CHIEF COMPLAINT: Back pain

PRESENT ILLNESS: 62 year old female with chief complaint of low back pain. Hx of
Hodgkin's Lymphoma last treated on [**11-7**] with liposomal
doxorubicin. Patient was seen in clinic last week for
exacerbation of long standing low back pain, concerning for
spinal stenosis. Pt has had years of lower midline back pain;
past 2 weeks of back pain have been different in nature as it
radiates laterally. Pt's pain regimen at home include oxycontin
10mg TID, vicodin prn, has been taking [**2-7**] doses per day on
average. Completed a course of methylprednisolone recently. MRI
ordered as an outpatient on [**2181-11-14**] and it was concerning for
osseous lymphomatous infiltration at L3-5. Admitted for pain
management and lymphoma restaging and treatment.
.
In the ED recieved:
Hydrocodone-Acetaminophen 5/500 Tablet
Albuterol 0.083% Neb Soln 0.083%
Ipratropium Bromide Neb 2.5mL Vial 1
MetFORMIN (Glucophage) 500mg Tablet 1
Ranitidine 150mg Tablet 1
Levothyroxine Sodium 25mcg Tablet 2
Levothyroxine Sodium 100mcg Tablet 2
Atenolol 25 mg Tab 1
Lisinopril 20mg Tablet 1
Insulin Human Regular 100 Units / mL - 10 mL Vial 20
Insulin Glargine 100 Units / mL - 10 mL Vial 30
Insulin Glargine 100 Units / mL - 10 mL Vial 30
Insulin Human Regular 100 Units / mL - 10 mL
.
Last VS in ED: T 97, HR 61, 112/52, RR 16, 95%
.
Review of Systems:
(+) Per HPI: pt notes yellow sputum production for last 2 days
(-) 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 or abdominal 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.

MEDICAL HISTORY: Past Oncologic History:
- [**2180-6-19**]: completed 6 cycles modified ABVD
- [**2180-7-26**]: completed 1 cycle ICE
- [**2181-3-18**]: completed 6 cycles Doxil/Navelbine
- [**2181-3-26**]: Started Doxil monotherapy
- [**2181-5-21**]: Held C3 Doxil because of possible rash
- [**2181-6-15**]: C3 Doxil
- [**2181-7-13**]: C4 Doxil
- [**2181-8-8**]: C5 Doxil
- [**2181-9-12**]: C6 Doxil
- [**2181-10-10**]: C7 Doxil
- [**2181-11-7**]: C8 Doxil
.
PMH:
- Insulin Dependent Diabetes
- Hypercholesterolemia
- Peripheral Vascular Disease in LE
- Osteoperosis
- hypothyroidism
- abdominal aneurysm
- s/p unilateral oopherectomy (Pt is unsure of what side)
- s/p thyroidectomy
- s/p tubal ligation
- s/p vascular stent placement in R leg for allevation of
claudication
- Asthma/COPD

MEDICATION ON ADMISSION: Lorazepam 0.5 mg PO/NG Q6H:PRN anxiety
Magnesium Sulfate Replacement (Oncology) IV Sliding Scale
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN affected areas
Acetaminophen 1000 mg PO/NG Q6H:PRN pain
Multivitamins 1 TAB PO/NG DAILY
Albuterol Inhaler [**1-6**] PUFF IH [**Hospital1 **]
Ondansetron ODT 8 mg PO/NG Q8H:PRN nausea
Atenolol 25 mg PO/NG DAILY
Ondansetron 4 mg IV Q8H:PRN nausea
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Oxycodone SR (OxyconTIN) 10 mg PO Q8H
Calcium Carbonate 500 mg PO/NG QID:PRN heartburn
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain
Potassium Chloride Replacement (Oncology) IV Sliding Scale Order

ALLERGIES: Tetanus

PHYSICAL EXAM: VS: 97.0, 122/68, 55, 18, 95% RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. Upper dentures in place. no LAD. no JVD.
neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, end exp wheezes throughout, no
crackles. No spinal tenderness.
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising, hairs noted on LE, no evidence of
venous stasis
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait
WNL. Rectal tone intact.

