CHIEF COMPLAINT: Cord compression, esophageal cancer.

PRESENT ILLNESS: This is a 66 year old male with PMH significant for squamous
cell esophageal cancer diagnosed in [**2149**], s/p 3 cycles of
cisplatin and 5FU and XRT, history of radiation pneumonitis,
history of SVT s/p ablation, who is transferred from [**Hospital **]
Hospital due to concern for cord compression and urgent
neurosurgical evaluation.
.
Patient was admitted to OSH on [**2150-12-7**] due to acute abdominal
pain and found to have a partial bowel obstruction. He improved
with conservative therapy. However, on the morning of [**2150-12-9**],
patient found to have inability to move his legs or feet. CT
scan was performed at 7:30PM on [**2150-12-9**] demonstrating severe
compression of the T6 vertebral body, resulting in a kyphotic
angulation of the spine, with significant retropulsion of bone
fragments into the spinal canal at this level, which reduces the
diameter of the spinal canal by approximately 50%.
.
Prior to his transfer, Dr. [**Last Name (STitle) **] of neurosurgery was consulted,
who believed that the chance for a neurologic recovery was very
low given the period between onset of symptoms and transfer for
evaluation. His prior workup is notable for history of
persistent tachycardia with heart rates in the 150s, with two
prior CTAs (one on [**2150-11-24**] and one on [**2150-12-4**]) both of which
were negative for PE.
.
Patient was directly admitted to the floor, but triggered upon
arrival due to HR in the 150s, which initially was sinus
tachycardia, but which quickly escalated to 210s with stable
blood pressures and oxygen saturations, with telemetry findings
consistent with SVT. Broke with 5mg IV lopressor X 1. Patient
was asymptomatic through his tachycardia.
.
On the floor, patient reports that he is anxious. He is able to
wiggle his toes but cannot move his thighs and his sensation is
gone from the mid thighs downward.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain.

MEDICAL HISTORY: - squamous cell esophageal cancer: diagnosed in [**2149**] by EGD with
presence of bulky mediastinal adenopathy involving the upper
mediastinum; s/p 3 cycles of cisplatin and 5FU and XRT then two
more cycles of chemo
- history of radiation pneumonitis
- intermittent dysphagia
- history of supraventricular tachycardia s/p ablation
- compression of spinal cord level T6 secondary to fracture of
his T6 vertebral body
- history of radiation pneumonitis treated with solumedrol
- subacute T6 compression fracture
- s/p right nephrectomy
- cholelithiasis

MEDICATION ON ADMISSION: HOME medications:
- mucinex PO BID
- prednisone 10mg PO daily
- MVI
- megestrol 2 tsp PO daily
- metoprolol 50mg PO BID
- oxycontin 40mg PO daily
- oxycodone 10mg PO q6h
- ativan 0.5mg PO TID
- omeprazole 20mg PO BID
- citalopram 40mg PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 97.8, BP: 141/107, P: 153, R: 22, O2 sat: 97%RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds in the bases, no wheezes or
rales.
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+O X 3. CN 2-12 intact. Decreased rectal tone. No spinal
anesthesia. Decreased sensation starting at the mid thighs
progressing down to the feet. Unable to lift thighs bilaterally.
Unable to dorsiflex/plantarflex foot. Able to move toes
bilaterally. Absent patellar reflexes bilaterally.

FAMILY HISTORY: No history of esophageal or renal cancer.

