CHIEF COMPLAINT: Neck pain

PRESENT ILLNESS: Mr. [**Known lastname 13060**] is a 68 year old man with history of cervical
spondylysis and disc degeneration who underwent C4-C7
discectomies and C4-C7 spinal stabilization on [**2192-2-13**].
His post-operative course was complicated by fever and
leukocytosis on [**2-23**]; a urine culture grew E. coli, and an
infected PIV site grew MSSA; he was started on Cipro and Vanco
on [**2-23**] and then was transitioned to Levofloxicin for 7 day
course on [**2-28**]. He initially did well after discharge, but for
the past 5-6 weeks he has been complaining of neck pain and
restricted movement. His symptoms have worsened over the past ~
10 days, with difficulty swallowing, decreased PO intake, rigors
and possibly fevers. On [**4-13**] his symptoms worsened further, with
[**10-13**] pain and inability to move his right side. He was referred
to the emergency room early in the morning on [**4-14**] where an MRI
revealed an epidural abscess from C2-C4, with spinal cord
compression.

MEDICAL HISTORY: - Cervical spondylosis/disc degeneration
- Obstructive sleep apnea (not on CPAP)
- History of partial empty sella syndrome
- Hypertension
- Dyslipidemia
- Seasonal asthma
- Migraine headaches
- Back pain, L5-S1 disc disease
- Hypothyroidism
- Ischemic colitis
- Hemochromatosis
- Retinal detachment [**2191**]
- EtOH withdrawal/DT's
.
PSH:
- Carpal tunnel repair 20 yr ago
- liver bx
- [**2191-7-6**] Left shoulder arthroscopic subacromial decompression.
- Arthroscopic rotator cuff repair.
- [**2192-2-13**] Anterior cervical diskectomy C4-C5, C5-C6 and C6-C7.
Fusion C4-C7. Anterior instrumentation C4-C7. Structural
allograft.

MEDICATION ON ADMISSION: (Per OMR)
- Alprazole 0.25mg TID PRN
- Butalbital-Acetaminophen-Caff [Fioricet], 325 mg-40 mg-50 mg
Tablet [**1-6**] Tablet(s) by mouth q4-6 PRN
- CPAP Device
- Zyrtec 10mg tablet daily PRN itching
- Clonazepam 0.5mg TID PRN muscle spasm
- Colchicine 0.6 mg Tablet. Q1H until symptoms abate or
diarrhea, max of 8 tabs per attack
- Diltiazem HCl, 90 mg Capsule, Sust. Release 12 hr; 1
Capsule(s) by mouth once a day
- Duloxetine 20mg [**Hospital1 **]
- Fluticasone 50mcg spray [**Hospital1 **]
- Indomethacin 25mg TID PRN
- Lisinopril 40mg daily
- Oxycodone 5mg Q4-6H PRN
- Ranitidine 150mg [**Hospital1 **]
- Sildenafil 50mg PRN
- Simvastatin 40mg daily
- Synthroid 100mcg daily
- Testosterone 5mg/24h Patch Q24H

ALLERGIES: Penicillins / Norvasc / Nifedipine / Atenolol / Codeine

PHYSICAL EXAM: On presentation (per ortho-spine attending):
Elderly white man in obvious distress. HEENT: limited ROM of
head and neck secondary to pain. Right leg [**3-8**] IR/ER of hip, [**2-9**]
knee flex/ext, ankle 0/5 DF/PF. FHL, [**Last Name (un) 938**].
Left [**5-8**] deltoid/biceps/tricepts/wrist ext/flex, finger
flex/ext.
Left leg [**4-8**] hip flex, knee flex/ext, ankle DF/PF
On transfer to medicine service...
VITALS: Tm 99.7F, Tc 99.7F, BP 140/90 (140-185/72-118), HR 104,
Sat 94-97%
GENERAL: C-collar in place, no acute distress
HEENT: EOMI, PERRL, OP clear without lesions
NECK: Unable to examine because of neck brace
CARD: RRR, normal S1/S2, no m/r/g
RESP: Course rhonchi bilaterally
ABD: Soft, nontender, nondistended, normoactive bowel sounds, no
hepatosplenomegaly
BACK: No spinal tenderness below cervical region
EXT: No clubbing/cyanosis/edema, 2+ DP pulses
NEURO: CN II-XII (grossly; difficult to perform full exam given
limited patient cooperation), A&O x 0, Strength 3-/5 in right
upper and right lower extremity, full on left. Unable to test
for sensory deficits, gait not tested.
PSYCH: Mumbles, inappropriate affect

FAMILY HISTORY: Non-contributory. His mother died from complications from a
cerebrovascular accident.  His father died from "old age."  He
has a sister with diabetes, another sister with MS, and a
62-year-old brother who died from a myocardial infarction.

