CHIEF COMPLAINT: neck pain, leg and arm weakness

PRESENT ILLNESS: Pt is a 50 yo woman with h/o depression/anxiety and Hep C who
presents with ~5-6 days of neck pain, constipation, and urinary
retention as well as right sided weakness and numbness.

MEDICAL HISTORY: -h/o depression/anxiety
-Hep C

MEDICATION ON ADMISSION: Ativan
Aleve
Motrin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon evalVitals:100.1-->103, 100, 119/74, 32, 97% on RA
Gen:Mod distress due to pain. Pt sleepy after medication.
HEENT:MMM. Sclera clear. OP clear
Neck:  Has C-collar on so can't assess meningismus.
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
uatiNeurologic examination:
Mental status: Awake and alert, cooperative with exam sometimes.
Delays answers due to pain often.
Orientation: Oriented to person, place, and date
Attention: Sleepy, but tries to pay attention.
Language: Fluent with good comprehension.  No dysarthria or
paraphasic errors
No apraxia, no neglect

FAMILY HISTORY: No CAD. No CA. No stroke/sz

SOCIAL HISTORY: Patient states that she started use IV drugs ~2-3 years ago with
a friend of hers "who wasn't really a good friend." Denies
alcohol use.
.
The patient states that she has a large, very supportive family.
She has 6 children ranging from ages 32 to 14.
Worked as crossing
guard and stopped due to depression.
Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute respiratory failure,Acute osteomyelitis, other specified sites,Retention of urine, unspecified,Chronic hepatitis C without mention of hepatic coma,Urinary tract infection, site not specified,Cocaine abuse, unspecified,Severe sepsis,Intervertebral disc disorder with myelopathy, cervical region,Dysthymic disorder,Anemia of other chronic disease
Meth susc Staph aur sept,Intraspinal abscess,Acute respiratry failure,Ac osteomyelitis NEC,Retention urine NOS,Chrnc hpt C wo hpat coma,Urin tract infection NOS,Cocaine abuse-unspec,Severe sepsis,Cerv disc dis w myelopat,Dysthymic disorder,Anemia-other chronic dis
Admission Date:  [**2106-10-29**]              Discharge Date:   [**2106-11-11**]

Date of Birth:  [**2056-9-29**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2160**]
Chief Complaint:
neck pain, leg and arm weakness

Major Surgical or Invasive Procedure:
Posterior Laminectomy at C2-C3

History of Present Illness:
Pt is a 50 yo woman with h/o depression/anxiety and Hep C who
presents with ~5-6 days of neck pain, constipation, and urinary
retention as well as right sided weakness and numbness.

She reports that she sat is a massage chair 8 days ago and fell
asleep x1 hour. Unclear what position. She then developed onset
of lower back pain 2 days later by her report to the ED, but she
denies LBP to me.  She tells me that her pain has been all in
her
neck and shoulders region.  She says that since 6 days ago, she
has had no BM.  She also reports that she has not urinated for 6
days.  She states that 5-6 days ago, on Saturday, her RLE felt
numb and weak.  Since Sunday, she states she has been unable to
walk.  Her RUE has also been weak and tingling/numb for about
the
same time frame.  She has pain as above.  She claims no LBP.
She
also says that her "private area" is numb.  Per her report, she
went to the [**Hospital1 112**] ED 4 times in the past week with this story and
was not imaged, given ativan and aleve and sent home.  She has
had pain in her abdomen.  She says she has not urinated in 5
days.

Here, she has extreme neck pain and was catheterized for 1200 cc
urine.  She also continues to have weakness.

ROS: Patient denies any fever, she had some nausea/vomiting. She
had a mild bifrontal HA, now resolved.She had some dysarthria 4
days ago. No dysphagia. + dizziness/LH. No visual changes,
diplopia, hearing changes, or vertigo. No facial symptoms.


Past Medical History:
-h/o depression/anxiety
-Hep C

Social History:
Patient states that she started use IV drugs ~2-3 years ago with
a friend of hers "who wasn't really a good friend." Denies
alcohol use.
.
The patient states that she has a large, very supportive family.
She has 6 children ranging from ages 32 to 14.
Worked as crossing
guard and stopped due to depression.

