CHIEF COMPLAINT: OSH transfer- Lower extremity weakness/cauda equina
Perforated bowel

PRESENT ILLNESS: 57 y/o male w/ probable metastatic lung ca, met to L5 spine, who
presents from OSH with leg weakness secondary to cauda equina
syndrome. He was admitted to [**Hospital **] hospital on [**2152-4-17**] with a
20 lb weight loss and long standing history of progressive low
back pain, followed by leg weakness. The low back pain has been
an issue for the last 2-3 years, but over the last 2 months has
become more severe and has radiated to his posterior thigh and
calves. In addition he reports numbness of his feet, which began
2-3 years ago. Within the last 2 weeks he has not been able to
walk and has been wheelchair bound. He reports that he cannot
stand due to pain rather than to weakness. He denies loss of
bowel or bladder function.

MEDICAL HISTORY: probable metastatic lung ca (9mm lesion RUL)
h/o low back pain
hepatitis C
h/o ETOH

MEDICATION ON ADMISSION: Duragesic 25mcg q72 hours
Senokot-S 2mg PO bid
flexiril 10mg PO bid
decadron 4mg PO qid
reglan 10mg PO bid prn nausea
lactulose 30mL PO bid prn
zofran 8mg PO tid prn
dilaudid 4-8mg PO q4prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals- 98.6, 129/88, HR 82, RR 20, 95% RA, Wt 124 lb
gen- cachectic appearing male, awake, alert, NAD
heent- EOMI. MM moist. OP clear.
neck- supple, no lad
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, distended, tympanic to persussion, w/o tenderness to
palpation, rebound or guarding. hypoactive bs.
ext- + clubbing, no edema, rash. 2+ dp pulses
neuro- CNII-XII intact. UE motor [**4-24**] b/l, w/ nl sensation. LE:
no ability to plantar/dorsiflex b/l. not able to lift LLE
against resistance, and only minimally against gravity. RLE able
to lift leg strt against gravity, but easily breaks against
resistance. passive ROM full. no pain ellicitid w/ knee
flexion/extention. Pain ellicitid in right hip/low back w/ R hip
flexion. no sciatica.  Sensation largely intact to pinprick and
light touch with exception of decreased sensation in large toes
b/l (L>R) and reported decreased sensation in buttocks area,
however felt examiner easily on rectal exam. unable to elicit
anal wink on rectal exam, with decreased rectal tone. babinski
reflexes equivocal b/l. unable to ellicit L patella reflex, with
R patella reflex 1 + . Did not assess gait.

FAMILY HISTORY: Mother with lung ca

SOCIAL HISTORY: smokes [**12-22**] pack cigarettes per day. drinks ETOH heavily, [**1-23**]
beers per day and sometimes [**12-22**] pint of vodka per day
Malignant neoplasm of upper lobe, bronchus or lung,Perforation of intestine,Abscess of lung,Unspecified septicemia,Acute respiratory failure,Pneumonia, organism unspecified,Secondary malignant neoplasm of bone and bone marrow,Cauda equina syndrome without mention of neurogenic bladder,Pathologic fracture of vertebrae,Dependence on respirator, status,Acute posthemorrhagic anemia,Candidiasis of other urogenital sites,Hyposmolality and/or hyponatremia,Encounter for palliative care,Constipation, unspecified,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Chronic hepatitis C without mention of hepatic coma,Other specified cardiac dysrhythmias,Other and unspecified alcohol dependence, unspecified,Urinary incontinence, unspecified,Other iatrogenic hypotension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic ulcer of other specified sites
Mal neo upper lobe lung,Perforation of intestine,Abscess of lung,Septicemia NOS,Acute respiratry failure,Pneumonia, organism NOS,Secondary malig neo bone,Cauda equina synd NOS,Path fx vertebrae,Respirator depend status,Ac posthemorrhag anemia,Candidias urogenital NEC,Hyposmolality,Encountr palliative care,Constipation NOS,Adv eff analgesics NEC,Chrnc hpt C wo hpat coma,Cardiac dysrhythmias NEC,Alcoh dep NEC/NOS-unspec,Urinary incontinence NOS,Iatrogenc hypotnsion NEC,Abn react-procedure NEC,Abn react-surg proc NEC,Chronic skin ulcer NEC
Admission Date:  [**2152-4-24**]              Discharge Date:   [**2152-5-12**]

Date of Birth:  [**2094-11-13**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 668**]
Chief Complaint:
OSH transfer- Lower extremity weakness/cauda equina
Perforated bowel

Major Surgical or Invasive Procedure:
[**2152-4-27**] Exploratory laparotomy, Right colectomy, ileostomy
placement
[**2152-5-9**] Tracheostomy and percutaneous endoscopic gastrostomy.