SOCIAL HISTORY: Lives with wife in [**Name (NI) **]. No recent travel. Pet cat at home.
Previously worked as a school bus driver. Active in the
community, and with gardening and carpentry.
Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Intraspinal abscess,Staphylococcal meningitis,Bacteremia,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Intervertebral disc disorder with myelopathy, cervical region,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified hyperlipidemia,Benign essential hypertension,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Unspecified acquired hypothyroidism,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation
React-oth int ortho dev,Intraspinal abscess,Staphylococc meningitis,Bacteremia,Int inf clstrdium dfcile,Hyposmolality,Cerv disc dis w myelopat,Ac posthemorrhag anemia,Delirium d/t other cond,Mth sus Stph aur els/NOS,Hyperlipidemia NEC/NOS,Benign hypertension,Obstructive sleep apnea,Asthma NOS,Hypothyroidism NOS,Abn react-surg proc NEC
Admission Date:  [**2192-4-14**]              Discharge Date:   [**2192-5-4**]

Date of Birth:  [**2123-8-14**]             Sex:   M

Service: MEDICINE

Allergies:
Penicillins / Norvasc / Nifedipine / Atenolol / Codeine

Attending:[**First Name3 (LF) 905**]
Chief Complaint:
Neck pain

Major Surgical or Invasive Procedure:
[**2192-4-14**]: 1. Anterior fusion exploration. 2. Removal of
instrumentation. 3. Incision and drainage.
.
[**2192-4-14**]: 1. Total laminectomy C 4,5,6. 2. Incision and drainage
.
[**2192-4-15**]: 1. Vertebrectomy of C4. 2. Instrumentation C3-C5. 3.
Cage placement C4. 4. Incision and drainage. 5. Bone graft.
.
[**2192-4-24**]: G-tube placement via interventional radiology

History of Present Illness:
Mr. [**Known lastname 13060**] is a 68 year old man with history of cervical
spondylysis and disc degeneration who underwent C4-C7
discectomies and C4-C7 spinal stabilization on [**2192-2-13**].
His post-operative course was complicated by fever and
leukocytosis on [**2-23**]; a urine culture grew E. coli, and an
infected PIV site grew MSSA; he was started on Cipro and Vanco
on [**2-23**] and then was transitioned to Levofloxicin for 7 day
course on [**2-28**]. He initially did well after discharge, but for
the past 5-6 weeks he has been complaining of neck pain and
restricted movement. His symptoms have worsened over the past ~
10 days, with difficulty swallowing, decreased PO intake, rigors
and possibly fevers. On [**4-13**] his symptoms worsened further, with
[**10-13**] pain and inability to move his right side. He was referred
to the emergency room early in the morning on [**4-14**] where an MRI
revealed an epidural abscess from C2-C4, with spinal cord
compression.

Past Medical History:
- Cervical spondylosis/disc degeneration
- Obstructive sleep apnea (not on CPAP)
- History of partial empty sella syndrome
- Hypertension
- Dyslipidemia
- Seasonal asthma
- Migraine headaches
- Back pain, L5-S1 disc disease
- Hypothyroidism
- Ischemic colitis
- Hemochromatosis
- Retinal detachment [**2191**]
- EtOH withdrawal/DT's
.
PSH:
- Carpal tunnel repair 20 yr ago
- liver bx
- [**2191-7-6**] Left shoulder arthroscopic subacromial decompression.
- Arthroscopic rotator cuff repair.
- [**2192-2-13**] Anterior cervical diskectomy C4-C5, C5-C6 and C6-C7.
Fusion C4-C7. Anterior instrumentation C4-C7. Structural
allograft.


Social History:
Lives with wife in [**Name (NI) **]. No recent travel. Pet cat at home.
Previously worked as a school bus driver. Active in the
community, and with gardening and carpentry.

