CHIEF COMPLAINT: Weakness. Inability to walk.

PRESENT ILLNESS: CC: Increasing numbness/tingling BLE with known paraspinal fluid
collection, discitis, osteomyelitis

MEDICAL HISTORY: see HPI

MEDICATION ON ADMISSION: Medications: amlodipine, insulin
                               glargine, oxycodone,
                               morphine, prochlorperazine
                               maleate, zolpidem, insulin
                               lispro, Vitamin B Complex,
                               sertraline, gabapentin,
                               ergocalciferol (vitamin D2),
                               pantoprazole, Lantus,
                               carbidopa-levodopa,
                               vancomycin

ALLERGIES: antihistamines / decongestants / Amitriptyline / Adhesive
Bandage

PHYSICAL EXAM: see HPI

FAMILY HISTORY: see HPI

SOCIAL HISTORY: see HPi
Pathologic fracture of vertebrae,Acute respiratory failure following trauma and surgery,Acute osteomyelitis, other specified sites,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Body Mass Index 45.0-49.9, adult,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Other bone involvement in diseases classified elsewhere,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Long-term (current) use of insulin,Other and unspecified disc disorder, thoracic region,Kyphosis (acquired) (postural),Background diabetic retinopathy,Unspecified essential hypertension,Morbid obesity,Knee joint replacement,Unspecified acquired hypothyroidism,Examination of participant in clinical trial,Iron deficiency anemia secondary to blood loss (chronic),Neurogenic bladder NOS,Swelling, mass, or lump in head and neck
Path fx vertebrae,Ac resp flr fol trma/srg,Ac osteomyelitis NEC,Hyposmolality,Acute kidney failure NOS,BMI 45.0-49.9, adult,DMII oth nt st uncntrld,Bone involv in oth dis,MRSA elsewhere/NOS,Long-term use of insulin,Disc dis NEC/NOS-thorac,Kyphosis NOS,Diabetic retinopathy NOS,Hypertension NOS,Morbid obesity,Joint replaced knee,Hypothyroidism NOS,Exam-clincal trial,Chr blood loss anemia,Neurogenic bladder NOS,Swelling in head & neck
Admission Date:  [**2201-2-10**]              Discharge Date:   [**2201-2-20**]

Date of Birth:  [**2141-8-26**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
antihistamines / decongestants / Amitriptyline / Adhesive
Bandage

Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Weakness. Inability to walk.

Major Surgical or Invasive Procedure:
1. Laminectomy T6 without facetectomy.
2. Laminectomy T7 with facetectomy.
3. Costovertebral decompression T6, T7.
4. Extra cavitary corpectomy T6, T7.
5. Lateral extra cavitary arthrodesis T6, T7.
6. Posterior fusion T4 through T9.
7. Posterior instrumentation T4 through T9.
8. Open treatment thoracic fracture/dislocation posterior.
9. Incision and debridement deep abscess thoracic.
10.Open biopsy deep bone.
11.Local autograft for fusion.
12.Allograft for fusion.


History of Present Illness:
CC: Increasing numbness/tingling BLE with known paraspinal fluid
collection, discitis, osteomyelitis

HPI: 59y F who per review of OMR had a recent history of long
admission for MRSA bacteremia thought [**2-26**] UTI complicated by
hypotension, ICU admission, paraspinal abscess s/p drainage in
[**10-6**] which was c/b pneumothorax, as well as IV contrast
nephropathy, who has continued on IV Vanco as outpatient and now
presents with increasing back pain and BIL LE numbness/tingling.

Onset: [**2200-9-25**].  Charac: gradually worsening, midline lower
thoracic back pain (unchanged location), dull ache at rest, now
exacerbated to [**11-4**] sharp/stabbing pain with movement.
Alleviated mildly with narcotics.  ASx: 1 day of new
numbness/tingling in BIL LE (radiating from lateral thigh to
dorsum of feet BIL, severity has increased to point of unable to
ambulate), -weakness, -f/c, -n/v/d, -HA/change in vision,
-CP/SOB/cough, -abd pain, -dysuria, -GI incont, -GU retention.

Per review of OMR: MRI of her thoracic spine on [**2200-12-16**], which showed a paraspinal fluid collection, discitis,
osteomyelitis at the T6-T7 region without spinal
cordcompression.