SOCIAL HISTORY: Married, lives with wife and son.
Secondary malignant neoplasm of bone and bone marrow,Iatrogenic pulmonary embolism and infarction,Pneumonitis due to inhalation of food or vomitus,Cardiogenic shock,Myelopathy in other diseases classified elsewhere,Malignant neoplasm of other specified part of esophagus,Pathologic fracture of vertebrae,Peripheral vascular complications, not elsewhere classified,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified pleural effusion,Urinary tract infection, site not specified,Unspecified intestinal obstruction,Paraplegia,Other vascular complications of medical care, not elsewhere classified,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Dysthymic disorder,Personal history of malignant neoplasm of kidney,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Frontal lobe and executive function deficit,Do not resuscitate status,Other fluid overload
Secondary malig neo bone,Iatrogen pulm emb/infarc,Food/vomit pneumonitis,Cardiogenic shock,Myelopathy in oth dis,Mal neo esophagus NEC,Path fx vertebrae,Surg comp-peri vasc syst,Ac DVT/emb prox low ext,Pleural effusion NOS,Urin tract infection NOS,Intestinal obstruct NOS,Paraplegia NOS,Vasc comp med care NEC,Phlbts sprfc vn up extrm,Klebsiella pneumoniae,Dysthymic disorder,Hx of kidney malignancy,Abn react-procedure NEC,Frontal lobe deficit,Do not resusctate status,Fluid overload NEC
Admission Date:  [**2150-12-10**]              Discharge Date:   [**2150-12-28**]

Date of Birth:  [**2084-12-6**]             Sex:   M

Service: MEDICINE

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 11839**]
Chief Complaint:
Cord compression, esophageal cancer.

Major Surgical or Invasive Procedure:
[**2150-12-11**]: Neurosurgery of the spine with T5, T6 and T7 bilateral
laminectomy, Anterior decompression with removal of disk
material and
soft tissue, Posterior instrumented fusion T4, T5, T6, T7 and T8
using pedicle screws, rods and cross-link (EBI spine array),
with Autologous graft and Allograft.
[**2150-12-17**]: IVC filter placement.

History of Present Illness:
This is a 66 year old male with PMH significant for squamous
cell esophageal cancer diagnosed in [**2149**], s/p 3 cycles of
cisplatin and 5FU and XRT, history of radiation pneumonitis,
history of SVT s/p ablation, who is transferred from [**Hospital **]
Hospital due to concern for cord compression and urgent
neurosurgical evaluation.
.
Patient was admitted to OSH on [**2150-12-7**] due to acute abdominal
pain and found to have a partial bowel obstruction. He improved
with conservative therapy. However, on the morning of [**2150-12-9**],
patient found to have inability to move his legs or feet. CT
scan was performed at 7:30PM on [**2150-12-9**] demonstrating severe
compression of the T6 vertebral body, resulting in a kyphotic
angulation of the spine, with significant retropulsion of bone
fragments into the spinal canal at this level, which reduces the
diameter of the spinal canal by approximately 50%.
.
Prior to his transfer, Dr. [**Last Name (STitle) **] of neurosurgery was consulted,
who believed that the chance for a neurologic recovery was very
low given the period between onset of symptoms and transfer for
evaluation. His prior workup is notable for history of
persistent tachycardia with heart rates in the 150s, with two
prior CTAs (one on [**2150-11-24**] and one on [**2150-12-4**]) both of which
were negative for PE.
.
Patient was directly admitted to the floor, but triggered upon
arrival due to HR in the 150s, which initially was sinus
tachycardia, but which quickly escalated to 210s with stable
blood pressures and oxygen saturations, with telemetry findings
consistent with SVT. Broke with 5mg IV lopressor X 1. Patient
was asymptomatic through his tachycardia.
.
On the floor, patient reports that he is anxious. He is able to
wiggle his toes but cannot move his thighs and his sensation is
gone from the mid thighs downward.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain.

Past Medical History:
- squamous cell esophageal cancer: diagnosed in [**2149**] by EGD with
presence of bulky mediastinal adenopathy involving the upper
mediastinum; s/p 3 cycles of cisplatin and 5FU and XRT then two
more cycles of chemo
- history of radiation pneumonitis
- intermittent dysphagia
- history of supraventricular tachycardia s/p ablation
- compression of spinal cord level T6 secondary to fracture of
his T6 vertebral body
- history of radiation pneumonitis treated with solumedrol
- subacute T6 compression fracture
- s/p right nephrectomy
- cholelithiasis

Social History:
Married, lives with wife and son.

Family History:
No history of esophageal or renal cancer.