Family History:
Non-contributory. His mother died from complications from a
cerebrovascular accident.  His father died from "old age."  He
has a sister with diabetes, another sister with MS, and a
62-year-old brother who died from a myocardial infarction.


Physical Exam:
On presentation (per ortho-spine attending):
Elderly white man in obvious distress. HEENT: limited ROM of
head and neck secondary to pain. Right leg [**3-8**] IR/ER of hip, [**2-9**]
knee flex/ext, ankle 0/5 DF/PF. FHL, [**Last Name (un) 938**].
Left [**5-8**] deltoid/biceps/tricepts/wrist ext/flex, finger
flex/ext.
Left leg [**4-8**] hip flex, knee flex/ext, ankle DF/PF
On transfer to medicine service...
VITALS: Tm 99.7F, Tc 99.7F, BP 140/90 (140-185/72-118), HR 104,
Sat 94-97%
GENERAL: C-collar in place, no acute distress
HEENT: EOMI, PERRL, OP clear without lesions
NECK: Unable to examine because of neck brace
CARD: RRR, normal S1/S2, no m/r/g
RESP: Course rhonchi bilaterally
ABD: Soft, nontender, nondistended, normoactive bowel sounds, no
hepatosplenomegaly
BACK: No spinal tenderness below cervical region
EXT: No clubbing/cyanosis/edema, 2+ DP pulses
NEURO: CN II-XII (grossly; difficult to perform full exam given
limited patient cooperation), A&O x 0, Strength 3-/5 in right
upper and right lower extremity, full on left. Unable to test
for sensory deficits, gait not tested.
PSYCH: Mumbles, inappropriate affect