Per review of OMR and confirmed with pt:
[**Name (NI) 3262**]:
paraspinal abscess/discitis/osteomyelitis per above
recent admission for MRSA BACTEREMIA
DM - TYPE 2
HYPERCHOLESTEROLEMIA
DIABETIC ULCER OF THE TOE
HYPERTENSION
OBESITY - MORBID
HISTORY TOTAL KNEE REPLACEMENT LEFT
HISTORY TOTAL KNEE REPLACEMENT RIGHT
ISCHEMIC COLITIS
HYPOTHYROIDISM
HEMORRHOIDS
ANEMIA
ESOPHAGEAL REFLUX
HEADACHE - MIGRAINE, UNSPEC
HISTORY OF APPENDECTOMY
HYSTERECTOMY & OOPHORECTOMY
.
SHx:
no alcohol
distant smoking history
denies drug abuse
.
Meds:
ambien
oxycodone
morphine
lorazepam
sertaline
iron
lasix
amlodipine
lantus
humalog
fenofibrate
gabapentin
flonase
albuterol
levodoopa/carbidopa
nystatin
.
All:
amitryptiline
anti-histamine
jewelry
tomatoes

PE:
Vitals: 97 100 130/80 18 100% r/a
General: NAD
Mental Status: AAOx3

Cranial nerves II-XII grossly intact.

Vascular
	Radial	 Ulnar	Fem 	[**Doctor Last Name **] 	DP   	PT
R	 2	   2	  2      2	  2	 2
L	 2	   2	  2      2	  2	 2

Sensory:
UE	C5	C6	C7	C8	T1
R	intact      intact   intact    intact     intact
L	intact      intact   intact    intact     intact

T2-L1 (Trunk) intact

LE     	 L2      L3	  L4	     L5	     S1	         S2

R	intact	intact	decreased LT decreased LT intact	intact
L	intact	intact	decreased LT decreased L intact	intact	

Motor:
UE	Dlt(C5)	Bic(C6)	WE(C6)	Tri(C7)	WF(C7)	FF(C8)	FinAbd(T1)
R	   5	   5	    5	    5	    5	   5	   5
L	   5	   5	    5	    5	    5	   5	   5

LE  	Flex(L1)	Add(L2)
	Quad(L3)	TA(L4)	[**Last Name (un) 938**](L5)	Per(S1)	GS(S1-2/T)
R	   4	   4	   4	    4	    4	    4     4
L	   4	   4	   4	    4	    4	    4	  4

Reflexes
	Bic(C4-5)	BR(C5-6)	Tri(C6-7)	Pat(L3-4)	Ach(L5-S1)
R	   2	    2	    2	    2	     2
L	   2	    2	    2	    2	     2

Babinski:  downgoing
Perianal sensation: intact
Rectal tone: WNL
Estimated Level of Cooperation: high
Estimated Reliability of Exam: reliable


IMPRESSION & RECOMMENDATIONS:
59yo F known paraspinal abscess, discitis/osteomyelitis at T6/T7
now with worsening midline lower T spine pain and subjective
decrease in LT and proprioception along L4/L5 distribition; no
appreciable weakness on exam.