Family History:
No CAD. No CA. No stroke/sz


Physical Exam:
Upon evalVitals:100.1-->103, 100, 119/74, 32, 97% on RA
Gen:Mod distress due to pain. Pt sleepy after medication.
HEENT:MMM. Sclera clear. OP clear
Neck:  Has C-collar on so can't assess meningismus.
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
uatiNeurologic examination:
Mental status: Awake and alert, cooperative with exam sometimes.
Delays answers due to pain often.
Orientation: Oriented to person, place, and date
Attention: Sleepy, but tries to pay attention.
Language: Fluent with good comprehension.  No dysarthria or
paraphasic errors
No apraxia, no neglect

Cranial Nerves:
I: not tested
II: Pupils equally round and reactive to light, 5 to 3
mm bilaterally. Visual fields are full to finger movement. Fundi
normal bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations, intact movements

Motor:
Normal bulk and tone bilaterally
No tremor
Pt has severe motor impersistence throughout.  She refuses/is
unable to left RUE, but can move at least in plane of bed and
can
use FF fully.  She can't lift or hold arm off of bed.  Her LUE,
she can initially hold up and has at least 4/5 strength
throughout, but later in exam, refuses/is unable to lift off of
the bed well.
In LEs, she can push me away strongly with both legs and bend
her
knees equally, but will not cooperate with formal strength
testing.  She moves both feet and toes at least [**4-7**].
Unable to test pronator drift

Sensation: Very spotty and changes with multiple exams, but LT
and PP are [**Month (only) **] in RLE over L4-S1 regions, but otherwise intact.
Prop and temp normal. Vib increased in RLE.  No sensory level to
PP on either side of her body.  She does later change and report
less sensation over right lateral thigh, but then says this is
actually the same as the left.  Overall, she is distracted by
pain and gives an inaccurate exam.

Reflexes: B T Br Pa Ankle
Right     t 1 t  2  2+
Left      t 1 t  2  2

Toes were downgoing bilaterally

Coordination: Will not cooperate, but does do FFM with hands
well.  Won't lift either arm up to do FNF.

Gait: Refuses/unable

Per ED exam, she has normal perianal sensation, but no sphincter
tone.
on in the ED

Pertinent Results:
[**2106-10-29**]: MRI C/T spine:  Markedly abnormal study with evidence
of extensive prevertebral and epidural space inflammatory
process, perhaps originating with the consolidation involving
the medial aspect of the right lung at its apex, by contiguous
extension. There is some ventral impression of the cord,
particularly at the C2 through C4 levels. There is evidence of
extensive secondary leptomeningeal involvement, which may extend
throughout the thoracic spine to the level of the conus. Of
note, there is a strong suggestion of cord intrinsic signal
abnormality, raising the possibility of venous edema related to
septic thrombophlebitis, without cord hemorrhage. Also of note,
the prevertebral process includes apparent defined fluid locules
within the longus [**Last Name (un) **] muscles which may, at least in part,
reach the spinal epidural space via the left C6-7 neural
foramen. Secondary leptomeningeal involvement may extend
throughout the thoracic levels to the level of the conus
medullaris.