Pertinent Results:
[**2192-4-14**] ECG: Baseline artifact. Rhythm is probably an ectopic
atrial rhythm, although this cannot be confirmed on the basis of
this study. Otherwise, normal tracing. Compared to the previous
tracing of [**2192-2-14**] poor R wave progression is not seen on the
current tracing.
.
[**2192-4-14**] CT Head: No acute intracranial process. If there is
further clinical concern for acute stroke, an MR is more
sensitive.
.
[**2192-4-14**] CXR: No acute cardiopulmonary process.
.
[**2192-4-14**] MR [**First Name (Titles) 11598**] [**Last Name (Titles) 1093**]: 1. Fluid collection in the epidural
space from C2 to C4 level with compression of the spinal cord.
The fluid collection could represent an epidural abscess or
hematoma. Contrast gadolinium-enhanced MRI can help for further
assessment. 2. Spinal cord edema at C2 level. 3. Prevertebral
soft tissue swelling, which could be due to combination of
abscess or hematoma or inflammatory changes. Again,
contrast-enhanced MRI can help for further assessment. 4. Low
signal is identified on T1-weighted images in the T1 vertebra
which could be due to marrow edema.
.
[**2192-4-14**] Spine film: 1) Status post laminectomy, with marked
prominence of soft tissues both anterior and posterior to the
cervical spine, with small locules of air as described. 2)
Alignment from C1 through C6 is preserved, without listhesis. 3)
The cortical surfaces of the C4, C5, and C6 levels are not well
demonstrated in part this likely relates to degenerative
changes. However, review of prior studies suggests that there
has been prior instrumentation and intervertebral fusion devices
at these levels and this may represent residua from that.
Possibility of superimposed osteolysis due to infection cannot
be excluded.
.
[**2192-4-15**] Tissue: Intervertebral disc, C3-C4, excision:
Fibrocartilage and bone with acute inflammation and fibrin,
consistent with abscess formation.
.
[**2192-4-15**] CXR: ET tube tip is 5.6 cm above the carina. There is
mild cardiomegaly. Aside from atelectasis in the right base the
lungs are clear. There is pneumothorax. Small right pleural
effusion is unchanged.
.
[**2192-4-15**] C-spine MRI: Progression of abnormality since the
cervical spine MR of [**2192-4-14**]. Markedly increased spinal cord
edema. Enlarged anterior epidural fluid collection. Increased
abnormal signal in the C7-T1 intervertebral disc, worrisome for
discitis. Extensive epidural and leptomeningeal enhancement
compatible with epidural abscess as well as meningitis.
.
[**2192-4-16**] CXR: Small left pleural effusion and pulmonary and
mediastinal
vascular congestion suggest volume overload and/or cardiac
decompensation,
increased since [**4-15**]. ET tube in standard placement. No
pneumothorax.
Heart size normal, unchanged. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10752**] paged to report
these findings at the time of dictation.
.
[**2192-4-16**] Left upper extremity ultrasound: No left upper extremity
DVT.
.
[**2192-4-17**] CXR: In comparison with study of [**4-16**], the hemidiaphragm
on the left is more sharply seen, suggesting some decrease in
the left pleural effusion.  However, some of this difference may
reflect the semi-erect position of the patient. Again, there is
no evidence of acute focal pneumonia. Endotracheal tube remains
in place.
.
[**2192-4-18**] CT Head: 1. No acute intracranial process. 2. New
opacification of the ethmoidal sinus and sphenoid sinuses and
decreased opacification of the mastoid air cells. Correlate
clinically. This may relate to intubation.
.
[**2192-4-18**] CT C-spine: 1. Extensive post-surgical changes as
described above with no findings to suggest hardware failure
status post recent corpectomy with C3-C5 anterior fusion. 2.
Marked continued swelling involving the
retropharyngeal/prevertebral soft tissues. Air pocket with
simple-appearing fluid collection noted adjacent to the right
hyoid, also likely postoperative. 3. Poor visualization of
remaining epidural phlegmon/fluid collection which is better
depicted on recently performed [**2192-4-17**], C-spine MRI.
.
[**2192-4-18**] CT L-spine: 1. No definite findings of infection
identified. Equivocal small epidural hematoma noted at the L4-L5
interspace likely in conjunction with regions of ligamentum
flavum hypertrophy at this level. Mild inflammatory changes are
noted around the L5 and L3 spinous processes. This should be
correlated with the site of recent lumbar puncture. 2. Small
bilateral pleural effusions with adjacent compressive
atelectasis. Please note, if further evaluation of the spine and
epidural spaces is desired, dedicated MRI could be obtained.
.
[**2192-4-20**] CXR: The ET tube tip is 2.5 cm above the carina. The NG
tube tip passes below the diaphragm terminating in the stomach.
The left subclavian line tip is in mid SVC. There is no
significant change compared to the prior study in bibasal
opacities consistent at least partially with atelectasis and
bilateral pleural effusion. The patient is in mild pulmonary
edema. No pneumothorax is demonstrated.
.
[**2192-4-22**] CXR: ET tube tip is 4.7 cm above the carina. Left lower
lobe aeration has markedly improved. Right lower lobe
atelectasis is persistent. Small bilateral pleural effusions are
stable. Mild cardiomegaly is unchanged. Left subclavian catheter
remains in place. NG tube tip is out of view below the
diaphragm. IMPRESSION: Almost complete resolution of left lower
lobe atelectasis.
.
[**2192-4-24**] CXR: As compared to the previous examination, the
patient has been
extubated and the nasogastric tube has been removed. The
left-sided central venous access line remains in place.
Persistent pre-existing right-sided basal atelectasis,
otherwise, the lung parenchyma is clear, there is no evidence of
focal parenchymal opacities suggesting pneumonia. No pleural
effusions, no pneumothorax.
.
[**2192-4-24**] CT Abd/Pelvis without contrast: No interposed loops of
large bowel between the stomach and the anterior abdominal wall.
The top portion of the stomach and the body and antrum is
covered by the liver, although the more inferior aspects are
not. The patient proceeded to the interventional radiology
suite, for percutaneous gastrostomy placement.
.
[**2192-4-28**] CXR: There is an unchanged left sided central venous
catheter. There is a right upper abdomen pigtail catheter. Lungs
are grossly clear without evidence for overt pulmonary edema,
pleural effusions, or focal consolidation. Cardiac silhouette
and mediastinum is normal. There are no pneumothoraces
identified. The feeding tube has been removed in the interim.
.
[**2192-4-29**] AXR: A pigtail catheter is seen across the abdominal
midline. There is an unremarkable bowel gas pattern with air and
stool seen throughout colon. No dilated loops of small bowel are
seen. There are no signs for free intra-abdominal air.
.
[**2192-4-30**] CXR: 1. Newly placed right central venous access line
ascending into the right internal jugular vein. 2. Interval
development of bilateral basilar opacities which may indicate
aspiration or atelectasis. Findings were discussed with the IV
nurse at the time of interpretation on [**2192-4-30**].
.
[**2192-4-30**] CXR:  Existing PICC line repositioned, now with tip in
the SVC. PICC line is ready to use.
.
[**2192-5-1**] MRI C-spine: Persistent extensive inflammatory changes
after repeated anterior and posterior decompression and fusion.
However, the intensity of enhancement, the size of epidural
fluid collections, the spinal cord edema, and prevertebral fluid
and enhancement have all improved dramatically since the
examination of [**2192-4-17**].
.
[**2192-5-2**] MRI Head: 1. Little change to region of old left basal
ganglia hemorrhage. No evidence of acute intracranial
hemorrhage, masses, or infarction. 2. Sinus disease. 3. Mild
cerebral atrophy.
.
[**2192-5-2**] RUQ Ultrasound: Limited visualization of the left lobe
of the liver. Otherwise, unremarkable examination.
.
[**2192-5-3**] Video Swallow: (prelim) continued silent aspiration,
keep patient NPO.