Past Medical History:
see HPI

Social History:
see HPi

Family History:
see HPI

Physical Exam:
see HPI

Pertinent Results:
[**2201-2-19**] 01:23PM BLOOD WBC-8.7 RBC-3.30* Hgb-9.1* Hct-27.5*
MCV-83 MCH-27.5 MCHC-33.0 RDW-15.3 Plt Ct-356
[**2201-2-19**] 11:58AM BLOOD WBC-8.7 RBC-3.33* Hgb-8.9* Hct-27.7*
MCV-83 MCH-26.9* MCHC-32.3 RDW-15.1 Plt Ct-312
[**2201-2-19**] 05:49AM BLOOD WBC-8.0 RBC-3.19* Hgb-8.9* Hct-26.5*
MCV-83 MCH-27.8 MCHC-33.4 RDW-15.3 Plt Ct-314
[**2201-2-18**] 05:13AM BLOOD WBC-8.3 RBC-3.18* Hgb-8.7* Hct-26.2*
MCV-82 MCH-27.3 MCHC-33.2 RDW-15.4 Plt Ct-267
[**2201-2-17**] 08:30AM BLOOD WBC-9.0 RBC-3.32* Hgb-9.0* Hct-27.2*
MCV-82 MCH-27.2 MCHC-33.2 RDW-14.9 Plt Ct-281
[**2201-2-13**] 05:29AM BLOOD WBC-9.3 RBC-3.32* Hgb-9.0* Hct-27.5*
MCV-83 MCH-27.1 MCHC-32.7 RDW-14.8 Plt Ct-213
[**2201-2-10**] 02:50PM BLOOD WBC-12.1* RBC-4.41 Hgb-11.9* Hct-36.1
MCV-82 MCH-26.9* MCHC-32.9 RDW-14.5 Plt Ct-266
[**2201-2-11**] 04:57AM BLOOD Neuts-76.0* Lymphs-17.9* Monos-2.3
Eos-3.3 Baso-0.4
[**2201-2-11**] 04:57AM BLOOD ESR-88*
[**2201-2-19**] 05:49AM BLOOD Glucose-130* UreaN-19 Creat-1.1 Na-137
K-3.9 Cl-105 HCO3-25 AnGap-11
[**2201-2-18**] 05:13AM BLOOD Glucose-142* UreaN-22* Creat-1.0 Na-131*
K-3.8 Cl-101 HCO3-25 AnGap-9
[**2201-2-17**] 08:30AM BLOOD Glucose-93 UreaN-24* Creat-1.2* Na-133
K-3.6 Cl-98 HCO3-23 AnGap-16
[**2201-2-16**] 05:26AM BLOOD Glucose-124* UreaN-23* Creat-1.4* Na-132*
K-3.7 Cl-96 HCO3-25 AnGap-15
[**2201-2-15**] 04:25AM BLOOD Glucose-135* UreaN-15 Creat-1.0 Na-135
K-3.8 Cl-98 HCO3-25 AnGap-16
[**2201-2-14**] 05:19AM BLOOD Glucose-299* UreaN-14 Creat-0.9 Na-136
K-3.7 Cl-99 HCO3-25 AnGap-16
[**2201-2-11**] 02:45PM BLOOD Glucose-212* UreaN-18 Creat-1.0 Na-134
K-4.2 Cl-104 HCO3-19* AnGap-15
[**2201-2-19**] 01:23PM BLOOD AST-41* LD(LDH)-209
[**2201-2-14**] 05:19AM BLOOD CK(CPK)-328*
[**2201-2-19**] 05:49AM BLOOD Albumin-2.6* Calcium-8.2* Phos-4.7*
Mg-1.5*
[**2201-2-12**] 02:38AM BLOOD Type-ART pO2-172* pCO2-36 pH-7.36
calTCO2-21 Base XS--4
[**2201-2-11**] 07:47PM BLOOD Glucose-200*

[**2201-2-11**] 11:05 am BIOPSY      T7 BIOPSY.

                            **FINAL REPORT [**2201-2-17**]**

   GRAM STAIN (Final [**2201-2-11**]):
      1+    (<1 per 1000X FIELD):   POLYMORPHONUCLEAR
LEUKOCYTES.
      NO MICROORGANISMS SEEN.

   TISSUE (Final [**2201-2-17**]):
      STAPH AUREUS COAG +.    RARE GROWTH.
         Reported to and read back by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (NURSE)
[**2201-2-13**] AT 0845.
         Oxacillin RESISTANT Staphylococci MUST be reported as
also
         RESISTANT to other penicillins, cephalosporins,
carbacephems,
         carbapenems, and beta-lactamase inhibitor combinations.

         Rifampin should not be used alone for therapy.
         Daptomycin AND LINEZOLID Susceptibility testing
requested by DR.
         [**Last Name (STitle) **] #[**Numeric Identifier 100855**] [**2201-2-14**].  Daptomycin MIC = 0.064 MCG/ML.
         Daptomycin Sensitivity testing performed by Etest.

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             STAPH AUREUS COAG +
                             |
CLINDAMYCIN-----------   =>8 R
DAPTOMYCIN------------       S
ERYTHROMYCIN----------   =>8 R
GENTAMICIN------------  =>16 R
LEVOFLOXACIN----------   =>8 R
LINEZOLID-------------     2 S
OXACILLIN-------------   =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE----------     2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------     1 S

   ANAEROBIC CULTURE (Final [**2201-2-15**]):    NO ANAEROBES ISOLATED.


Final Report
CLINICAL HISTORY: 59-year-old woman with known spine
osteomyelitis and
abscess. Presenting with weakness and numbness. To rule out
increase in the
size of the abscess.

STUDY: MR thoracic and lumbar spine without contrast.

COMPARISON STUDY: Outside MR thoracic spine dated [**2200-12-16**].

TECHNIQUE: Sagittal T1, T2, STIR and axial T2-weighted images
were obtained
of the thoracic and lumbar spine without administration of
contrast.
Post-contrast images could not be obtained as the patient has
allergy to
contrast. Some of the images are degraded by motion artifact.