Brief Hospital Course:
In brief, the patient is a 50 yo female with history of Hep C,
IVDU and depression who presented with fevers, chills, severe
neck pain and neurologic deficits found to have an epidural and
pre-vertebral abscess at C2-C3.
.
1.) Neuro compromise/spinal abscess/osteomyleitis: The patient
presented with signs and symptoms consistent with cervical
spinal cord compression.  Imaging revealed an epidural abscess
and osteomyelitis at C2-C3 (see complete report).  She was
started on empiric antibiotics and taken to the OR for C2-C3
laminectomy (please refer to operative report).  She was started
on steroids to decrease inflammation around the cord. Wound
cultures from the surgical site revealed Staph aureas which was
sensitive to methacillin.  She was started on nafcillin with an
anticipated 6 week course via a PICC line that was placed.  She
made gradual improvement in her neurologic deficits and worked
regularly with PT and OT.  A repeat MRI on [**2106-11-4**] revealed a
persistent fluid collection, however, the patient was making
steady progress in neurologic recover and remained afebrile, so
the decision was made to continue to follow her exam closely and
monitor for a need for a new operative intervention to drain the
collection.  She completed a steroid taper.  She will be
discharged with follow-up in the Infectious Disease clinic and
the Neurosurgery Department with a repeat MRI prior to the
Neurosurgery appointment. While on nafcillin she will need
weekly monitoring of LFTs, BUN and Cr.
.
3.) MSSA bacteremia - Patient was bacteremic on admission to ICU
from ED. Found to be MSSA consistent with the species identified
from the surgical specimen. Her blood cultures cleared rapidly
once starting antibiotics.  A TTE revealed no valvular
abnormality and she had no signs of septic emboli. By time of
discharge, follow-up blood cultures were negative.  She will
receive antibiotics as above.

.
3.) Respiratory failure: Unclear precipitant of resp failure.
Patient extubated without difficulty on [**11-2**]. She was
discharged with normal oxygenation on room air.
.
4.) Hepatitis C - The patient has an ~2 year history of HepC
likely acquired through IVDU.  Her LFT were initially elevated
(ALT primarily) but rapidly normalized. Her synthetic function
(INR) was normal. HIV negative. HCV Viral load >700,000. Hep B
serologies reveal non-immune pattern.  [**Last Name (un) **] serology was
positive. She will need to complete a Hepatitis B vaccine
series.  She received the first dose of Hepatits B vaccine on
[**2106-11-11**].  She should receive her next dose in 1 month and the
final dose in 6 months from now. She should receive a referal
from her PCP to the Liver Center to evaluate her Hep C after her
treatment course for this bacterial infection.

.
5.) Depression: The patient has a questionable history of
depression.  Currently not on meds. The patient was evaluated by
social work to help with coping strategies and access to care.
.
6.) Urinary Tract Infection: The patient developed a low grade
fever late in her hospital course.  She had no localizing signs
or symptoms.  A UA revealed elevated WBC c/w infection.  She was
started on 7 days of ciprofloxacin and had her foley catheter
changed. Her fever resolved.  At discharge, urine and blood
cultures were pending.
.
7.) Anemia: Unclear etiology. HCT stable. Iron studies were
consistent with mild anemia of chronic disease.  Her liver
disease is likely an exacerbating factor. This should be
follow-up as an outpatient.
.
8.) Elevated lipase: unclear etiology no peri-meal symptoms. no
abdominal pain or tenderness. Weekly follow-up with other lab
tests is recommended.
.
9.) FEN: tolerating soft solids well with max assist feeding.
.
10.) PPX: SC heparin, pneumoboots, PPI
.
11.) Access: PICC
.
12.) Code: Full
.
13.) Dispo: to acute rehab with Infectious Disease and
Neurosurgery follow-up and a new PCP


Medications on Admission:
Ativan
Aleve
Motrin


Discharge Medications:
1. Outpatient Lab Work
Please draw the following labs every Monday for the next 5 weeks
(i.e. [**11-15**]): LFTs, Bun, Cr and fax the result to
Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] [**Telephone/Fax (1) 1419**]
2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Nafcillin in D2.4W 2 g/100 mL Piggyback Sig: Two (2) gram
Intravenous  Q4H (every 4 hours) for until [**2106-12-12**] weeks.
5. PICC Line Care
PICC Line Care per protocol
6. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: One (1)
Tablet Sustained Release 12HR PO Q12H (every 12 hours).
7. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed.
8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for back pain.
10. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
[**Hospital1 **] (2 times a day) as needed for 1 BM daily.
11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 6 days.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7**] & Rehab Center - [**Hospital1 8**]

Discharge Diagnosis:
Primary:
Epidural abscess
Osteomyelitis
.
Secondary:
Hepatitis C
Urinary Tract Infection


Discharge Condition:
stable.  afebrile. stable vital signs.  improving neurologic
function. tolerating oral medications and nutrition