Brief Hospital Course:
BRIEF HOSPITAL COURSE ON SURGERY:
Mr. [**Known lastname 13060**] is a 68 year old man with history of cervical
spondylysis and disc degeneration who underwent C4-C7
discectomies and C4-C7 spinal stabilization on [**2192-2-13**].
His post-operative course was complicated by fever and
leukocytosis on [**2-23**]; a urine culture grew E. coli, and an
infected PIV site grew MSSA; he was started on Cipro and Vanco
on [**2-23**] and then was transitioned to Levofloxicin for 7 day
course on [**2-28**]. He initially did well after discharge, but for
the past [**5-9**]  weeks he has been complaining of neck pain and
restricted movement. His symptoms have worsened over the past ~
10 days, with difficulty swallowing, decreased PO intake, rigors
and possibly fevers. On [**4-13**] his symptoms worsened further, with
[**10-13**] pain and inability to move his right side. He was referred
to the emergency room early in the morning on [**4-14**] where an MRI
revealed an epidural abscess from C2-C4, with spinal cord
compression. He underwent anterior and posterior approach
removal of hardware and evacuation of epidural abscess with a
posterior laminectomy to decompress. Post-operatively he
developed right sided hemiparesis and went back for repeat
operation on [**4-15**] after repeat imaging showed increase in size
of the epidural abscess. He had a C4 vertebrectomy and incision
of C3-C4 disk, with placement of anterior hardware for cervical
spine instability.

He was initially started on vancomycin, ceftazidime, and
metronidazole (on [**2192-4-14**]) for broad empiric coverage. Blood and
wound cultures from admission and the OR grew MSSA. Antibiotic
coverage was switched to cefazolin once the Staph aureus was
identified as MSSA. A repeat MRI was performed [**4-17**] with
continued expansion of the epidural abscess and leptomeningeal
enhancement. An LP was performed on [**4-17**] concerning for
meningitis with high protein (590), low glucose (34), 33 WBC,
but negative gram stain and culture. He was started on
meropenem, and vancomycin was re-added on [**4-19**]. He was found to
be C. diff positive on [**4-19**], and PO vancomycin was initiated.

He was extubated on [**4-23**]. On [**4-24**] a percutanous gastrostomy tube
was placed in IR (given concern for aspiration). He was
transferred out of the ICU to the surgical floor, seen by
medicine for altered mental status, and transferred to the
medicine service.
BRIEF HOSPITAL COURSE, BY PROBLEM, WHILE ON MEDICINE SERVICE:
Mr. [**Known lastname 13060**] is a 68yM with history of cervical spondylitis s/p
C4-C7 discectomies and C4-C7 spinal stabilization on [**2192-2-13**]
complicated by epidural abscess s/p evacuation and hardware
removal on [**4-14**], growing MSSA, elevated WBC/protein in CSF
concerning for meningitis, now extubated and transferred to the
medical service for altered mental status/confusion.