FAMILY HISTORY: No known family history of cancer or other pertinent family hx.

SOCIAL HISTORY: Pt is originally from [**Male First Name (un) 1056**] and does not speak English.
Lives with her 65 y/o boyfriend, has [**Name (NI) 269**] daily to help clean,
meals. She ambulates with cane. She has three children, 2 adult
sons and 1 adult daughter. [**Name (NI) **] daughter works as an
administrator and [**Hospital6 13753**] and is her primary
contact. Pt admits to smoking 1-2 packs per day, started at age
of 7. Pt also admits to occasional ETOH, and denies illicit drug
use.
Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Lumbago,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hyperpotassemia,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Peripheral vascular disease, unspecified,Tobacco use disorder,Anemia, unspecified,Osteoporosis, unspecified,Long-term (current) use of insulin
Hdgk dis unsp xtrndl org,Acute respiratry failure,Ch obst asth w (ac) exac,Lumbago,DMII oth nt st uncntrld,Hyperpotassemia,Hypothyroidism NOS,Pure hypercholesterolem,Periph vascular dis NOS,Tobacco use disorder,Anemia NOS,Osteoporosis NOS,Long-term use of insulin
Admission Date:  [**2181-11-19**]              Discharge Date:   [**2181-11-25**]

Date of Birth:  [**2119-7-7**]             Sex:   F

Service: MEDICINE

Allergies:
Tetanus

Attending:[**First Name3 (LF) 3963**]
Chief Complaint:
Back pain


Major Surgical or Invasive Procedure:
None


History of Present Illness:
62 year old female with chief complaint of low back pain. Hx of
Hodgkin's Lymphoma last treated on [**11-7**] with liposomal
doxorubicin. Patient was seen in clinic last week for
exacerbation of long standing low back pain, concerning for
spinal stenosis. Pt has had years of lower midline back pain;
past 2 weeks of back pain have been different in nature as it
radiates laterally. Pt's pain regimen at home include oxycontin
10mg TID, vicodin prn, has been taking [**2-7**] doses per day on
average. Completed a course of methylprednisolone recently. MRI
ordered as an outpatient on [**2181-11-14**] and it was concerning for
osseous lymphomatous infiltration at L3-5. Admitted for pain
management and lymphoma restaging and treatment.
.
In the ED recieved:
Hydrocodone-Acetaminophen 5/500 Tablet
Albuterol 0.083% Neb Soln 0.083%
Ipratropium Bromide Neb 2.5mL Vial 1
MetFORMIN (Glucophage) 500mg Tablet 1
Ranitidine 150mg Tablet 1
Levothyroxine Sodium 25mcg Tablet 2
Levothyroxine Sodium 100mcg Tablet 2
Atenolol 25 mg Tab 1
Lisinopril 20mg Tablet 1
Insulin Human Regular 100 Units / mL - 10 mL Vial 20
Insulin Glargine 100 Units / mL - 10 mL Vial 30
Insulin Glargine 100 Units / mL - 10 mL Vial 30
Insulin Human Regular 100 Units / mL - 10 mL
.
Last VS in ED: T 97, HR 61, 112/52, RR 16, 95%
.
Review of Systems:
(+) Per HPI: pt notes yellow sputum production for last 2 days
(-) 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 or abdominal 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:
Past Oncologic History:
- [**2180-6-19**]: completed 6 cycles modified ABVD
- [**2180-7-26**]: completed 1 cycle ICE
- [**2181-3-18**]: completed 6 cycles Doxil/Navelbine
- [**2181-3-26**]: Started Doxil monotherapy
- [**2181-5-21**]: Held C3 Doxil because of possible rash
- [**2181-6-15**]: C3 Doxil
- [**2181-7-13**]: C4 Doxil
- [**2181-8-8**]: C5 Doxil
- [**2181-9-12**]: C6 Doxil
- [**2181-10-10**]: C7 Doxil
- [**2181-11-7**]: C8 Doxil
.
PMH:
- Insulin Dependent Diabetes
- Hypercholesterolemia
- Peripheral Vascular Disease in LE
- Osteoperosis
- hypothyroidism
- abdominal aneurysm
- s/p unilateral oopherectomy (Pt is unsure of what side)
- s/p thyroidectomy
- s/p tubal ligation
- s/p vascular stent placement in R leg for allevation of
claudication
- Asthma/COPD

