CHIEF COMPLAINT: BACK PAIN

PRESENT ILLNESS: HPI: 55 y/o male with metastatic renal Ca to spine, transferred
from rehab due to worsening drainage from surgical incision
site at midincision point (about 3cm opening), recent admit
[**Date range (3) 75880**] during which on [**2194-1-28**] he
underwent thoracic instrumented fusion T1-12 by Dr. [**Last Name (STitle) 548**] for
stabilization and due to increased difficulty walking and
numbness/weakness/pain in his legs.  Prior to this the patient
was found to have a renal tumor in [**2190**] s/p resection. In [**6-21**]
the patient was found to have an extradural mass at T5 that was
felt to be metastatic. The patient is also known to have a
kyphotic collapse at T10. On [**1-28**] he underwent excisional
biopsy
T5, T19, T10 vertebrectomy; instrumented fusion
T1-T12 with pedicle screws; iliac crest bone graft.

MEDICAL HISTORY: rheumatoid arthritis x 20 years
renal ca s/p nephrectomy
metastatic spine disease s/p thoracic instrumented fusion T1-12
on [**2194-1-28**] for extradural mass at T5 and kyphotic collapse at
T10
h/o IVDA

MEDICATION ON ADMISSION: Active Medication list as of [**2194-5-3**]:

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM
General: lying in bed, NAD
HEENT: NCAT, dry and erythematous mucous membranes
Neck: supple, no carotid bruits
Pulmonary: CTA b/l
Cardiac: tachycardia, regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, mildly distended with some echymoses,
normal bowel sounds
Extremities: radial deviation of MCP joints of both hands due to
RA.  Left elbow open wound with exposed bone.
Back: covered in extensive tattoos, 2 JP drain sutures removed,
R
paraspinal hematoma unchanged, mild serosanguinous drainage from
wound, no wound dehiscence.

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

SOCIAL HISTORY: Lives with a friend and his wife; tobacco 2 ppd x 30-40 years
but notes has not smoked for the last 2 weeks; recovering
alcoholic but no ETOH recently; history of drug abuse, but none
for last two years, on Methadone.
Mechanical complication of nervous system device, implant, and graft,Intraspinal abscess,Other postoperative infection,Unspecified septicemia,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Secondary malignant neoplasm of brain and spinal cord,Arthrodesis status,Kyphosis (acquired) (postural),Chronic hepatitis C without mention of hepatic coma,Other, mixed, or unspecified drug abuse, unspecified,Rheumatoid arthritis,Personal history of malignant neoplasm of kidney,Anemia, unspecified
Malfun neuro device/graf,Intraspinal abscess,Other postop infection,Septicemia NOS,Pleural effusion NOS,Int inf clstrdium dfcile,Sec mal neo brain/spine,Arthrodesis status,Kyphosis NOS,Chrnc hpt C wo hpat coma,Drug abuse NEC-unspec,Rheumatoid arthritis,Hx of kidney malignancy,Anemia NOS
Admission Date:  [**2194-5-3**]              Discharge Date:   [**2194-5-26**]

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

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
BACK PAIN

Major Surgical or Invasive Procedure:
1) debridement and removal of hardware/ placement of VACS
2) wound debridement/removal VACS
3) Thoracic fusion
4) Wound washout/debridement


History of Present Illness:

HPI: 55 y/o male with metastatic renal Ca to spine, transferred
from rehab due to worsening drainage from surgical incision
site at midincision point (about 3cm opening), recent admit
[**Date range (3) 75880**] during which on [**2194-1-28**] he
underwent thoracic instrumented fusion T1-12 by Dr. [**Last Name (STitle) 548**] for
stabilization and due to increased difficulty walking and
numbness/weakness/pain in his legs.  Prior to this the patient
was found to have a renal tumor in [**2190**] s/p resection. In [**6-21**]
the patient was found to have an extradural mass at T5 that was
felt to be metastatic. The patient is also known to have a
kyphotic collapse at T10. On [**1-28**] he underwent excisional
biopsy
T5, T19, T10 vertebrectomy; instrumented fusion
T1-T12 with pedicle screws; iliac crest bone graft.