Discharge Instructions:
You have been evaluated and treated for neck pain and weakness
in your arms and legs.  Your symptoms were caused by an
infection around your spinal cord in your neck.  You had a
surgery to drain a fluid collection.  You will continue to
receive antibiotics for several more weeks to make sure the
infection is treated adequately.
.
Take all the medications as prescribed.
.
Attend the follow-up appointments scheduled for you.
.
You need to make an appointment with a new Primary Care
Physician.  [**Name10 (NameIs) **] initiate care at [**First Name8 (NamePattern2) **] [**Hospital3 66399**] outpatient
medicine clinic "Heathcare Associates," you need to call your
insurance company ([**Hospital3 **]) to tell them that you will be
transferring your primary medical care to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **].
After talking with [**Last Name (NamePattern1) **], you need to call Dr.[**Name (NI) 11574**]
office at [**Telephone/Fax (1) 250**] to talk with the registration department.
.
You will be working with physical therapy and occupational
therapy to rebuild strength in your arms and legs to the best of
their ability.

Followup Instructions:
You have the following appointments scheduled for you:
1) Infectious Disease: Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 3394**] on on [**2106-12-7**] at 9am
(telephone) [**Telephone/Fax (1) 457**] Date/Time:[**2106-12-7**] 9:00
2) Neurosurgery with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**5-8**] weeks. Please call
[**Telephone/Fax (1) 2731**] next week to schedule the appointment.  You will
need to have another MRI prior to that appointment. The
Neurosurgery office will help to schedule the test for you.
3) Medicine: with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] who works with your new PCP [**Last Name (NamePattern4) **].
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2106-12-13**] at 3:30pm. Please call [**Telephone/Fax (1) 250**]
to confirm the appointment after contacting [**Name (NI) **] as above.
{'Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute respiratory failure,Acute osteomyelitis, other specified sites,Retention of urine, unspecified,Chronic hepatitis C without mention of hepatic coma,Urinary tract infection, site not specified,Cocaine abuse, unspecified,Severe sepsis,Intervertebral disc disorder with myelopathy, cervical region,Dysthymic disorder,Anemia of other chronic disease'}


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: neck pain, leg and arm weakness

PRESENT ILLNESS: Pt is a 50 yo woman with h/o depression/anxiety and Hep C who
presents with ~5-6 days of neck pain, constipation, and urinary
retention as well as right sided weakness and numbness.

MEDICAL HISTORY: -h/o depression/anxiety
-Hep C

MEDICATION ON ADMISSION: Ativan
Aleve
Motrin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon evalVitals:100.1-->103, 100, 119/74, 32, 97% on RA
Gen:Mod distress due to pain. Pt sleepy after medication.
HEENT:MMM. Sclera clear. OP clear
Neck:  Has C-collar on so can't assess meningismus.
CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs
Lung: Clear to auscultation bilaterally
Ext:No cyanosis/edema
uatiNeurologic examination:
Mental status: Awake and alert, cooperative with exam sometimes.
Delays answers due to pain often.
Orientation: Oriented to person, place, and date
Attention: Sleepy, but tries to pay attention.
Language: Fluent with good comprehension.  No dysarthria or
paraphasic errors
No apraxia, no neglect

FAMILY HISTORY: No CAD. No CA. No stroke/sz

SOCIAL HISTORY: Patient states that she started use IV drugs ~2-3 years ago with
a friend of hers "who wasn't really a good friend." Denies
alcohol use.
.
The patient states that she has a large, very supportive family.
She has 6 children ranging from ages 32 to 14.
Worked as crossing
guard and stopped due to depression. 

### Response:
{'Methicillin susceptible Staphylococcus aureus septicemia,Intraspinal abscess,Acute respiratory failure,Acute osteomyelitis, other specified sites,Retention of urine, unspecified,Chronic hepatitis C without mention of hepatic coma,Urinary tract infection, site not specified,Cocaine abuse, unspecified,Severe sepsis,Intervertebral disc disorder with myelopathy, cervical region,Dysthymic disorder,Anemia of other chronic disease'}