Social History:
Pt is originally from [**Male First Name (un) 1056**] and does not speak English.
Lives with her 65 y/o boyfriend, has [**Name (NI) 269**] daily to help clean,
meals. She ambulates with cane. She has three children, 2 adult
sons and 1 adult daughter. [**Name (NI) **] daughter works as an
administrator and [**Hospital6 13753**] and is her primary
contact. Pt admits to smoking 1-2 packs per day, started at age
of 7. Pt also admits to occasional ETOH, and denies illicit drug
use.

Family History:
No known family history of cancer or other pertinent family hx.

Physical Exam:
VS: 97.0, 122/68, 55, 18, 95% RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. Upper dentures in place. no LAD. no JVD.
neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, end exp wheezes throughout, no
crackles. No spinal tenderness.
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising, hairs noted on LE, no evidence of
venous stasis
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait
WNL. Rectal tone intact.

Pertinent Results:
Labs upon admission:

[**2181-11-19**] 12:50PM BLOOD WBC-7.9 RBC-3.55* Hgb-11.0* Hct-32.0*
MCV-90 MCH-30.9 MCHC-34.2 RDW-18.6* Plt Ct-174
[**2181-11-19**] 12:50PM BLOOD Neuts-86.6* Lymphs-8.3* Monos-2.7 Eos-2.0
Baso-0.3
[**2181-11-19**] 12:50PM BLOOD PT-14.4* PTT-27.0 INR(PT)-1.2*
[**2181-11-19**] 12:50PM BLOOD Glucose-338* UreaN-32* Creat-1.0 Na-134
K-5.0 Cl-102 HCO3-25 AnGap-12
[**2181-11-20**] 06:00AM BLOOD Calcium-8.8 Phos-4.6* Mg-1.5*
[**2181-11-22**] 04:00AM BLOOD TSH-6.2*
[**2181-11-22**] 04:00AM BLOOD Cortsol-26.9*
[**2181-11-19**] 12:50PM BLOOD PEP-NO SPECIFI IgG-1066 IgA-288 IgM-50
[**2181-11-22**] 04:29AM BLOOD Type-ART pO2-81* pCO2-70* pH-7.22*
calTCO2-30 Base XS-0
[**2181-11-22**] 04:29AM BLOOD Glucose-94 Lactate-0.7 Na-134* K-5.5*
Cl-98*
[**2181-11-22**] 04:29AM BLOOD O2 Sat-93
[**2181-11-22**] 04:29AM BLOOD freeCa-1.20

Microbiology
Urine culture [**2181-11-23**]: NGTD (pending final)
Blood culture [**2181-11-22**]: NGTD (pending final)

Labs upon discharge: *******************

CT chest/abd/pelvis [**2181-11-20**]: 1. Interval decrease in multiple
mediastinal and retroperitoneal lymph nodes.
2. MR of the L-spine is more sensitive for evaluation of the
central canal, however, no gross evidence of spine or central
canal involvement is noted.  Mild collapse of the L4 vertebral
body inferior endplate and L3 vertebral body superior endplate
is new since [**2179**] and may represent lymphomatous involvement.
Correlation with recent MR is recommended.
3. Diffuse ulcerated soft plaque throughout the aorta with an
unchanged
infrarenal abdominal aortic aneurysm measuring 32 x 35 mm.