Physical Exam:
ADMISSION EXAM:
Vitals: T: 97.8, BP: 141/107, P: 153, R: 22, O2 sat: 97%RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds in the bases, no wheezes or
rales.
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+O X 3. CN 2-12 intact. Decreased rectal tone. No spinal
anesthesia. Decreased sensation starting at the mid thighs
progressing down to the feet. Unable to lift thighs bilaterally.
Unable to dorsiflex/plantarflex foot. Able to move toes
bilaterally. Absent patellar reflexes bilaterally.

Pertinent Results:
OSH CT abdomen/pelvis [**2150-12-6**]: Findings raise concern for a mid
small bowel early or partial obstruction, exact site uncertain.
No specific signs of closed loop obstruction are identified. No
fre air. Distal esophageal changes, consistent with previous
clinical diagnosis of esophageal carcinoma. Post right
nephrectomy. Gallstones. Pleural effusions.
.
OSH CT head [**2150-12-7**]: There is a 1cm enhancing mass at the
grey-white matter junction of the posterior left frontal lobe,
with some associated edema but no significant mass effect. Given
history, likely metastasis.
.
OSH CT thoracic spine [**2150-12-9**]: severe compression of the T6
vertebral body, resulting in a kyphotic angulation of the spine
at this level. There is significant retropulsion of bone
fragments into the spinal canal at this level which reduces the
diameter of the spinal canal by approximately 50%. Although soft
tissue resolution in the spinal canal is limited, suspect that
soft tissue material is suspicious for tumor extending from the
compressed vertebra into the spinal canal. Moderate sized
bilateral pleural effusions.
.
OSH CT lumbar spine [**2150-12-9**]: Moderate compression of L2, L4,
L5, appearance of osteoporotic compression fractures. Moderate
acquired spinal stenosis at the L3-L4 and L4-L5 levels.
.
[**2150-12-10**] T & L spine MRI: IMPRESSION:
1. T6: Severe compression fracture, with areas of increased
signal intensity on the STIR sequence, likely related to edema.
Retropulsion of the posterior aspect of the vertebral body into
the spinal canal resulting in severe spinal canal stenosis and
moderate degree of compression on the spinal cord at this level.
Pre- and paravertebral and epidural component noted. Pathologic
compression fracture likely, with involvement by tumor. However,
assessment can be better performed with post-contrast images.
2. L2: Moderate degree of loss of height of the L2 with areas of
marrow
edema. Pathologic compression fracture cannot be completely
excluded.
Possible prevertebral soft tissue swelling. Post-contrast images
can be
helpful to assess for tumor at this level. Correlation with bone
sca/PET can be considered to assess for neoplastic
etiology.
3. Multilevel degenerative changes, multifactorial in the lumbar
spine with moderate-to-severe canal stenosis at L4-5 level,
crowding of the roots of the cauda equina. Edema in the cord in
the thoracic spine from T4-T8 levels.  Increased signal
intensity in the posterior spinous soft tissues in the mid
thoracic spine, question trauma/dependent edema. To correlate
clinically. Bilateral pleural effusions, left more than right.
Please see other details in the CT chest report.
.
[**2150-12-10**] Chest CTA: IMPRESSION:
1. No pulmonary embolism or aortic dissection. 2. Moderate
bilateral pleural effusions, increased from the comparison
study. 3. Collapse of the T6 vertebral body with resultant
severe narrowing of the central spinal canal. 4. Thickening of
esophagus and para-esophageal lymphadenopathy concordant with
history of esophageal cancer.
.
[**2150-12-11**] Brain MRI: IMPRESSION:
1. Mass with intrinsic susceptibility artifact within the left
insular
subcortical white matter with adjacent edema. This could
represent an aneurysm or pseudoaneurysm, as an M2 branch extends
into it. However, a hemorrhagic metastasis (especially given
history of renal cell carcinoma) is also possible, as is a small
parenchymal hgematoma. Comparison with prior images,
particularly the CTA from [**Hospital1 2025**] referred to in Dr.[**Name (NI) 87744**] note,
would be helpful. 2. Moderate to severe intracranial
atherosclerosis.
.
[**2150-12-11**] C Spine MRI IMPRESSION:
No evidence of cervical metastases on this examination on this
limited, incompete examination. If clinical suspicion warrants,
the patient could return for sagittal STIR and post-contrast
images when he is able.





