermal Q72H (every 72 hours): Please do not combine with
alcohol or drive while taking this medication.
Disp:*40 Patch 72 hr(s)* Refills:*2*
6. hydromorphone 4 mg Tablet Sig: 1-4 Tablets PO Q3H (every 3
hours) as needed for pain: Please do not combine with alcohol or
drive while taking this medication.
Disp:*30 Tablet(s)* Refills:*2*
7. methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day):
Please do not combine with alcohol or drive while taking this
medication.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
[**Hospital1 **] VNA, [**University/College **]

Discharge Diagnosis:
Epidural spinal cord compression from T 12 Spinal metastasis
Metastatic renal cell cancer
Severe postoperative headache ? dural tear with subsequenc
spinal fluid leak

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

Discharge Instructions:
Dear Mr. [**Known lastname 73639**],
It was a pleasure participating in your health care.  You were
admitted to [**Hospital1 69**] for pain
control.  Your pain was managed with a fentanyl patch,
intravenous dilaudid, and gabapentin prior to your operation.
After surgery, your pain was controlled with a fentanyl patch,
oral dilaudid, gabapentin, indomethacin, tylenol, and methadone.

Please make the following changes to your medications:
STOP flexeril 5mg three times daily
START Fentanyl patch 400 mcg/hr every 72 hours
START Gabapentin 300 mg every 8 hours
START Indomethacin 25 mg three times a day
START Methadone 2.5 m twice a day
START HYDROmorphone (Dilaudid) 4-8 mg every 3 hours as needed
for uncontrolled pain.
START Acetaminophen (Tylenol) 1000 mg three times a day

Please work with your physician to reduce the amount of pain
medications that you are taking as your pain improves.

Please continue your other home medications.

In addition, please follow the instructions below:
??????        Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2111-10-12**]
??????        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 above;
??????        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

Followup Instructions:
The following appointments have been made for you:

Department: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9402**], 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: HEMATOLOGY/ONCOLOGY
When: WEDNESDAY [**2111-10-14**] at 4:00 PM
With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 6575**], 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

* PLEASE RETURN TO Dr[**Name (NI) 2845**] OFFICE IN [**4-13**] DAYS FOR REMOVAL OF
YOUR STAPLES/SUTURE(CLINIC DAYS TUES OR FRI).  PLEASE CALL
[**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT.

* 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 THIS
APPOINTMENT

* Please arrange an appointment with your primary care physician
[**Name9 (PRE) **] [**Last Name (NamePattern4) 73647**],MD for 2-3 weeks after discharge.  Please call
[**Telephone/Fax (1) 73645**] to arrange an appointment.
{'Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of lung,Myelopathy in other diseases classified elsewhere,Acute posthemorrhagic anemia,Other nervous system complications,Leukocytosis, unspecified,Neoplasm related pain (acute) (chronic),Hypopotassemia,Other constipation,Personal history of venous thrombosis and embolism,Personal history of malignant neoplasm of bladder,Arthrodesis status,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of large intestine,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: back pain

PRESENT ILLNESS: 47 yo male with renal cell cancer with intrahepatic and
paraspinal metastasis treated with stereotactic body
radiotherapy, completed on [**2111-8-5**], who is admitted
for pain control.  He was doing well after completion of
radiotherapy but within a few weeks developed severe left leg
pain as well as muscular spasms and areas of numbness.  Since
this weekend, he has developed severe left leg and back pain.
However, he denied fecal or urinary incontinence and focalized
weakness.

MEDICAL HISTORY: - Renal Cell Carcinoma (please see below)

MEDICATION ON ADMISSION: Transfer meds:
Duragesic patch 400mcg Q3 days
Lidoderm patch for 12 hours
ativan 1mg daily
Miralax 17g daily
Dilaudid 2-3 mg Q 2hours PRN
Flexeril 5mg tid
Ativan 1mg QHS
Zofran 2mg IV Q 6hours PRN

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: VS: T 98, BP 120/80, P 91, R 18, saO2 98 @ RA
GEN: AOx3, NAD
HEENT:  PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, CTAB no crackles or wheezes
Abd: soft, tender in his right flank and RUQ area, +BS. no
rebound/guarding. neg HSM. neg [**Doctor Last Name **] sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.

FAMILY HISTORY: Mother died of a brain tumor. Father diagnosed with prostate
cancer in his 70s and is still living. He has 3 siblings and 2
children without medical concerns. Maternal aunt with lymphoma.
Father and sister have had h/o "blood clots."

SOCIAL HISTORY: Married. Quit drinking alcohol. [**Doctor First Name **] tobacco and illicit drug
use. Not currently emplyed, but worked as an electrician. 2
Healthy children. 

### Response:
{'Secondary malignant neoplasm of bone and bone marrow,Secondary malignant neoplasm of lung,Myelopathy in other diseases classified elsewhere,Acute posthemorrhagic anemia,Other nervous system complications,Leukocytosis, unspecified,Neoplasm related pain (acute) (chronic),Hypopotassemia,Other constipation,Personal history of venous thrombosis and embolism,Personal history of malignant neoplasm of bladder,Arthrodesis status,Personal history of antineoplastic chemotherapy,Personal history of irradiation, presenting hazards to health,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of large intestine,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