#) Altered mental status. All altering medications
(benzodiazepenes, narcotics) were held, and his infection was
treated as below. His mental status continues slowly to improve,
with waxing and [**Doctor Last Name 688**] and occasional nighttime agitation. His
mental status was thought likely to be multifactorial from
infection, medications, ICU/hospital stay, and chronic sleep
deprivation. His chemistries were initially notable for
hypernatremia, which was corrected with free water repletion; at
the time of discharge, they are within normal limits. He is not
uremic; his transaminases were mildly elevated (thought
secondary to meropenem, which was discontinued on [**5-2**], RUQ
ultrasound negative). Cultures and other infectious workup
unrevealing. MRI head showed no structural abnormalities or
evidence of septic infarct. Pain was treated with standing
acetaminophen (500-1000mg Q6H), and tramadol was added when his
medication improved. He was started on low dose quetiapine for
sleep and agitation.

#) Epidural abscess/likely meningitis. Vancomycin was continued
(through [**6-8**]), meropenem finished [**5-2**]. CT C-spine showed
extensive inflammatory changes, but improved appearance overall.
Follow up with Dr. [**Last Name (STitle) 363**] in two weeks; he should continue to
wear cervical collar until then.
<br>
#) Elevated white blood cell count. Unclear source, but
resolved; known C. diff positive, but with benign abdominal
exam. Has been afebrile since [**4-30**]. His respiratory status will
need to be monitored (concern for aspiration; aspiration
precautions and NPO until speech and swallow clears him). All
surveillance cultures have been negative to date.
<br>
#) C. difficile infection. Diagnosed as above during course on
surgical service. Stable, with benign abdominal exam; abdominal
x-ray showed no dilatation. Continue PO vancomycin; will need to
continue 5 days past finishing IV vancomycin (until finished
with IV antibiotics).
<br>
#) Risk for aspiration. Given posterior oropharyngeal swelling,
has silent aspiration. Appreciate speech & swallow
recommendations. Video swallow will need to be repeated PRN so
that if needed, can starting taking PO.
<br>
#) Transaminitis. Thought mildly elevated secondary to
meropenem. RUQ ultrasound was unrevealing for cause.
Downtrending at the time of admission.
<br>
#) Hypertension. Continue metoprolol, lisinopril, HCTZ (started
this admission) at maximum doses; increased diltiazem to 90mg
QID (although doubt much help with blood pressure). Blood
pressures improved on current regimen. Allergy to amlodipine
(leg swelling, sexual dysfunction).
<br>
#) Dyslipidemia. Held statin for now given elevated
transaminases.
<br>
#) Hypothyroidism. Continued levothyroxine.
<br>
#) F/E/N. Continue NPO and continue tube feeds. Monitor/replete
electrolytes.
#) Prophylaxis. Heparin SubQ, bowel regimen PRN given diarrhea,
famotidine. Insulin sliding scale while on tube feeds.
#) Communication. With patient's wife [**Name (NI) **]. [**Name2 (NI) **] [**Telephone/Fax (1) 13061**],
Cell [**Telephone/Fax (1) 13062**].
#) Access. PICC placed; CVL from course on surgery was pulled.
#) Code Status. Full code, confirmed with wife.

Medications on Admission:
(Per OMR)
- Alprazole 0.25mg TID PRN
- Butalbital-Acetaminophen-Caff [Fioricet], 325 mg-40 mg-50 mg
Tablet [**1-6**] Tablet(s) by mouth q4-6 PRN
- CPAP Device
- Zyrtec 10mg tablet daily PRN itching
- Clonazepam 0.5mg TID PRN muscle spasm
- Colchicine 0.6 mg Tablet. Q1H until symptoms abate or
diarrhea, max of 8 tabs per attack
- Diltiazem HCl, 90 mg Capsule, Sust. Release 12 hr; 1
Capsule(s) by mouth once a day
- Duloxetine 20mg [**Hospital1 **]
- Fluticasone 50mcg spray [**Hospital1 **]
- Indomethacin 25mg TID PRN
- Lisinopril 40mg daily
- Oxycodone 5mg Q4-6H PRN
- Ranitidine 150mg [**Hospital1 **]
- Sildenafil 50mg PRN
- Simvastatin 40mg daily
- Synthroid 100mcg daily
- Testosterone 5mg/24h Patch Q24H