Past Medical History:
rheumatoid arthritis x 20 years
renal ca s/p nephrectomy
metastatic spine disease s/p thoracic instrumented fusion T1-12
on [**2194-1-28**] for extradural mass at T5 and kyphotic collapse at
T10
h/o IVDA

Social History:
Lives with a friend and his wife; tobacco 2 ppd x 30-40 years
but notes has not smoked for the last 2 weeks; recovering
alcoholic but no ETOH recently; history of drug abuse, but none
for last two years, on Methadone.


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


Physical Exam:
PHYSICAL EXAM
General: lying in bed, NAD
HEENT: NCAT, dry and erythematous mucous membranes
Neck: supple, no carotid bruits
Pulmonary: CTA b/l
Cardiac: tachycardia, regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, mildly distended with some echymoses,
normal bowel sounds
Extremities: radial deviation of MCP joints of both hands due to
RA.  Left elbow open wound with exposed bone.
Back: covered in extensive tattoos, 2 JP drain sutures removed,
R
paraspinal hematoma unchanged, mild serosanguinous drainage from
wound, no wound dehiscence.

NEURO
MSE: alert, oriented times 3, follows commands all 4 extremities

CN: PERRL 4-->2mm bilat, EOMI without nystagmus, facial
sensation
intact, smile symmetric but weak orbicularis oculi bilat,
hearing
intact b/l to finger rubbing, palatal elevation symmetrical, SCM
[**5-19**], tongue midline without fasciculations.
MOTOR: Normal bulk. Normal tone. No pronator drift. Mild
asterixis.
     Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham   DF PF [**Last Name (un) 938**] EDB
     C5   C7  C6          C8 L2 L3 L4-S1 L4    L5  L5
RT:   5    5  5   5 5  5  5  5-  5  5-    5-  5  5-  5-
LEFT: 5    5  5   5 5  5  5  5- 5   5-    5  5  4+   5
SENSATION: normal to light touch in bilateral upper extremites,
mild decreased sensation over bilateral lowers
REFLEXES: DTRs 1 + and symmetric, plantars upgoing bilat
COORDINATION: FNF intact with RUE, some tremor with LUE.

Pertinent Results:
[**2194-5-3**] 05:30PM URINE  COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.028
[**2194-5-3**] 05:30PM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-SM
[**2194-5-3**] 05:30PM URINE  RBC-[**3-19**]* WBC-[**3-19**] BACTERIA-FEW YEAST-NONE
EPI-0-2
[**2194-5-3**] 04:00PM   GLUCOSE-115* UREA N-13 CREAT-0.7 SODIUM-133
POTASSIUM-3.8 CHLORIDE-94* TOTAL CO2-31 ANION GAP-12
[**2194-5-3**] 04:00PM   WBC-15.0*# RBC-3.95* HGB-11.0* HCT-33.7*
MCV-85 MCH-27.9 MCHC-32.7 RDW-15.4
[**2194-5-3**] 04:00PM   NEUTS-90.5* BANDS-0 LYMPHS-4.1* MONOS-4.1
EOS-1.2 BASOS-0.1
[**2194-5-3**] 04:00PM   HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-1+
[**2194-5-3**] 04:00PM   PLT SMR-HIGH PLT COUNT-501*

[**2194-5-21**] 04:46AM BLOOD Hct-25.5*
[**2194-5-20**] 06:35AM BLOOD WBC-6.1 RBC-3.11* Hgb-8.5* Hct-25.6*
MCV-82 MCH-27.4 MCHC-33.3 RDW-15.2 Plt Ct-407
[**2194-5-20**] 06:35AM BLOOD Neuts-68.7 Bands-0 Lymphs-18.8 Monos-9.8
Eos-2.4 Baso-0.2
[**2194-5-20**] 06:35AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-OCCASIONAL
Tear Dr[**Last Name (STitle) 833**]
[**2194-5-20**] 06:35AM BLOOD Plt Smr-NORMAL Plt Ct-407
[**2194-5-21**] 04:46AM BLOOD K-3.3
[**2194-5-4**] 05:45AM BLOOD CRP-282.0*
[**2194-5-4**] 05:45AM BLOOD ESR-67*

[**2194-5-15**] 10:11 am PLEURAL FLUID

   GRAM STAIN (Final [**2194-5-16**]):
      4+   (>10 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.
      This is a concentrated smear made by cytospin method,
please refer to
      hematology for a quantitative white blood cell count..