FINDINGS:

THORACIC SPINE:

Numbering used is shown on se 9, im 12.

There is partial destruction of T6 and T7 vertebrae with
associated altered
marrow signal, appearing hypointense on T1- and T2-weighted
images and mildly
hyperintense on STIR images. There is involvement of intervening
T6-T7
intervertebral disc. There is associated pre- and para-vertebral
soft tissue
at T6-T7 level. There is also associated anterior epidural
component causing
severe spinal canal stenosis at T6-T7 level and causing
compression of the
spinal cord. Hyperintense signal is noted in the spinal cord
from T5 to T7
level which likely represents edema. Hyperintense signal is
noted in the
posterior paraspinal soft tissues at T6-T7 level which likely
represents
edema. Assessment for associated inflammation/infection is
limited due to lack
of IV contrast images.

There has been interval progression of the disease from the
prior study of
[**2200-12-16**] with increased destruction of T6 and T7
vertebrae and new
epidural component causing compression of the spinal cord.

Rest of the thoracic vertebrae are normal in signal intensity
and height.

At C6-C7, there is central disc protrusion contacting the spinal
cord.

LUMBAR SPINE: The normal curvature of the lumbar spine is
maintained. There
is grade 1 anterolisthesis of L3 over L4 vertebra. The lumbar
vertebral
bodies are normal in height and marrow signal intensity.

L2-L3 to L4-L5 discs are desiccated. There is decreased height
of L2-L3
intervertebral disc.

At L2-L3, there is disc bulge causing indentation of the ventral
thecal sac.
The disc with endplate and facet osteophytes causes mild
bilateral neural
foraminal stenosis.

At L3-L4, there is uncovering of the disc with possible
superimposed disc
extrusion which along with facet arthropathy and ligamentum
flavum thickening
causes severe spinal canal stenosis with crowding and some
degree of
compression on the nerves of the thecal sac. The disc with
endplate and facet
osteophytes causes moderate right and mild left neural foraminal
stenosis.
Small synovial effusion is noted in bilateral facet joints.

At L4-L5, there is diffuse posterior disc bulge causing
indentation of the
ventral thecal sac. There is associated ligamentum flavum
thickening and
facet arthropathy. The disc with endplate and facet osteophytes
causes
moderate right and mild left neural foraminal stenosis.

At L5-S1, there is mild disc bulge without significant spinal
canal or neural
foraminal stenosis.

The conus medullaris ends at L1 level. The pre- and
para-vertebral soft
tissues appear normal. The bladder is markedly distended.

IMPRESSION:
1. Partial destruction with altered marrow signals of T6 and T7
vertebrae
with involvement of intervening T6-T7 intervertebral disc
suggestive of
spondylodiscitis. There is associated pre- and para-vertebral
soft tissue and
epidural soft tissue at T6-T7 level. The epidural component
causes severe
spinal canal stenosis and compression of the spinal
cord.Assessment for
inflmmation, infection or abscess is limited on the present
study and cannot
be excluded.
Hyperintense signal is noted in the spinal cord from T5 to T7
level which
likely represents edema. The disease has significantly
progressed since the
prior study with increased destruction of T6 and T7 vertebrae
with new pre-
and para-vertebral and epidural soft tissue components and
posterior spinous
edema. Refer to the concurrent CT spine report for osseous
details and
posisbility of fracture with DISH.
2. Degenerative changes in the lumbar spine, most notable at
L3-L4 level
where there is severe spinal canal stenosis from disc bulge and
possible
extrusion and facet changes with crowding of the nerves of the
thecal sac.


The study and the report were reviewed by the staff radiologist.

DR. [**Last Name (STitle) **] K. CHAUDHARY
DR. [**First Name (STitle) 10627**] PERI
Approved: [**First Name8 (NamePattern2) **] [**2201-2-12**] 9:33 AM


Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure.  Refer to
the dictated operative note for further details.  The surgery
was without complication and the patient was transferred to the
ICU in a stable condition.  Patient was extubated the next day
and shofted to the floor. TEDs/pnemoboots were used for
postoperative DVT prophylaxis.  Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA.  Diet was advanced as tolerated.
 The patient was transitioned to oral pain medication when
tolerating PO diet.

Physical therapy was consulted for mobilization OOB. Patient was
moved to the chair but was unable to walk.