Discharge Medications:
1. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Ten (10) ML
Intravenous PRN (as needed) as needed for line flush.
2. Vancomycin 500 mg Recon Soln Sig: 1.5 Recon Solns Intravenous
Q 12H (Every 12 Hours): FOR A TOTAL OF 750MG Q12H.
3. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours).
4. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID
(3 times a day).
5. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

7. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
8. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO
DAILY (Daily).
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
11. Docusate Sodium 50 mg/5 mL Liquid Sig: [**5-13**] mL PO BID (2
times a day).
12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
14. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
injection Injection ASDIR (AS DIRECTED): According to sliding
scale (Attached).
15. Tylenol Extra Strength 500 mg Tablet Sig: 1-2 Tablets PO
every six (6) hours: Standing Tylenol for pain control.
16. Ultram 50 mg Tablet Sig: One (1) Tablet PO four times a day
as needed for pain.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Epidural abscess, MSSA
C. difficile infection
Aspiration
Delirium

Discharge Condition:
Stable vital signs, neurologic exam as documented in the
discharge summary

Discharge Instructions:
You were admitted with neurologic deficits and were found to
have an epidural abscess, which was treated neurosurgically by
Dr. [**Last Name (STitle) 363**]. You are being treated with a total of 6 weeks of
intravenous antibiotics for this infection. Your post-operative
course was complicated by C. difficile infection, for which you
are taking oral antibiotics. In addition, because of the
swelling around the site of the spinal infection, you have
difficulty swallowing, for which a tube was inserted directly
into your stomach. As the swelling improvees, and as you
continue your rehab, this tube will likely be able to be removed
and you will be able to eat on your own.
.
Please keep all of your follow up appointments and take all of
your medications as prescribed. If you develop any shortness of
breath, high fever, worsening pain, worsening neurologic
deficits, chest pain, or other concerning symptoms, please seek
medical attention immediately.

Followup Instructions:
Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 3573**] Date/Time:[**2192-5-18**]
10:00
Provider: [**First Name4 (NamePattern1) 8495**] [**Last Name (NamePattern1) 8496**], MD Phone:[**Telephone/Fax (1) 457**]
Date/Time:[**2192-5-24**] 10:30
Provider: [**Name10 (NameIs) 454**],TWO [**Name10 (NameIs) 454**] Date/Time:[**2192-7-25**] 8:30
Provider: [**Name10 (NameIs) 6122**] WEST OUTPATIENT RADIOLOGY Phone:[**Telephone/Fax (1) 8243**]
Date/Time:[**2192-7-25**] 10:00


                             [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Intraspinal abscess,Staphylococcal meningitis,Bacteremia,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Intervertebral disc disorder with myelopathy, cervical region,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified hyperlipidemia,Benign essential hypertension,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Unspecified acquired hypothyroidism,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}


You are an AI assistant analyzing clinical admission notes from the MIMIC III dataset. Your task is to map symptoms mentioned in the notes to a list of provided ICD-9 LONG_TEXT.



### Clinical text :
CHIEF COMPLAINT: Neck pain

PRESENT ILLNESS: Mr. [**Known lastname 13060**] is a 68 year old man with history of cervical
spondylysis and disc degeneration who underwent C4-C7
discectomies and C4-C7 spinal stabilization on [**2192-2-13**].
His post-operative course was complicated by fever and
leukocytosis on [**2-23**]; a urine culture grew E. coli, and an
infected PIV site grew MSSA; he was started on Cipro and Vanco
on [**2-23**] and then was transitioned to Levofloxicin for 7 day
course on [**2-28**]. He initially did well after discharge, but for
the past 5-6 weeks he has been complaining of neck pain and
restricted movement. His symptoms have worsened over the past ~
10 days, with difficulty swallowing, decreased PO intake, rigors
and possibly fevers. On [**4-13**] his symptoms worsened further, with
[**10-13**] pain and inability to move his right side. He was referred
to the emergency room early in the morning on [**4-14**] where an MRI
revealed an epidural abscess from C2-C4, with spinal cord
compression.