Brief Hospital Course:
66 year old man with metastatic squamous cell esophageal cancer
diagnosed in [**2149**] s/p 3 cycles of cisplatin and 5FU and XRT,
history of radiation pneumonitis, history of SVT s/p ablation
admitted for cord compression and urgent neurosurgical
evaluation with bilateral pleural effusions; his hospital course
was complicated by MICU admission for bilateral widespread
pulmonary emboli, pressor requirement, and intubation.
.
# Cord compression: The patient was transferred from an outside
hospital (OSH) for urgent neurosurgical evaluation of new cord
compression beginning on [**12-9**] from a known subacute compression
fracture at T6 resulting in a dense, complete paraplegia and
sensory loss of bilateral lower extremeties. He was continued on
Dexamethasone and evaluated by both radiation oncology and
neurosurgical services. He was taken to the operating room on
[**2150-12-11**] and underwent T5, T6 and T7 bilateral laminectomy,
anterior decompression with removal of disk material and soft
tissue, posterior instrumented fusion T4, T5, T6, T7 and T8
using pedicle screws, rods and cross-link (EBI spine array),
autologous graft, and allograft. Overnight he was cared for in
the PACU and returned to the medical service on [**12-12**]. He had
been noted to regain minimal motor and sensory function of
bilateral lower extremities.
.
#  Pulmonary emboli/admission to MICU for hemodynamic
instability & Persistent left lower extremity DVT: The pt was
transferred to the MICU on [**2150-12-16**] for hypotension, tachycardia,
and multiple bilateral pulmonary emboli seen on CTA with
extensive clot burden seen in the deep veins of his L leg. He
was treated initially with a Heparin gtt and transitioned to
likely lifelong anticoagulation with Lovenox. He received an IVC
filter [**2150-12-17**] for persistent extensive occlusive deep venous
thrombosis of the left lower extremity involving the common
femoral vein throughout the calf veins documented on [**2150-12-16**]
bilateral lower extremity ultrasounds. Of note, the pt had made
an informed decision regarding anticoagulation in the face of
having had recent nuerosurgery (had been discussed with NSurg
attending as well) and also from this unclear lesion noted in
his brain.
.
# Through his course in the MICU, the pt required pressors and
intubation. He was successfully extubated after 5 days of
intubation. His pressors were also weaned successfully. The
etiology of his hypotension was thought to be sepsis (however,
all BCx's this admission were negative) vs cardiogenic shock due
to the pulmonary emboli. He briefly received steroids for a
random am cortisol of 13 but this was stopped by time of
discharge from MICU without significant consequence.
.
Regarding volume status: through his course in MICU was being
diuresed with 10-20 mg IV Lasix boluses at a time. By the time
of call out from MICU, the pt was recorded as still being net
positive approximately 4L.
.
By time of call out, pt's hemodynamics were stable with pulses
in the low 100's and sbp's in the 110-120's.
.
# Respiratory failure: The pt was intubated for 5 days for
respiratory failure after failing non-invasive ventilation. He
was extubated successfully and remained stable thereafter. The
pt was satting 97-100% on 2-4L NC by discharge from MICU and on
d/c from the hospital as well.
.
# Cognitive dysfuntion: on [**2150-12-24**] the patient was seen in
consulation by occupational therapy. Formal testing revealed
significant cognitive deficits that call into question the
patient's ability to make complex medical decisions. For this
reason, all further medical decisions were made in conjuction
with the patient's wife who is his health care proxy.
.
# Code status and disposition: The patient and his wife
confirmed on [**2150-12-25**] that the patient is DNR/DNI.After lengthy
discussions with the patient and his wife, they do not want the
patient to be placed in rehabilitation but prefer to go home
with the support of hospice care. Their initial interest in
rehabilitation was predicated on the belief that the patient
would regain his ability to walk in a rehabilitation program.