CT head [**2181-11-22**]:  No acute intracranial process including no
evidence of hemorrhage or mass effect.

CXR [**2181-11-12**]: The heart size is enlarged, slightly more than on
the prior study, which might be attributed to the film
technique. The left Port-A-Cath catheter tip is at the level of
cavoatrial junction. Mediastinal contours are unchanged
including mild prominence of the aortopulmonic window due to
known lymph nodes. Hilar prominence due to known lymph nodes on
the left is unchanged as well. There is no interval development
of focal abnormality, but diffuse prominence of the perihilar
interstitium and lower lungs might be consistent with interval
development of pulmonary edema versus infectious process such as
mycoplasma or viral infection. Close followup is suggested. No
appreciable pleural effusion or pneumothorax is seen.

Discharge Labs:
[**2181-11-24**] 12:00AM BLOOD WBC-4.6 RBC-3.27* Hgb-9.8* Hct-29.4*
MCV-90 MCH-29.9 MCHC-33.3 RDW-19.3* Plt Ct-179
[**2181-11-24**] 12:00AM BLOOD Neuts-75.6* Lymphs-13.7* Monos-7.3
Eos-3.0 Baso-0.3
[**2181-11-24**] 12:00AM BLOOD Plt Ct-179
[**2181-11-24**] 12:00AM BLOOD Glucose-105* UreaN-30* Creat-1.1 Na-134
K-4.0 Cl-96 HCO3-30 AnGap-12
[**2181-11-24**] 12:00AM BLOOD ALT-20 AST-19 LD(LDH)-201 AlkPhos-80
TotBili-0.4

Brief Hospital Course:
62F w/Hodgkin's lymphoma last treated on [**11-7**] w/liposomal
doxorubicin presenting w/worsening low back pain, imaging c/w
possible lymphomatous infiltrate with chief complaint of low
back pain, who was briefly admitted to the ICU for respiratory
monitoring in addition to hypoglycemia.
.
# Altered Mental Status: The Patient was sent to the MICU with
with altered mental status and hypercarbia.  CT head was
negative for acute intracranial processes.  Her AMS was likely
secondary to hypoventilation due to opiates as she became
lethargic and desaturated after administration of oxycodone,
prompting initiation of BiPAP.  Her opiates were held and she
was given naloxone, after which time she became more alert.  Her
long acting opiates were discontinued as noted below.  She was
kept on short acting opiates prior to discharge with follow up
in [**Hospital 3242**] clinic for management of her lower back pain.
.
# Respiratory Depression: She was sent to the ICU for
hypoventilation and hypercarbia in the setting of long acting
opiates and underlying obstructive lung disease.  Her long
acting opiates were stopped and her respiratory status improved
and she was gradually transitioned from BiPAP to face mask and
eventually weaned to 2L nasal cannula before call out to the
floor.  She had evidence of mild pulmonary edema on CXR and was
given gentle diuresis with IV lasix 10mg x2.  She was also given
albuteral and ipratropium nebs for her underlying asthma/COPD
due to concern she may have had a COPD/Asthma exacerbation.
.
#Back pain:  She presented with pronounced back pain which was
moderately controlled at home on oxycontin 10mg TID, vicodin for
break through. Likely a combination of chronic spinal stenosis
(pain previously improved w/PT), now w/evidence of lymphomatous
involvement of L3-L4 on imaging.  The imaging had suggested that
this may represent lytic metastases of her lymphoma verses
infection.  CT did not reveal any spinal cord involvement and
the patient was mobile from bed to chair with assistance and did
not exhibit a sensory level to suggest intra-spinal abscess. We
continued home oxycontin 10mg TID and start oxycodone for
breakthrough; we transitioned to longer acting [**Doctor Last Name 360**] based on
24hr requirement.  However, she developed respiratory depression
after the initiation of long acting opiates, and she was resumed
on short acting opiates after she was briefly admitted to the
ICU for respiratory monitoring in addition to hypoglycemia.
Upon return to the floor her pain was well controlled with short
acting opiates.  She was scheduled to return to the [**Doctor Last Name 3242**] floor
for further follow up regarding her blood sugars in addition to
her lower back pain.
.
#Lymphoma: C8D14 of Doxil, now with possible involvement of
L3-L4. CT torso w/contrast revealed involvement of L4, MRI more
sensitive; no evidence of cord involvement.  She will be
followed by [**Doctor Last Name 3242**].
.
#Hypoglycemia with DM2: HgbA1c 7.6 on [**2181-7-23**]. Patient
persistently hypoglycemic during admission w/finger stick
glucose values ranging from 40s-90s; pt was written for home
regimen, however did not receive any of her standing or sliding
scale insulin. Pt was asymptomatic.  Her hypoglycemia was
probably secondary to poor PO intake due to persistent pain.
Adrenal insufficiency was ruled out with a fasting cortisol.
Prior to discharge, the patient's Lantus was decreased with
plans for outpatient follow up and insulin readjustment.
.
#Anemia: Likely secondary to her underlying lymphoma, diabetes,
chronic disease. Stable, 32.0 on admission.  This will need to
be followed as an outpatient.
.
#Asthma/COPD: Pt denying SOB, occasional SOB w/exertion. Stable
on home albuterol and advair, continued during admission.  Of
note, she did receive additional nebs in the ICU for concern of
a COPD flare.  However, upon arrival to the floor her
respiratory depression and hypercarbia were thought to be
secondary to opiates and not an underlying flare of her
obstructive respiratory disease.