History of Present Illness:
57 y/o male w/ probable metastatic lung ca, met to L5 spine, who
presents from OSH with leg weakness secondary to cauda equina
syndrome. He was admitted to [**Hospital **] hospital on [**2152-4-17**] with a
20 lb weight loss and long standing history of progressive low
back pain, followed by leg weakness. The low back pain has been
an issue for the last 2-3 years, but over the last 2 months has
become more severe and has radiated to his posterior thigh and
calves. In addition he reports numbness of his feet, which began
2-3 years ago. Within the last 2 weeks he has not been able to
walk and has been wheelchair bound. He reports that he cannot
stand due to pain rather than to weakness. He denies loss of
bowel or bladder function.

Neuro evaluation there on [**2152-4-17**] showed normal pin sensation of
LEs, although there was subjective numbness of the feet. No
focal weakness of the extremity muscles was noted to manual
testing and DTRs were noted to be 1+ and symmetric at knees, and
absent at ankles.

Work-up showed a destructive lesion in L5 with a soft tissue
component, likely representing metastatic disease. There was
also evidence of pathologic compression of the body of L5 and
severe foraminal narrowing at L5-S1 with cauda equina
compression.  He was also found to have a cavitary lesion in the
right upper lobe of the lung measuring almost 1cm, suspicious
for nonsmall cell lung cancer, likely squamous cell. Biopsy of
the L5 lesion was performed and results were pendning at time of
transfer. The patient was started on reglan and external beam
XRT. His pain improved after optimization of his pain regimen,
however he became constipated. He also had a foley placed for
?urinary retention. He was seen daily by neurosurgery and there
was a long debate on how to proceed. Clinically the patient was
not improving and still had significant leg weakness, and
therefore it was recommended by the neurosurgeons to transfer
him for consideration of cyberknife treatment.

Note dated [**2152-4-20**] comments that patient reported legs were
weaker than the day prior. Note dated [**2152-4-24**] reports patient can
lift lower extremities bilaterally but cannot wiggle toes with
slight foot drop on L.

On arrival today, patient reports pain in low back. Complains of
weakness and numbness of his lower extremities, which he reports
has become worse over the last 2 days. He reports constipation
and abdominal distention, however he does admit to having a
small BM yesterday. He also admits though that he does have
numbness in his buttocks and does not feel that he has full
control over his bowel movements. In regards to urinary
retention, this is less clear, because he currently has a foley
catheter. He reports this was placed after he was told his urine
output was not as good as it should be.
Denies upper extremity weakness or numbness. no cough,
hoarseness, chest pain, sob.

ROS: as per hpi. also denies cough, sob, sputum production or
hemoptysis. no headache, n/v, vision changes. low back pain, +
left hip pain, lower extremity weakness, and numbness in toes.


Past Medical History:
probable metastatic lung ca (9mm lesion RUL)
h/o low back pain
hepatitis C
h/o ETOH


Social History:
smokes [**12-22**] pack cigarettes per day. drinks ETOH heavily, [**1-23**]
beers per day and sometimes [**12-22**] pint of vodka per day

Family History:
Mother with lung ca

Physical Exam:
vitals- 98.6, 129/88, HR 82, RR 20, 95% RA, Wt 124 lb
gen- cachectic appearing male, awake, alert, NAD
heent- EOMI. MM moist. OP clear.
neck- supple, no lad
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, distended, tympanic to persussion, w/o tenderness to
palpation, rebound or guarding. hypoactive bs.
ext- + clubbing, no edema, rash. 2+ dp pulses
neuro- CNII-XII intact. UE motor [**4-24**] b/l, w/ nl sensation. LE:
no ability to plantar/dorsiflex b/l. not able to lift LLE
against resistance, and only minimally against gravity. RLE able
to lift leg strt against gravity, but easily breaks against
resistance. passive ROM full. no pain ellicitid w/ knee
flexion/extention. Pain ellicitid in right hip/low back w/ R hip
flexion. no sciatica.  Sensation largely intact to pinprick and
light touch with exception of decreased sensation in large toes
b/l (L>R) and reported decreased sensation in buttocks area,
however felt examiner easily on rectal exam. unable to elicit
anal wink on rectal exam, with decreased rectal tone. babinski
reflexes equivocal b/l. unable to ellicit L patella reflex, with
R patella reflex 1 + . Did not assess gait.