Infectious disease - changed the Vancomycin to Daptomycin post
operatively. PICC line was removed and a new one inserted.
[**Last Name (un) **] were consulted for diabetes control and patient was
managed on insulin sliding scale.

On [**2-16**] patient developed raised creatinine levels. Renal were
consulted and a diagnosis as prerenal [**Last Name (un) **]. Patients renal
function improved with hydration.

During this admission 2 units of blood were transfused for blood
loss anemia

Trial of Foley removal failed as patient failed to void probably
due to neurogenic bladder.

On the day of discharge the patient was afebrile with stable
vital signs, comfortable on oral pain control and tolerating a
regular diet.


Medications on Admission:
 Medications: amlodipine, insulin
                               glargine, oxycodone,
                               morphine, prochlorperazine
                               maleate, zolpidem, insulin
                               lispro, Vitamin B Complex,
                               sertraline, gabapentin,
                               ergocalciferol (vitamin D2),
                               pantoprazole, Lantus,
                               carbidopa-levodopa,
                               vancomycin

Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

5. carbidopa-levodopa 25-100 mg Tablet Sig: One (1) Tablet PO Q
24H (Every 24 Hours).
6. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q12H (every 12 hours).
Disp:*24 Tablet Extended Release(s)* Refills:*0*
7. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3
times a day).
9. oxycodone 20 mg Tablet Sig: One (1) Tablet PO Q3H (every 3
hours) as needed for pain.
Disp:*72 Tablet(s)* Refills:*0*
10. daptomycin 500 mg Recon Soln Sig: 650mg Recon Solns
Intravenous Q24H (every 24 hours).
11. sertraline 100 mg Tablet Sig: One (1) Tablet PO once a day.

12. insulin pleae see separate sheet


Discharge Disposition:
Extended Care

Facility:
[**Hospital 66**] Rehab & Nursing Center - [**Hospital1 392**]

Discharge Diagnosis:
1. T6, T7 diskitis.
2. T6, T7 osteomyelitis.
3. T7 fracture with kyphosis.
4. Spinal stenosis with incomplete spinal cord injury.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
Immediately after the operation:

-        Activity: As tolerated

-        Rehabilitation/ Physical Therapy:
o   2-3 times a day you should move to the chair. Activity as
tolerated
o   Limit any kind of lifting.

-        Diet: Eat a normal healthy diet. You may have some
constipation after surgery.  You have been given medication to
help with this issue.

-        Brace: You  have been given a brace. This brace is to
be worn when you are walking. You may take it off when sitting
in a chair or while lying in bed.

-        Wound Care: Remove the dressing in 2 days.  If the
incision is draining cover it with a new sterile dressing.  If
it is dry then you can leave the incision open to the air.  Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool.  If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing.  Call the office.

-        You should resume taking your normal home medications.

-        You have also been given Additional Medications to
control your pain.  Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead.  You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2.  We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
 In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.

-        Follow up:
o   Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o   At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o   We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.

Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Neurological weakness. Unable to walk independently.
Out of bed to chair recommended as frequently as possible.
Should wear brace when the back is unsupported (example sitting
in chair without back support or while walking).
No need for brace in bed.

Treatments Frequency:
see discharge instructions. The incision can be kept open to
air. If persisted discharge please contact [**Numeric Identifier 18919**].

Patient as history of diabetic foot. left second toe has a
healing 0.5 mm superficial abrasion.

Outpatient Lab Work please draw weekly cbc bun cr cpk lfts
please fax results to dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] fax number is
[**Numeric Identifier 109921**]
Immediately after the operation:

-        Activity: As tolerated

-        Rehabilitation/ Physical Therapy:
o   2-3 times a day you should move to the chair. Activity as
tolerated
o   Limit any kind of lifting.

-        Diet: Eat a normal healthy diet. You may have some
constipation after surgery.  You have been given medication to
help with this issue.

-        Brace: You  have been given a brace. This brace is to
be worn when you are walking. You may take it off when sitting
in a chair or while lying in bed.

-        Wound Care: Remove the dressing in 2 days.  If the
incision is draining cover it with a new sterile dressing.  If
it is dry then you can leave the incision open to the air.  Once
the incision is completely dry (usually 2-3 days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool.  If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing.  Call the office.

-        You should resume taking your normal home medications.

-        You have also been given Additional Medications to
control your pain.  Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead.  You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2.  We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
 In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.