Medications on Admission:
Lorazepam 0.5 mg PO/NG Q6H:PRN anxiety
Magnesium Sulfate Replacement (Oncology) IV Sliding Scale
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN affected areas
Acetaminophen 1000 mg PO/NG Q6H:PRN pain
Multivitamins 1 TAB PO/NG DAILY
Albuterol Inhaler [**1-6**] PUFF IH [**Hospital1 **]
Ondansetron ODT 8 mg PO/NG Q8H:PRN nausea
Atenolol 25 mg PO/NG DAILY
Ondansetron 4 mg IV Q8H:PRN nausea
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Oxycodone SR (OxyconTIN) 10 mg PO Q8H
Calcium Carbonate 500 mg PO/NG QID:PRN heartburn
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain
Potassium Chloride Replacement (Oncology) IV Sliding Scale Order

Docusate Sodium 100 mg PO BID
Potassium Chloride Replacement (Oncology) PO Sliding Scale Order

Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **]
Polyethylene Glycol 17 g PO/NG DAILY:PRN constipation
Gemfibrozil 600 mg PO BID
Prochlorperazine 10 mg IV Q6H:PRN nausea
Heparin 5000 UNIT SC TID
Ranitidine 150 mg PO/NG [**Hospital1 **]
Heparin Flush (10 units/ml) 5 mL IV PRN line flush
Senna 1 TAB PO/NG [**Hospital1 **]:PRN constipation
Sertraline 100 mg PO/NG HS
Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR Q6H:PRN discomfort
Simvastatin 40 mg PO/NG DAILY
Insulin SC Sliding Scale
Levothyroxine Sodium 250 mcg PO/NG DAILY
Vitamin D 400 UNIT PO/NG DAILY


Discharge Medications:
1. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation [**Hospital1 **] (2 times a day).
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day).
6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO once a
day.
9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
Disp:*20 Adhesive Patch, Medicated(s)* Refills:*0*
12. sertraline 50 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain.
15. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal Q6H
(every 6 hours) as needed for discomfort.
16. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One
(1) Tablet, Chewable PO QID (4 times a day) as needed for
heartburn.
17. calcium carbonate-vitamin D3 600-400 mg-unit Tablet Sig: One
(1) Tablet PO twice a day.
18. multivitamin     Tablet Sig: One (1) Tablet PO DAILY
(Daily).
19. metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day.

20. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **]
(2 times a day) as needed for affected areas: Please apply to
affected areas.
21. insulin glargine 100 unit/mL Solution Sig: One (1) 20 units
Subcutaneous qAM: Please take in the morning.  Please check
sugars with every meal for your next clinic visit.


Discharge Disposition:
Home With Service

Facility:
Multicultural [**Hospital1 269**]

Discharge Diagnosis:
Primary Diagnosis:
Lower Back Pain
.
Secondary Diagnosis:
Lymphoma


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


Discharge Instructions:
Dear Ms. [**Known lastname 22771**]-

You were admitted to the hospital to help control your lower
back pain.  Imaging of the spine revealed degenerative changes
in the spine, and potentially cancer in the spine.  Your
hospital course was complicated by an admission to the ICU due
to an episode of slow breathing, as well as low blood sugars.
Your blood sugars are normal, and your pain is now well
controlled.  You will need to follow up with your doctor for the
appointments below:
.
The following medications were adjusted this admission:

Please DECREASE your Lantus from 60 units daily to 20 units
daily.

Please STOP taking OXYCONTIN(long acting Oxycodone) and take
only short-acting OXYCODONE 5-10mg every 4 hours as needed for
pain.

Please STOP taking Lorazepam because it can make you sleepy.

Followup Instructions:
Please call your PCP for an appointment to help manage your
blood glucose.

You will need to come to [**Hospital Ward Name 1826**] 7 on [**11-26**] at 10:00am in the
morning to the outpatient clinic to have your blood sugar
checked and evaluate your pain.  You will also need to have an
echo of the heart.

Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 54448**], MD Phone:[**Telephone/Fax (1) 3736**] Date/Time:[**2181-11-26**]
11:15
Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN Phone:[**Telephone/Fax (1) 3241**]
Date/Time:[**2181-12-5**] 12:30
Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 9575**] [**Apartment Address(1) 3242**] CHAIRS & ROOMS Date/Time:[**2181-12-5**]
12:30



Completed by:[**2182-7-4**]
{"Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Lumbago,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hyperpotassemia,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Peripheral vascular disease, unspecified,Tobacco use disorder,Anemia, unspecified,Osteoporosis, unspecified,Long-term (current) use of insulin"}


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: 62 year old female with chief complaint of low back pain. Hx of
Hodgkin's Lymphoma last treated on [**11-7**] with liposomal
doxorubicin. Patient was seen in clinic last week for
exacerbation of long standing low back pain, concerning for
spinal stenosis. Pt has had years of lower midline back pain;
past 2 weeks of back pain have been different in nature as it
radiates laterally. Pt's pain regimen at home include oxycontin
10mg TID, vicodin prn, has been taking [**2-7**] doses per day on
average. Completed a course of methylprednisolone recently. MRI
ordered as an outpatient on [**2181-11-14**] and it was concerning for
osseous lymphomatous infiltration at L3-5. Admitted for pain
management and lymphoma restaging and treatment.
.
In the ED recieved:
Hydrocodone-Acetaminophen 5/500 Tablet
Albuterol 0.083% Neb Soln 0.083%
Ipratropium Bromide Neb 2.5mL Vial 1
MetFORMIN (Glucophage) 500mg Tablet 1
Ranitidine 150mg Tablet 1
Levothyroxine Sodium 25mcg Tablet 2
Levothyroxine Sodium 100mcg Tablet 2
Atenolol 25 mg Tab 1
Lisinopril 20mg Tablet 1
Insulin Human Regular 100 Units / mL - 10 mL Vial 20
Insulin Glargine 100 Units / mL - 10 mL Vial 30
Insulin Glargine 100 Units / mL - 10 mL Vial 30
Insulin Human Regular 100 Units / mL - 10 mL
.
Last VS in ED: T 97, HR 61, 112/52, RR 16, 95%
.
Review of Systems:
(+) Per HPI: pt notes yellow sputum production for last 2 days
(-) 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 or abdominal 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.