On discharge:
102.8, 99.8, 101, 96/57, 27, 100 Trach mask
Alert and Oriented
He is able to fully move UE - has no LE motor function
Tracheostomy in proper position without surrounding erythema or
exudate
Tachycardia but regular rhythm
Coarse breath sounds bilateral lungs with R>L
Abdomen is flat and nondistended.  He has PEG in good position
that is 2cm at skin.  He has a midline wound that is granulating
in nicely.  Ostomy is pink and has good function.
LE as mentioned no motor function. No edema


Pertinent Results:
Reports-
MRI [**2152-4-18**]- Mild pathologic compression fx of L5. Tumor has
destroyed posterior cortex of the vertebral body and causes
critical spinal stenosis at this level with critical compression
of the cauda equina. Extension of tumor into the posterior
elements. Severe bilateral foraminal narrowing at L5-S1 and
moderate bilateral foraminal narrowing at L4-L5.

Ct guided bone bx [**2152-4-21**]- pending at time of transfer

[**2152-4-22**] KUB no intestinal obstruction or other acute
intr-abdominal abnormality. lytic metastatic dx involving left
side body L5.

[**2152-4-19**] Bone scan- probable mild to moderate generalized
peripheral arthritic changes as described above. Otherwise
negative for significant focal skeletal lesion in the rest of
the whole body. Negative for significant focal skeletal lesion
in the thoracolumbar vertebrae.

[**2152-4-20**]- MRI brain- no evidence of intracranial metastasis.
normal contrast enhanced brain MRI.   Trace chronic paranasal
sinus disease.

[**2152-4-18**]- CT chest- Cavity lesion right upper lung, 9mm. Right
hilar adenopathy. calcied lymph node left hilum. small
non-calcified nodule left upper lung posteriorly.

[**2152-4-18**]- CT abd- liver, spleen, panc, gb unremarkable. no extra
or intrahepatic ductal dilatation. right and left kidneys
unremarkable

[**2152-4-27**] AXR - FINDINGS: There is a large amount of free
intraperitoneal air. There is contrast in the large bowel. There
is a right upper lobe lung mass, better characterized on recent
chest radiograph, but appears to contain cavitation.

CTA Chest [**2152-4-30**]
FINDINGS:
1. No evidence of pulmonary embolism.
2. Multifocal ground-glass opacity and consolidation
superimposed upon diffuse centrilobular emphysema. The most
likely cause for these findings includes ARDS or multifocal
pneumonia.
3. Small pneumoperitoneum.

[**2152-5-4**]
IMPRESSION:
1. Increase in size of the patient's right upper lobe cavitary
lesion as noted. Decreased prominence of bilateral patchy
airspace opacities previously noted. Persistent airspace
opacities seen within the right lung with debris in the right
mainstem bronchus as noted. Soft tissue attenuation surrounding
the airways of the right lung as noted, likely reflecting the
patient's known lung carcinoma.
2. Significant distention of numerous loops of small bowel. The
diffuse nature of this distention suggests a functional ileus.
No area of transition is seen to suggest a mechanical
small-bowel obstruction.
3. Free fluid seen within the peritoneal cavity. If clinically
dictated, this may be accessed for aspiration via ultrasound
guidance to exclude infection.
4. Lytic L5 vertebral body lesion, previously seen on prior CT
to better detail.

[**2152-5-10**] CXR (most recent)
REASON FOR THIS EXAMINATION:
Assess cardiopulmonary process
HISTORY: Ventilator-dependent failure with right cavitary
lesion.

FINDINGS: In comparison with the previous study, there is little
overall change. Again there is a large left upper lung cavity.
The atelectatic change at the left base has essentially cleared.
The left lung also is clear.

IMPRESSION Little change.

Laboratory:
CBC: [**2152-4-25**] HCT 34, WBC 34, Platelets 888
CBC: [**2152-5-12**] HCT 20, WBC 7.7, Platelets 435

Coags: [**2152-5-3**] INR 1.4, PTT 31.4

Chemistry: [**2152-5-12**] Na 128, K 4.0, Cl 108, HCO3 21, BUN 18, Cr.
.6, Glc 100

LFTs: [**2152-5-5**] AST 13, ALT 20, Alk Phos 64, Amylase 109*, T. bili
4.6*

CEA 2.1
PSA 1.1


Brief Hospital Course:
A/P: 57 y/o male w/ probable metastatic lung ca, met to L5
spine, who presents from OSH with leg weakness secondary to
cauda equina syndrome - will resulting colonic perforation.