   FLUID CULTURE (Final [**2194-5-18**]):    NO GROWTH.

   ANAEROBIC CULTURE (Final [**2194-5-21**]):    NO GROWTH.

   ACID FAST SMEAR (Final [**2194-5-16**]):
      NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.

   ACID FAST CULTURE (Pending):

[**2194-5-14**] 12:25 pm BLOOD CULTURE      Source: Venipuncture 2 OF
2.

                            **FINAL REPORT [**2194-5-20**]**

   Blood Culture, Routine (Final [**2194-5-20**]):    NO GROWTH.



[**2194-5-13**] 8:30 pm SWAB      T9.

                            **FINAL REPORT [**2194-5-16**]**

   GRAM STAIN (Final [**2194-5-13**]):
      NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
      NO MICROORGANISMS SEEN.

   WOUND CULTURE (Final [**2194-5-16**]):
      STAPH AUREUS COAG +.    RARE GROWTH.
         SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 75881**]
([**2194-5-7**]).

[**2194-5-4**] 1:20 pm BLOOD CULTURE

                            **FINAL REPORT [**2194-5-10**]**

   Blood Culture, Routine (Final [**2194-5-10**]):
      STAPH AUREUS COAG +.
         SENSITIVITIES PERFORMED ON CULTURE # 249-7676P [**2194-5-3**].


   Anaerobic Bottle Gram Stain (Final [**2194-5-5**]):
      GRAM POSITIVE COCCI.
      IN PAIRS AND CLUSTERS.


Brief Hospital Course:
Pt was admitted to the hospital and monitored closely in ICU.
He was seen in consultation by ID and plastic surgery.  He was
begun on antibiotics. He was brought to the OR [**2194-5-6**] for wound
debridement, removal of hardware and placement of VAC
dressing.He was also seen by pain service.He was kept at strict
bedrest while hardware was out. He returned to OR [**2194-5-9**] for
debridement and application of VAC device. He then returned to
OR [**2194-5-13**] for removal of instrumentation,
debridement,reinsertion of spinal instrumentation, revision
arthrodesis/pseudoarthrosis repair. He was extubated [**2194-5-15**]. He
was evalutaed by thoracic surgery for increasing plueral
effusions with recommendation to tap which was performed without
difficulty [**2194-5-16**]. He was transferred out of ICU to floor.  His
drainage was monitored from JP. Incision is healing
well/clean/dry. He was followed closely by ID throughout his
hospital course. He had post op xrays that showed good hardware
positioning. He worked with PT/OT and was recommended for acute
rehab.  His albumin and protein were low and he has been given
supplements at each meal.



Medications on Admission:
Active Medication list as of [**2194-5-3**]:

Medications - Prescription
Atenolol -  (Prescribed by Other Provider) - 25 mg Tablet - 1
Tablet(s) by mouth daily
Citalopram -  (Prescribed by Other Provider) - 20 mg Tablet - 1
Tablet(s) by mouth daily
Enoxaparin -  (Prescribed by Other Provider) - 40 mg/0.4 mL
Syringe - 40mg subq daily
Folic Acid -  (Prescribed by Other Provider) - 1 mg Tablet - 1
Tablet(s) by mouth daily
Gabapentin -  (Prescribed by Other Provider) - 400 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours
Methadone -  (Prescribed by Other Provider) - 10 mg Tablet - 3
Tablet(s) by mouth three times a day
Methotrexate Sodium -  (Prescribed by Other Provider) - 15 mg
Tablet - 1 Tablet(s) by mouth q7days
Modafinil -  (Prescribed by Other Provider) - 200 mg Tablet - 1
Tablet(s) by mouth daily
Omeprazole -  (Prescribed by Other Provider) - 20 mg Capsule,
Delayed Release(E.C.) - 1 Capsule(s) by mouth twice a day
Oxycodone -  (Prescribed by Other Provider) - 60 mg Tablet
Sustained Release 12 hr - 1 Tablet(s) by mouth three times a day
Tizanidine -  (Prescribed by Other Provider) - 4 mg Tablet - 1
Tablet(s) by mouth every eight (8) hours