MEDICAL HISTORY: - Cervical spondylosis/disc degeneration
- Obstructive sleep apnea (not on CPAP)
- History of partial empty sella syndrome
- Hypertension
- Dyslipidemia
- Seasonal asthma
- Migraine headaches
- Back pain, L5-S1 disc disease
- Hypothyroidism
- Ischemic colitis
- Hemochromatosis
- Retinal detachment [**2191**]
- EtOH withdrawal/DT's
.
PSH:
- Carpal tunnel repair 20 yr ago
- liver bx
- [**2191-7-6**] Left shoulder arthroscopic subacromial decompression.
- Arthroscopic rotator cuff repair.
- [**2192-2-13**] Anterior cervical diskectomy C4-C5, C5-C6 and C6-C7.
Fusion C4-C7. Anterior instrumentation C4-C7. Structural
allograft.

MEDICATION ON ADMISSION: (Per OMR)
- Alprazole 0.25mg TID PRN
- Butalbital-Acetaminophen-Caff [Fioricet], 325 mg-40 mg-50 mg
Tablet [**1-6**] Tablet(s) by mouth q4-6 PRN
- CPAP Device
- Zyrtec 10mg tablet daily PRN itching
- Clonazepam 0.5mg TID PRN muscle spasm
- Colchicine 0.6 mg Tablet. Q1H until symptoms abate or
diarrhea, max of 8 tabs per attack
- Diltiazem HCl, 90 mg Capsule, Sust. Release 12 hr; 1
Capsule(s) by mouth once a day
- Duloxetine 20mg [**Hospital1 **]
- Fluticasone 50mcg spray [**Hospital1 **]
- Indomethacin 25mg TID PRN
- Lisinopril 40mg daily
- Oxycodone 5mg Q4-6H PRN
- Ranitidine 150mg [**Hospital1 **]
- Sildenafil 50mg PRN
- Simvastatin 40mg daily
- Synthroid 100mcg daily
- Testosterone 5mg/24h Patch Q24H

ALLERGIES: Penicillins / Norvasc / Nifedipine / Atenolol / Codeine

PHYSICAL EXAM: On presentation (per ortho-spine attending):
Elderly white man in obvious distress. HEENT: limited ROM of
head and neck secondary to pain. Right leg [**3-8**] IR/ER of hip, [**2-9**]
knee flex/ext, ankle 0/5 DF/PF. FHL, [**Last Name (un) 938**].
Left [**5-8**] deltoid/biceps/tricepts/wrist ext/flex, finger
flex/ext.
Left leg [**4-8**] hip flex, knee flex/ext, ankle DF/PF
On transfer to medicine service...
VITALS: Tm 99.7F, Tc 99.7F, BP 140/90 (140-185/72-118), HR 104,
Sat 94-97%
GENERAL: C-collar in place, no acute distress
HEENT: EOMI, PERRL, OP clear without lesions
NECK: Unable to examine because of neck brace
CARD: RRR, normal S1/S2, no m/r/g
RESP: Course rhonchi bilaterally
ABD: Soft, nontender, nondistended, normoactive bowel sounds, no
hepatosplenomegaly
BACK: No spinal tenderness below cervical region
EXT: No clubbing/cyanosis/edema, 2+ DP pulses
NEURO: CN II-XII (grossly; difficult to perform full exam given
limited patient cooperation), A&O x 0, Strength 3-/5 in right
upper and right lower extremity, full on left. Unable to test
for sensory deficits, gait not tested.
PSYCH: Mumbles, inappropriate affect

FAMILY HISTORY: Non-contributory. His mother died from complications from a
cerebrovascular accident.  His father died from "old age."  He
has a sister with diabetes, another sister with MS, and a
62-year-old brother who died from a myocardial infarction.

SOCIAL HISTORY: Lives with wife in [**Name (NI) **]. No recent travel. Pet cat at home.
Previously worked as a school bus driver. Active in the
community, and with gardening and carpentry. 

### Response:
{'Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Intraspinal abscess,Staphylococcal meningitis,Bacteremia,Intestinal infection due to Clostridium difficile,Hyposmolality and/or hyponatremia,Intervertebral disc disorder with myelopathy, cervical region,Acute posthemorrhagic anemia,Delirium due to conditions classified elsewhere,Methicillin susceptible Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Other and unspecified hyperlipidemia,Benign essential hypertension,Obstructive sleep apnea (adult)(pediatric),Asthma, unspecified type, unspecified,Unspecified acquired hypothyroidism,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation'}