After further discussion, they understood that rehabilitation
would not restore the patient's ability to walk. Rather, the
goal of rehabilitation would be to maximize the patient's
ability to safely carry out activities of daily living with his
permanent paraplegia, including transfer from bed to commode and
wheelchair but that he would likely not be able to walk again.
.
# Dysphagia and aspiration risk: On [**2150-12-24**] formal speech and
swallowing study showed the patient to be at risk to aspirate
all food consistencies, but particularly thin liquids. The
service recommended either 1) nectar/thick liquids/ ground
solids diet if a palliative approach was chosen for the
patient's care (with knowledge that he would be at ongoing risk
to aspirate) PEG or 2) a feeding tube if there was a
nonpalliative appraoch to the patient's care. These findings and
recommendations were reviewed with the patient and his wife (as
health care proxy) on [**2150-12-25**], they chose to accept the risks
of aspiration and chose the nectar/thick liquids/ ground solids
diet. The patient had a feeding tube during concurrent chemo/xrt
for his esophageal cancer and adamantly does not want another
feeding tube. He is DNR/DNI and takes considerable pleasure in
eating so does not want to give this up.
.
# Ground glass opacities seen on CTA: Could not rule out
infectious process/aspiration PNA, so pt was started on
Vanc/Cefepime, was eventually switched to Merrem, and by time of
call out from MICU had completed an approximately 7 day course
of antibiotics. Sputum culture was negative. He was not noted to
have any fevers for at least 3-4 days by time of call out of
MICU. He does however have a persistent leukocytosis that was
present since admission, peaked to 30, and was downtrending to
17 by time of MICU call out.
.
# Cardiac rhythm: While on the floor, pt noted to have narrow
complex SVT's to the 200's which were intermittently treated
with beta blockade. This was also seen in the MICU, in addition
to some runs of atrial fibrillation; this was also treated with
intermittent beta blockade but pt was not kept on this by time
of discharge from MICU.
.
# Unclear lesion in his brain: Per OMR notes and other reports,
this is unclear but DDx was metastatic malignancy or aneurysm vs
pseudoaneurysm. This was considered in the face of the necessity
of anticoagulation, but was not further evaluated in the MICU.
.
# Superficial thrombophlebitis: Was noted to have asymmetric L >
R UE swelling and had u/s showing LUE superficial clot, not
extending to his deep venous system.
.
# Bilateral pleural effusions: The etiology of these are unclear
(malignant vs parapneumonic vs transudative) but these were not
tapped in the MICU.
.
# Metastatic esophageal cancer: The patient has been treated
with 3 cycles of cisplatin and 5FU and XRT for esophageal cancer
diagnosed in [**2149**] that is now metastatic to spine. There has
been a question of brain metastasis versus aneurysm, versus
renal cell carcinoma recurrence and metastasis (from his prior
nephrectomy). Given pt's poor performance status and multiple
co-morbidities pt not a candidate for palliative chemotherapy
treatment and after discussions with wife and pt they decided to
pursue hospice care.
.
# UTI: The patient had a urine culture positive for pansensitive
klebsiella during his prior admission at the OSH. He was treated
with levofloxicin and continued on this after his admission to
[**Hospital1 18**]. Repeat urine cultures were negative and the patient
completed a full course of levofloxicin.
.
# Small bowel obstruction: The patient initially presented to
the OSH with symptoms c/w bowel obstruction. He was treated
conservatively and improved. Following his neurosurgery his diet
was advanced and this was no longer an issue through his MICU
course.
.
# Anxiety and depression: The patient was continued on lorazepam
and citalopram.
.
#Disposition: After multiple discussions with patient and family
in which concerns of pt's safety were discussed pt and family
decided that they did want pt t o go to rehab. Pt d/c home with
hospice services.