Medications - OTC
Ascorbic Acid -  (Prescribed by Other Provider) - 500 mg Tablet
-
1 Tablet(s) by mouth twice a day
Docusate Sodium [Colace] -  (Prescribed by Other Provider) - 100
mg Capsule - 1 Capsule(s) by mouth twice a day
Ferrous Sulfate [FerrouSul] -  (Prescribed by Other Provider) -
325 mg (65 mg Elemental Iron) Tablet - 1 Tablet(s) by mouth
three
times a day
Miconazole Nitrate -  (Prescribed by Other Provider) - Dosage
uncertain
Senna -  (Prescribed by Other Provider) - Dosage uncertain
Zinc Sulfate -  (Prescribed by Other Provider) - 220 mg Tablet -
1 Tablet(s) by mouth MWF

Discharge Medications:
1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
4. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours): You should continue this antibiotic until you complete
your course of other antibiotics. .
5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
6. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
7. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for fever or pain.
8. Clonidine 0.1 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly
Transdermal QTHUR (every Thursday).
9. Hydromorphone 4 mg Tablet Sig: 2.5 Tablets PO Q3H (every 3
hours) as needed for breakthru.
10. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): sliding scale coverage.
11. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3
times a day).
12. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
15. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
16. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime).
17. Methadone 10 mg Tablet Sig: Five (5) Tablet PO TID (3 times
a day).
18. Nafcillin 2 gram Recon Soln Sig: One (1)  Injection every
four (4) hours: this medication should continue until at minimum
[**2194-7-15**] per ID team .
19. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
20. Rifampin 300 mg IV Q 8H
21. Outpatient Lab Work
to be fax'd to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**Hospital **] clinic at [**Telephone/Fax (1) **]

CBC, Chem Panel, LFT's, CRP, ESR, LFT's please

thank you


Discharge Disposition:
Extended Care

Facility:
[**Hospital1 700**] - [**Location (un) 701**]

Discharge Diagnosis:
wound infection
hardware failure
septecemia
poor nutrition


Discharge Condition:
neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES

??????	Do not smoke
??????	Keep wound clean and dry / No tub baths or pools until cleared
by Dr. [**First Name (STitle) **] - plastic surgeon.
??????	No pulling up, lifting> 10 lbs., excessive bending or
twisting for 2 weeks.
??????	Check incision daily for signs of infection
??????	You are required to wear your back brace while out of bed,
even if only for short distances or being out of bed to chair.
??????	You may shower without the back brace.
??????	Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. - it decreases opportunity for
fusion.
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????	Pain that is continually increasing or not relieved by pain
medicine
??????	Any weakness, numbness, tingling in your extremities
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????	Fever greater than or equal to 101?????? F
??????	Any change in your bowel or bladder habits

Followup Instructions:
[**Last Name (un) **] CALL DR. [**Last Name (STitle) **]' OFFICE/ PLASTIC SURGERY UPON PTS ARRIVAL
TO YOUR INSTITUTION TO SCHEDULE FOLLOW UP APPOINMENT WITHIN NEXT
2 WEEKS AT [**Telephone/Fax (1) 1416**].

