CHIEF COMPLAINT: Right Leg Weakness

PRESENT ILLNESS: 58 M renal cell ca with mets s/p T12 vertebrectomy c/b wound
infection and revision in [**2194**] by Dr. [**Last Name (STitle) 548**], with one week
history worsening R>L weakness, numbness, sensation change with
OSH CT showing worsening thoracic mets.
Patient was undergoing Chemo therapy until 6 months ago and he
elected to stop therapy b/c he did not like how it made him
feel. He began metabolic nutritional therapy instead.
He began to notice some sensory changes in his right leg about
10 days ago and more recently in the past few days has had
difficulty placing weight on it. He denies loss of bowel or
bladder function. He did suffer a fall yesterday and landed on
his bottom and required help to get back up on his feet.

MEDICAL HISTORY: Renal Cell carcinoma-resected in [**2190**] with bony mets to spine.
s/p thoracic instrumented fusion T1-12 on [**2194-1-28**] for extradural
mass at T5 and kyphotic collapse at T10
h/o MSSA bacteremia/deep wound infection ([**1-22**])
h/o knee surgery with ? infection at [**Hospital3 **]
Rheumatoid arthritis
h/o HCV-treated with 6 mo IFN/Riba by Dr [**First Name (STitle) **] in approx [**2189**]
History of Tobacco use
History of Alcohol use/abuse-clean x 2 years
History of Polysubstance abuse including IVD-now clean
Depression

MEDICATION ON ADMISSION: Citalopram 20mg QD
Nexium 20 QD
Colace 100mg [**Hospital1 **]
Gabapentin 400 mg TID
Folic Acid 1mg qd
Zinc sulfate 220mg QD
Dilaudid 4mg 3tabs qid
methadone 10mg 6tabs every 6hrs.

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Physical Examination on admission to [**Hospital1 18**]:

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

SOCIAL HISTORY: Currently lives alone.
Esophageal reflux,Personal history of malignant neoplasm of kidney,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Other mechanical complication of other internal orthopedic device, implant, and graft,Rheumatoid arthritis,Neoplasm related pain (acute) (chronic),Anemia, unspecified,Depressive disorder, not elsewhere classified
Esophageal reflux,Hx of kidney malignancy,Hx of irradiation,Hx antineoplastic chemo,Abn react-artif implant,Secondary malig neo bone,Myelopathy in oth dis,Mech com orth dev NEC,Rheumatoid arthritis,Neoplasm related pain,Anemia NOS,Depressive disorder NEC
Admission Date:  [**2196-8-12**]              Discharge Date:   [**2196-8-22**]

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

Service: NEUROSURGERY

Allergies:
Heparin Agents

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
Right Leg Weakness


Major Surgical or Invasive Procedure:
[**2196-8-17**] angiogram with embolization
[**2196-8-17**] Posterior thoracic fusion revision


History of Present Illness:
58 M renal cell ca with mets s/p T12 vertebrectomy c/b wound
infection and revision in [**2194**] by Dr. [**Last Name (STitle) 548**], with one week
history worsening R>L weakness, numbness, sensation change with
OSH CT showing worsening thoracic mets.
Patient was undergoing Chemo therapy until 6 months ago and he
elected to stop therapy b/c he did not like how it made him
feel. He began metabolic nutritional therapy instead.
He began to notice some sensory changes in his right leg about
10 days ago and more recently in the past few days has had
difficulty placing weight on it. He denies loss of bowel or
bladder function. He did suffer a fall yesterday and landed on
his bottom and required help to get back up on his feet.

Past Medical History:
Renal Cell carcinoma-resected in [**2190**] with bony mets to spine.
s/p thoracic instrumented fusion T1-12 on [**2194-1-28**] for extradural
mass at T5 and kyphotic collapse at T10
h/o MSSA bacteremia/deep wound infection ([**1-22**])
h/o knee surgery with ? infection at [**Hospital3 **]
Rheumatoid arthritis
h/o HCV-treated with 6 mo IFN/Riba by Dr [**First Name (STitle) **] in approx [**2189**]
History of Tobacco use
History of Alcohol use/abuse-clean x 2 years
History of Polysubstance abuse including IVD-now clean
Depression


Social History:
Currently lives alone.

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


Physical Exam:
Physical Examination on admission to [**Hospital1 18**]:

PHYSICAL EXAM:
O: T:97.9  BP:169 /67         HR: 60   R 18      O2Sats100
Gen: WD/WN, comfortable, NAD.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

Motor:
      D    B     T    WE   WF    IP    Q  H     AT    [**Last Name (un) 938**]    G

Sensation: Intact to light touch, proprioception

Reflexes: B T Br Pa Ac
Right     1 1 1  0  0
Left      1 1 1  1  1

Toes downgoing bilaterally.

[**6-21**] beets of clonus bilaterally

Exam upon discharge:
R IP -[**4-18**], H -[**5-18**], Q [**5-18**]/, AT 3/5, [**Last Name (un) 938**] [**2-19**], G [**4-18**]
LLE full motor
BUE full motor


Pertinent Results:
CT: (Outside Hospital report)  comparison made to a CT of the T
spine
performed on [**2196-3-25**]: further loss of bone in the
posterior
aspect of the fourth T  vertebral body as well as the posterior
elements on the left and adjacent left rib. Compression
deformity
of the fifth T vertebral body nearly completely replaced by
tumor. increased degree of osseous destruction  when compared to
previous study....lit ic lesion involving 6th vertebral body.
Large lesion involving ninth T vertebral body and posterior
elements on right.... diffuse metastatic lesion of the Thoracic
spine, increased in degree of bone loss when compared to
previous
study

MRI [**2196-8-14**]
Destructive mass lesions are identified within T4, T5, T9 and
T10 vertebrae.As seem on prior exams, the T5 vertebral body is
collapsed and there isposterior extension of the soft tissue
mass, displacing the spinal cord. The spinal cord does not
demonstrate signal abnormality at any imaged level.
The T9 and T10 vertebral bodies are partially absent and there
is a marked
kyphotic deformity centered about these two vertebral bodies,
present on prior studies. The spinal canal is not well seen at
the T9 and T10 levels due to artifact from the posterior spinal
hardware but is likely significantly narrowed by tumor, with its
effect on the spinal cord, difficult to assess.
No evidence of acute thoracic or lumbar fracture.