Medications on Admission:
HOME medications:
- mucinex PO BID
- prednisone 10mg PO daily
- MVI
- megestrol 2 tsp PO daily
- metoprolol 50mg PO BID
- oxycontin 40mg PO daily
- oxycodone 10mg PO q6h
- ativan 0.5mg PO TID
- omeprazole 20mg PO BID
- citalopram 40mg PO daily

Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 0.8mL syringe
Subcutaneous Q12H (every 12 hours).
Disp:*60 0.8mL syringe* Refills:*2*
2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): This can be purchased over the counter.
4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*2*
5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
6. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation.
7. ondansetron HCl 8 mg Tablet Sig: One (1) Tablet PO every
eight (8) hours as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
8. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for Anxiety.
Disp:*30 Tablet(s)* Refills:*0*
9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO twice a
day: hold for systolic blood pressure below 100 or diastolic
blood pressure below 60.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Hospice of the [**Location (un) 1121**]

Discharge Diagnosis:
Cord compression with paraplegia.
Pulmonary emboli (clot in lungs) requiring admission to ICU.
Respiratory failure.
Esophageal cancer.
Persistent left lower extremity DVT.
Cognitive dysfuntion precluding complicated medical decision
making.
Dysphagia and aspiration risk.
Ground glass opacities on CTA consistent with aspiration
pneumonia.
Narrow complex SVT's.
Brain lesion consistent with aneurysm or pseudoaneurysm.
Superficial thrombophlebitis.
Bilateral pleural effusions.
Urinary tract infection.
Small bowel obstruction.
Anxiety.
Depression.
h/o resected renal cell cancer.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.


Discharge Instructions:
You were transferred from an outside hospital with a cord
compression of your thoracic spine.  You had surgery for your
cord compression and steroids that improved your pain, but these
only minimally improved the strength in your legs.  You then
developed blood clots in your legs, which traveled to your
lungs.  Because of these problems, you needed to be transferred
to the intensive care unit and put on a ventilator (breathing
machine) for several days.  Because you still had clot in your
leg, you had an filter placed in the inferior vena cava (large
vein to the heart/lungs) to prevent more clots from breaking off
and traveling to your lungs.  The speech and swallowing service
did testing that shows you aspirate thin liquids into your lungs
and are at risk to aspirate all liquids and foods into your
lungs.  Although, it was recommended that you have a feeding
tube, you and your wife decided against this.  You agreed to a
diet of thickened liquids and ground food even though you may
aspirate and develop pneumonia.  While in the hospital you were
seen by the occupational health service on [**2150-12-24**], they have
documented that you have severe cognitive deficits.  Since that
time, your medical decision making has been carried out with
your wife (your health care proxy).  Although you and your wife
were offered the option to go to a rehab hospital, when you
understood that a rehab hospital would not restore your ability
to walk, you and your wife have chosen to try to go home with
hospice services despite the difficulties of caring for you at
home.

Followup Instructions:
F/U with Neurosurgery, Dr [**Last Name (STitle) **], on [**2150-1-26**]: CT scan of
thoracic spine at 8:30 am, [**Hospital Ward Name **] clinical building, [**Location (un) 9158**]. [**Hospital 4695**] clinic [**Hospital Ward Name **] clinical building, 3B,at 9 am.


Appointments can be changed by calling [**Telephone/Fax (1) 1669**].
{"Secondary malignant neoplasm of bone and bone marrow,Iatrogenic pulmonary embolism and infarction,Pneumonitis due to inhalation of food or vomitus,Cardiogenic shock,Myelopathy in other diseases classified elsewhere,Malignant neoplasm of other specified part of esophagus,Pathologic fracture of vertebrae,Peripheral vascular complications, not elsewhere classified,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified pleural effusion,Urinary tract infection, site not specified,Unspecified intestinal obstruction,Paraplegia,Other vascular complications of medical care, not elsewhere classified,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Dysthymic disorder,Personal history of malignant neoplasm of kidney,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Frontal lobe and executive function deficit,Do not resuscitate status,Other fluid overload"}


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: Cord compression, esophageal cancer.