PLEASE SCHEDULE AN APPOINTMENT TO SEE DR. [**Last Name (STitle) **] / NEUROSURGERY
AT [**Telephone/Fax (1) **] TO BE SEEN IN 6 weeks WITH XRAYS OF YOUR
THORACO-LUMBAR SPINE

YOU HAVE A SCHEDULED APPOINTMENT TO SEE DR [**Last Name (STitle) **]- INFECTIOUS
DISEASE
Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2194-6-30**] 10:00



Completed by:[**2194-5-22**]

Name:  [**Known lastname 1799**],[**Known firstname 63**]                Unit No:   [**Numeric Identifier 12405**]

Admission Date:  [**2194-5-3**]              Discharge Date:   [**2194-5-26**]

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

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2427**]
Addendum:
Mr [**Known lastname **] [**Last Name (Titles) 532**] a temperature to 101.6 [**2194-5-23**] and his
discharge was postponed. A fever work up did not reveal a
infection source.  His antibiotics remained.  His temperature
was monitored thoroughout the weekend and did not spike again.
He appeared clinically well.  Drainage amount from his JPs are
trending down.

Discharge Disposition:
Extended Care

Facility:
[**Hospital1 49**] - [**Location (un) 50**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2428**] MD [**MD Number(2) 2429**]

Completed by:[**2194-5-26**]
{'Mechanical complication of nervous system device, implant, and graft,Intraspinal abscess,Other postoperative infection,Unspecified septicemia,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Secondary malignant neoplasm of brain and spinal cord,Arthrodesis status,Kyphosis (acquired) (postural),Chronic hepatitis C without mention of hepatic coma,Other, mixed, or unspecified drug abuse, unspecified,Rheumatoid arthritis,Personal history of malignant neoplasm of kidney,Anemia, 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: BACK PAIN

PRESENT ILLNESS: HPI: 55 y/o male with metastatic renal Ca to spine, transferred
from rehab due to worsening drainage from surgical incision
site at midincision point (about 3cm opening), recent admit
[**Date range (3) 75880**] during which on [**2194-1-28**] he
underwent thoracic instrumented fusion T1-12 by Dr. [**Last Name (STitle) 548**] for
stabilization and due to increased difficulty walking and
numbness/weakness/pain in his legs.  Prior to this the patient
was found to have a renal tumor in [**2190**] s/p resection. In [**6-21**]
the patient was found to have an extradural mass at T5 that was
felt to be metastatic. The patient is also known to have a
kyphotic collapse at T10. On [**1-28**] he underwent excisional
biopsy
T5, T19, T10 vertebrectomy; instrumented fusion
T1-T12 with pedicle screws; iliac crest bone graft.

MEDICAL HISTORY: rheumatoid arthritis x 20 years
renal ca s/p nephrectomy
metastatic spine disease s/p thoracic instrumented fusion T1-12
on [**2194-1-28**] for extradural mass at T5 and kyphotic collapse at
T10
h/o IVDA

MEDICATION ON ADMISSION: Active Medication list as of [**2194-5-3**]:

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PHYSICAL EXAM
General: lying in bed, NAD
HEENT: NCAT, dry and erythematous mucous membranes
Neck: supple, no carotid bruits
Pulmonary: CTA b/l
Cardiac: tachycardia, regular rate and rhythm, with no m/r/g
Abdomen: soft, nontender, mildly distended with some echymoses,
normal bowel sounds
Extremities: radial deviation of MCP joints of both hands due to
RA.  Left elbow open wound with exposed bone.
Back: covered in extensive tattoos, 2 JP drain sutures removed,
R
paraspinal hematoma unchanged, mild serosanguinous drainage from
wound, no wound dehiscence.

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

SOCIAL HISTORY: Lives with a friend and his wife; tobacco 2 ppd x 30-40 years
but notes has not smoked for the last 2 weeks; recovering
alcoholic but no ETOH recently; history of drug abuse, but none
for last two years, on Methadone. 

### Response:
{'Mechanical complication of nervous system device, implant, and graft,Intraspinal abscess,Other postoperative infection,Unspecified septicemia,Unspecified pleural effusion,Intestinal infection due to Clostridium difficile,Secondary malignant neoplasm of brain and spinal cord,Arthrodesis status,Kyphosis (acquired) (postural),Chronic hepatitis C without mention of hepatic coma,Other, mixed, or unspecified drug abuse, unspecified,Rheumatoid arthritis,Personal history of malignant neoplasm of kidney,Anemia, unspecified'}