-        Follow up:
o   Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o   At the 2-week visit we will check your incision, take
baseline X-rays and answer any questions. We may at that time
start physical therapy.
o   We will then see you at 6 weeks from the day of the
operation and at that time release you to full activity.

Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Neurological weakness. Unable to walk independently.
Out of bed to chair recommended as frequently as possible.
Should wear brace when the back is unsupported (example sitting
in chair without back support or while walking).
No need for brace in bed.

Treatments Frequency:
see discharge instructions. The incision can be kept open to
air. If persisted discharge please contact [**Numeric Identifier 18919**].

Patient as history of diabetic foot. left second toe has a
healing 0.5 mm superficial abrasion.


Followup Instructions:
Follow up with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] after 2 weeks of discharge. Spine
center: [**Numeric Identifier 18919**]

Please follow up with Infectious disease  DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at
[**Hospital **] hospital call [**Telephone/Fax (1) 109922**] for appt



Completed by:[**2201-2-20**]

Name:  [**Known lastname 17881**],[**Known firstname 7174**]                  Unit No:   [**Numeric Identifier 17882**]

Admission Date:  [**2201-2-10**]              Discharge Date:   [**2201-2-20**]

Date of Birth:  [**2141-8-26**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
antihistamines / decongestants / Amitriptyline / Adhesive
Bandage

Attending:[**Doctor Last Name 147**]
Addendum:
pt will be followed by [**Hospital1 **] id not dr [**Last Name (STitle) 17883**]

Major Surgical or Invasive Procedure:
1. Laminectomy T6 without facetectomy.
2. Laminectomy T7 with facetectomy.
3. Costovertebral decompression T6, T7.
4. Extra cavitary corpectomy T6, T7.
5. Lateral extra cavitary arthrodesis T6, T7.
6. Posterior fusion T4 through T9.
7. Posterior instrumentation T4 through T9.
8. Open treatment thoracic fracture/dislocation posterior.
9. Incision and debridement deep abscess thoracic.
10.Open biopsy deep bone.
11.Local autograft for fusion.
12.Allograft for fusion.


Discharge Disposition:
Extended Care

Facility:
[**Hospital 4426**] Rehab & Nursing Center - [**Hospital1 3983**]

                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 148**] MD [**MD Number(2) 149**]

Completed by:[**2201-2-20**]
{'Pathologic fracture of vertebrae,Acute respiratory failure following trauma and surgery,Acute osteomyelitis, other specified sites,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Body Mass Index 45.0-49.9, adult,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Other bone involvement in diseases classified elsewhere,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Long-term (current) use of insulin,Other and unspecified disc disorder, thoracic region,Kyphosis (acquired) (postural),Background diabetic retinopathy,Unspecified essential hypertension,Morbid obesity,Knee joint replacement,Unspecified acquired hypothyroidism,Examination of participant in clinical trial,Iron deficiency anemia secondary to blood loss (chronic),Neurogenic bladder NOS,Swelling, mass, or lump in head and neck'}


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: Weakness. Inability to walk.

PRESENT ILLNESS: CC: Increasing numbness/tingling BLE with known paraspinal fluid
collection, discitis, osteomyelitis

MEDICAL HISTORY: see HPI

MEDICATION ON ADMISSION: Medications: amlodipine, insulin
                               glargine, oxycodone,
                               morphine, prochlorperazine
                               maleate, zolpidem, insulin
                               lispro, Vitamin B Complex,
                               sertraline, gabapentin,
                               ergocalciferol (vitamin D2),
                               pantoprazole, Lantus,
                               carbidopa-levodopa,
                               vancomycin

ALLERGIES: antihistamines / decongestants / Amitriptyline / Adhesive
Bandage

PHYSICAL EXAM: see HPI

FAMILY HISTORY: see HPI

SOCIAL HISTORY: see HPi 

### Response:
{'Pathologic fracture of vertebrae,Acute respiratory failure following trauma and surgery,Acute osteomyelitis, other specified sites,Hyposmolality and/or hyponatremia,Acute kidney failure, unspecified,Body Mass Index 45.0-49.9, adult,Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled,Other bone involvement in diseases classified elsewhere,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Long-term (current) use of insulin,Other and unspecified disc disorder, thoracic region,Kyphosis (acquired) (postural),Background diabetic retinopathy,Unspecified essential hypertension,Morbid obesity,Knee joint replacement,Unspecified acquired hypothyroidism,Examination of participant in clinical trial,Iron deficiency anemia secondary to blood loss (chronic),Neurogenic bladder NOS,Swelling, mass, or lump in head and neck'}