 Bone scan [**2196-8-15**]:
Numerous lesions of increased MDP avidity including foci in the
mid and upper thoracic spine likely representing metastatic
osseous disease.


Brief Hospital Course:
Pt was admitted to neurosurgery.  He was started on pain
medication and bowel meds.  He was kept flat until was
determined that his spine was stable.  He underwent intubation
for MRI due to claustrophobia on [**2196-8-14**].He was readied for OR.
On [**2196-8-17**] he was brought to INR and underwent embolization of
thoracic tumor and then proceeded to OR. Post-op course was
uneventful- he was transferred to the floor from PACU on [**8-18**], on
[**8-19**] he received 2 units PRBC for HCT 23, repeat HCT has been
stable. [**8-21**] HCT 30.4

PT/OT evaluated patient and recommended Rehab. On [**8-22**] patient
was discharged to Rehab of [**Location (un) **] and Islands.

Medications on Admission:
Citalopram 20mg QD
Nexium 20 QD
Colace 100mg [**Hospital1 **]
Gabapentin 400 mg TID
Folic Acid 1mg qd
Zinc sulfate 220mg QD
Dilaudid 4mg 3tabs qid
methadone 10mg 6tabs every 6hrs.


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

2. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
5. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)
dose PO DAILY (Daily).
6. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
8. Methadone 10 mg Tablet Sig: Six (6) Tablet PO QID (4 times a
day).
9. Hydromorphone 2 mg Tablet Sig: 6-10 mg PO Q6H (every 6 hours)
as needed for pain.
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
11. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2)
Tablet, Chewable PO TID (3 times a day).
12. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
13. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours).
14. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q12 ()
for 1 days.
15. Dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO Q24 ()
for 1 days.
16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
17. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for abd folds.
18. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for groin/scrotum.


Discharge Disposition:
Extended Care

Facility:
[**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**]

Discharge Diagnosis:
Metastatic Renal cell carcinoma to spine


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up/ remove dressing POD#2   / begin daily showers POD#4
??????        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
??????        If you are required to wear one, wear  or back brace as
instructed
??????        You may shower briefly without  / back brace unless
instructed otherwise
??????        Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
??????        Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months.
??????        Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation
??????        Clearance to drive and return to work will be addressed
at your post-operative office visit


Followup Instructions:
Please follow up with Dr. [**Last Name (STitle) 548**] in 6 weeks with T/L spine Xrays.
Call [**Telephone/Fax (1) 2992**] to arrange appt.



Completed by:[**2196-8-22**]
{'Esophageal reflux,Personal history of malignant neoplasm of kidney,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Other mechanical complication of other internal orthopedic device, implant, and graft,Rheumatoid arthritis,Neoplasm related pain (acute) (chronic),Anemia, unspecified,Depressive disorder, not elsewhere classified'}


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: Right Leg Weakness

PRESENT ILLNESS: 58 M renal cell ca with mets s/p T12 vertebrectomy c/b wound
infection and revision in [**2194**] by Dr. [**Last Name (STitle) 548**], with one week
history worsening R>L weakness, numbness, sensation change with
OSH CT showing worsening thoracic mets.
Patient was undergoing Chemo therapy until 6 months ago and he
elected to stop therapy b/c he did not like how it made him
feel. He began metabolic nutritional therapy instead.
He began to notice some sensory changes in his right leg about
10 days ago and more recently in the past few days has had
difficulty placing weight on it. He denies loss of bowel or
bladder function. He did suffer a fall yesterday and landed on
his bottom and required help to get back up on his feet.

MEDICAL HISTORY: Renal Cell carcinoma-resected in [**2190**] with bony mets to spine.
s/p thoracic instrumented fusion T1-12 on [**2194-1-28**] for extradural
mass at T5 and kyphotic collapse at T10
h/o MSSA bacteremia/deep wound infection ([**1-22**])
h/o knee surgery with ? infection at [**Hospital3 **]
Rheumatoid arthritis
h/o HCV-treated with 6 mo IFN/Riba by Dr [**First Name (STitle) **] in approx [**2189**]
History of Tobacco use
History of Alcohol use/abuse-clean x 2 years
History of Polysubstance abuse including IVD-now clean
Depression

MEDICATION ON ADMISSION: Citalopram 20mg QD
Nexium 20 QD
Colace 100mg [**Hospital1 **]
Gabapentin 400 mg TID
Folic Acid 1mg qd
Zinc sulfate 220mg QD
Dilaudid 4mg 3tabs qid
methadone 10mg 6tabs every 6hrs.

ALLERGIES: Heparin Agents

PHYSICAL EXAM: Physical Examination on admission to [**Hospital1 18**]:

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

SOCIAL HISTORY: Currently lives alone. 

### Response:
{'Esophageal reflux,Personal history of malignant neoplasm of kidney,Personal history of irradiation, presenting hazards to health,Personal history of antineoplastic chemotherapy,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Other mechanical complication of other internal orthopedic device, implant, and graft,Rheumatoid arthritis,Neoplasm related pain (acute) (chronic),Anemia, unspecified,Depressive disorder, not elsewhere classified'}