PRESENT ILLNESS: This is a 66 year old male with PMH significant for squamous
cell esophageal cancer diagnosed in [**2149**], s/p 3 cycles of
cisplatin and 5FU and XRT, history of radiation pneumonitis,
history of SVT s/p ablation, who is transferred from [**Hospital **]
Hospital due to concern for cord compression and urgent
neurosurgical evaluation.
.
Patient was admitted to OSH on [**2150-12-7**] due to acute abdominal
pain and found to have a partial bowel obstruction. He improved
with conservative therapy. However, on the morning of [**2150-12-9**],
patient found to have inability to move his legs or feet. CT
scan was performed at 7:30PM on [**2150-12-9**] demonstrating severe
compression of the T6 vertebral body, resulting in a kyphotic
angulation of the spine, with significant retropulsion of bone
fragments into the spinal canal at this level, which reduces the
diameter of the spinal canal by approximately 50%.
.
Prior to his transfer, Dr. [**Last Name (STitle) **] of neurosurgery was consulted,
who believed that the chance for a neurologic recovery was very
low given the period between onset of symptoms and transfer for
evaluation. His prior workup is notable for history of
persistent tachycardia with heart rates in the 150s, with two
prior CTAs (one on [**2150-11-24**] and one on [**2150-12-4**]) both of which
were negative for PE.
.
Patient was directly admitted to the floor, but triggered upon
arrival due to HR in the 150s, which initially was sinus
tachycardia, but which quickly escalated to 210s with stable
blood pressures and oxygen saturations, with telemetry findings
consistent with SVT. Broke with 5mg IV lopressor X 1. Patient
was asymptomatic through his tachycardia.
.
On the floor, patient reports that he is anxious. He is able to
wiggle his toes but cannot move his thighs and his sensation is
gone from the mid thighs downward.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain.

MEDICAL HISTORY: - squamous cell esophageal cancer: diagnosed in [**2149**] by EGD with
presence of bulky mediastinal adenopathy involving the upper
mediastinum; s/p 3 cycles of cisplatin and 5FU and XRT then two
more cycles of chemo
- history of radiation pneumonitis
- intermittent dysphagia
- history of supraventricular tachycardia s/p ablation
- compression of spinal cord level T6 secondary to fracture of
his T6 vertebral body
- history of radiation pneumonitis treated with solumedrol
- subacute T6 compression fracture
- s/p right nephrectomy
- cholelithiasis

MEDICATION ON ADMISSION: HOME medications:
- mucinex PO BID
- prednisone 10mg PO daily
- MVI
- megestrol 2 tsp PO daily
- metoprolol 50mg PO BID
- oxycontin 40mg PO daily
- oxycodone 10mg PO q6h
- ativan 0.5mg PO TID
- omeprazole 20mg PO BID
- citalopram 40mg PO daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: ADMISSION EXAM:
Vitals: T: 97.8, BP: 141/107, P: 153, R: 22, O2 sat: 97%RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased breath sounds in the bases, no wheezes or
rales.
CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+O X 3. CN 2-12 intact. Decreased rectal tone. No spinal
anesthesia. Decreased sensation starting at the mid thighs
progressing down to the feet. Unable to lift thighs bilaterally.
Unable to dorsiflex/plantarflex foot. Able to move toes
bilaterally. Absent patellar reflexes bilaterally.

FAMILY HISTORY: No history of esophageal or renal cancer.

SOCIAL HISTORY: Married, lives with wife and son. 

### Response:
{"Secondary malignant neoplasm of bone and bone marrow,Iatrogenic pulmonary embolism and infarction,Pneumonitis due to inhalation of food or vomitus,Cardiogenic shock,Myelopathy in other diseases classified elsewhere,Malignant neoplasm of other specified part of esophagus,Pathologic fracture of vertebrae,Peripheral vascular complications, not elsewhere classified,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Unspecified pleural effusion,Urinary tract infection, site not specified,Unspecified intestinal obstruction,Paraplegia,Other vascular complications of medical care, not elsewhere classified,Phlebitis and thrombophlebitis of superficial veins of upper extremities,Friedl?nder's bacillus infection in conditions classified elsewhere and of unspecified site,Dysthymic disorder,Personal history of malignant neoplasm of kidney,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Frontal lobe and executive function deficit,Do not resuscitate status,Other fluid overload"}