Neuro:
He was admitted for workup and treatment of his symptomatic
spine lesion.  He was to be operated on but was found to have
perforated bowel.  He was never operated on and his symptoms of
cauda equina persisted.  After long discussion, it was decided
to not pursue spine stabilization.

CV:
Patient was in sinus tachycardia throughout the hospitalization.
 He was transfused one unit of blood for a HCT of 20 on the day
of discharge which brought his heart rate down to around 100.
He was rate controlled on IV metoprolol.

Pulm:
He was maintained on a ventilator throughout most of his
hospitalization.  He had a tracheostomy placed on [**5-9**] (three
days prior to d/c) and on the day of discharge was able to come
off the vent and have good 02 sats on trach mask.  He has a
large right lung abscess that was assessed by the thoracics
team.  It was determined by them that in the current setting IV
abx would be the best treatment.  Any intervention would not
likely improve survival

GI:
abdominal distention/constipation- KUB [**4-22**] w/o evidence of
obstruction.  suspect multifactorial from narcotics and cord
compression. On the operating table for spine surgery he was
found to have abdominal distension and a portable xray was done
which showed air under the diaphragm.  A STAT general surgery
consult was called and patient was taken emergently to the OR
for an exlap, R hemicolectomy, and placement of ileostomy.  His
fascia was closed but the skin was left open for wet to dry
dressing changes.  He was NPO and eventually had a PEG tube
placed without problem.  [**Name (NI) **] was tolerating tube feeds with good
ostomy function at discharge.

GU: He had has a foley in.  His urine output has been adequate

Endo: He was on a RISS

ID:  He was covered broadly for his lung abscess and post
operative prophylaxis.  He was discharged on Vanc, Cipro, Zosyn,
and Flagyl.  Fluconazole was started for yeast in Urine and
Sputum.  Should be d/c'ed on [**2152-5-15**].

FEN: has had hyponatremia - we have had him KVO and are trying
to fluid restrict him.

Prophylaxis: SQH

Full Code

Medications on Admission:
Duragesic 25mcg q72 hours
Senokot-S 2mg PO bid
flexiril 10mg PO bid
decadron 4mg PO qid
reglan 10mg PO bid prn nausea
lactulose 30mL PO bid prn
zofran 8mg PO tid prn
dilaudid 4-8mg PO q4prn

Discharge Medications:
1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
2. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML
Mucous membrane [**Hospital1 **] (2 times a day).
3. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever.
4. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed: given through G tube.
5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day): through J tube.
6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
7. Piperacillin-Tazobactam Na 4.5 g IV Q8H
8. Ciprofloxacin 400 mg IV Q12H
9. MetRONIDAZOLE (FLagyl) 500 mg IV Q8H
10. Vancomycin 1500 mg IV Q 12H
11. Sodium Chloride 0.9%  Flush 10 mL IV PRN line flush
Temporary Central Access-ICU: Flush with 10mL Normal Saline
daily and PRN.
12. Metoprolol Tartrate 5 mg IV Q6H:PRN HR > 100
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours).
14. Potassium Phosphate Dibasic 3 mMole/mL Parenteral Solution
Sig: One (1)  Intravenous PRN (as needed).
15. Magnesium Sulfate 4 % Solution Sig: One (1)  Injection PRN
(as needed): Sliding Scale.
16. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1)
Intravenous PRN (as needed): sliding scale.
17. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1)
Intravenous ASDIR (AS DIRECTED): sliding scale.
18. Insulin
Insulin sliding scale - please see printed sliding scale
included in discharge material
19. Pantoprazole 40 po qday


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 105**] Northeast - [**Hospital1 **]

Discharge Diagnosis:
Metastatic Lung CA
Perforated Bowel
R lung loculated abscess
L5 metastatic lesion with cord compression
Acute blood loss anemia
Nutrional depletion


Discharge Condition:
Fair


Discharge Instructions:
Patient should call for additional questions regarding managment
of ostomy, tracheostomy, PEG or any other surgical concerns.

He should continue to receive dressing changes and suction of
his tracheostomy.  A passy muir valve may be used for patient to
communicate. His tube feeds should be continued and q4 flushing
should be done.  Ostomy care should be undertaken.

Abdominal wound should continue to have wet to dry dressing
changes [**Hospital1 **].

Followup Instructions:
He should follow up with his PCP as needed.

Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] is available on a as needed basis
{'Malignant neoplasm of upper lobe, bronchus or lung,Perforation of intestine,Abscess of lung,Unspecified septicemia,Acute respiratory failure,Pneumonia, organism unspecified,Secondary malignant neoplasm of bone and bone marrow,Cauda equina syndrome without mention of neurogenic bladder,Pathologic fracture of vertebrae,Dependence on respirator, status,Acute posthemorrhagic anemia,Candidiasis of other urogenital sites,Hyposmolality and/or hyponatremia,Encounter for palliative care,Constipation, unspecified,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Chronic hepatitis C without mention of hepatic coma,Other specified cardiac dysrhythmias,Other and unspecified alcohol dependence, unspecified,Urinary incontinence, unspecified,Other iatrogenic hypotension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic ulcer of other specified sites'}


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: OSH transfer- Lower extremity weakness/cauda equina
Perforated bowel

PRESENT ILLNESS: 57 y/o male w/ probable metastatic lung ca, met to L5 spine, who
presents from OSH with leg weakness secondary to cauda equina
syndrome. He was admitted to [**Hospital **] hospital on [**2152-4-17**] with a
20 lb weight loss and long standing history of progressive low
back pain, followed by leg weakness. The low back pain has been
an issue for the last 2-3 years, but over the last 2 months has
become more severe and has radiated to his posterior thigh and
calves. In addition he reports numbness of his feet, which began
2-3 years ago. Within the last 2 weeks he has not been able to
walk and has been wheelchair bound. He reports that he cannot
stand due to pain rather than to weakness. He denies loss of
bowel or bladder function.

MEDICAL HISTORY: probable metastatic lung ca (9mm lesion RUL)
h/o low back pain
hepatitis C
h/o ETOH

MEDICATION ON ADMISSION: Duragesic 25mcg q72 hours
Senokot-S 2mg PO bid
flexiril 10mg PO bid
decadron 4mg PO qid
reglan 10mg PO bid prn nausea
lactulose 30mL PO bid prn
zofran 8mg PO tid prn
dilaudid 4-8mg PO q4prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: vitals- 98.6, 129/88, HR 82, RR 20, 95% RA, Wt 124 lb
gen- cachectic appearing male, awake, alert, NAD
heent- EOMI. MM moist. OP clear.
neck- supple, no lad
pulm- CTA b/l. no r/r/w
cv- RRR. no m/r/g
abd- soft, distended, tympanic to persussion, w/o tenderness to
palpation, rebound or guarding. hypoactive bs.
ext- + clubbing, no edema, rash. 2+ dp pulses
neuro- CNII-XII intact. UE motor [**4-24**] b/l, w/ nl sensation. LE:
no ability to plantar/dorsiflex b/l. not able to lift LLE
against resistance, and only minimally against gravity. RLE able
to lift leg strt against gravity, but easily breaks against
resistance. passive ROM full. no pain ellicitid w/ knee
flexion/extention. Pain ellicitid in right hip/low back w/ R hip
flexion. no sciatica.  Sensation largely intact to pinprick and
light touch with exception of decreased sensation in large toes
b/l (L>R) and reported decreased sensation in buttocks area,
however felt examiner easily on rectal exam. unable to elicit
anal wink on rectal exam, with decreased rectal tone. babinski
reflexes equivocal b/l. unable to ellicit L patella reflex, with
R patella reflex 1 + . Did not assess gait.

FAMILY HISTORY: Mother with lung ca

SOCIAL HISTORY: smokes [**12-22**] pack cigarettes per day. drinks ETOH heavily, [**1-23**]
beers per day and sometimes [**12-22**] pint of vodka per day 

### Response:
{'Malignant neoplasm of upper lobe, bronchus or lung,Perforation of intestine,Abscess of lung,Unspecified septicemia,Acute respiratory failure,Pneumonia, organism unspecified,Secondary malignant neoplasm of bone and bone marrow,Cauda equina syndrome without mention of neurogenic bladder,Pathologic fracture of vertebrae,Dependence on respirator, status,Acute posthemorrhagic anemia,Candidiasis of other urogenital sites,Hyposmolality and/or hyponatremia,Encounter for palliative care,Constipation, unspecified,Other specified analgesics and antipyretics causing adverse effects in therapeutic use,Chronic hepatitis C without mention of hepatic coma,Other specified cardiac dysrhythmias,Other and unspecified alcohol dependence, unspecified,Urinary incontinence, unspecified,Other iatrogenic hypotension,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Chronic ulcer of other specified sites'}