MEDICAL HISTORY: Past Oncologic History:
- [**2180-6-19**]: completed 6 cycles modified ABVD
- [**2180-7-26**]: completed 1 cycle ICE
- [**2181-3-18**]: completed 6 cycles Doxil/Navelbine
- [**2181-3-26**]: Started Doxil monotherapy
- [**2181-5-21**]: Held C3 Doxil because of possible rash
- [**2181-6-15**]: C3 Doxil
- [**2181-7-13**]: C4 Doxil
- [**2181-8-8**]: C5 Doxil
- [**2181-9-12**]: C6 Doxil
- [**2181-10-10**]: C7 Doxil
- [**2181-11-7**]: C8 Doxil
.
PMH:
- Insulin Dependent Diabetes
- Hypercholesterolemia
- Peripheral Vascular Disease in LE
- Osteoperosis
- hypothyroidism
- abdominal aneurysm
- s/p unilateral oopherectomy (Pt is unsure of what side)
- s/p thyroidectomy
- s/p tubal ligation
- s/p vascular stent placement in R leg for allevation of
claudication
- Asthma/COPD

MEDICATION ON ADMISSION: Lorazepam 0.5 mg PO/NG Q6H:PRN anxiety
Magnesium Sulfate Replacement (Oncology) IV Sliding Scale
Miconazole Powder 2% 1 Appl TP [**Hospital1 **]:PRN affected areas
Acetaminophen 1000 mg PO/NG Q6H:PRN pain
Multivitamins 1 TAB PO/NG DAILY
Albuterol Inhaler [**1-6**] PUFF IH [**Hospital1 **]
Ondansetron ODT 8 mg PO/NG Q8H:PRN nausea
Atenolol 25 mg PO/NG DAILY
Ondansetron 4 mg IV Q8H:PRN nausea
Bisacodyl 10 mg PO/PR DAILY:PRN constipation
Oxycodone SR (OxyconTIN) 10 mg PO Q8H
Calcium Carbonate 500 mg PO/NG QID:PRN heartburn
OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain
Potassium Chloride Replacement (Oncology) IV Sliding Scale Order

ALLERGIES: Tetanus

PHYSICAL EXAM: VS: 97.0, 122/68, 55, 18, 95% RA
GEN: AOx3, NAD
HEENT: PERRLA. MMM. Upper dentures in place. no LAD. no JVD.
neck supple.
Cards: RRR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: No dullness to percussion, end exp wheezes throughout, no
crackles. No spinal tenderness.
Abd: soft, NT, +BS. no rebound/guarding. neg HSM. neg [**Doctor Last Name 515**]
sign.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising, hairs noted on LE, no evidence of
venous stasis
Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities.
Sensation intact to LT, cerebellar fxn intact (FTN, HTS). gait
WNL. Rectal tone intact.

FAMILY HISTORY: No known family history of cancer or other pertinent family hx.

SOCIAL HISTORY: Pt is originally from [**Male First Name (un) 1056**] and does not speak English.
Lives with her 65 y/o boyfriend, has [**Name (NI) 269**] daily to help clean,
meals. She ambulates with cane. She has three children, 2 adult
sons and 1 adult daughter. [**Name (NI) **] daughter works as an
administrator and [**Hospital6 13753**] and is her primary
contact. Pt admits to smoking 1-2 packs per day, started at age
of 7. Pt also admits to occasional ETOH, and denies illicit drug
use. 

### Response:
{"Hodgkin's disease, unspecified type, unspecified site, extranodal and solid organ sites,Acute respiratory failure,Chronic obstructive asthma with (acute) exacerbation,Lumbago,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Hyperpotassemia,Unspecified acquired hypothyroidism,Pure hypercholesterolemia,Peripheral vascular disease, unspecified,Tobacco use disorder,Anemia, unspecified,Osteoporosis, unspecified,Long-term (current) use of insulin"}
