CHIEF COMPLAINT: Lower back and Right hip pain

PRESENT ILLNESS: 67 year old female with past medical history of metastatic lung
cancer with spinal metastases had L1 anterior resection on [**8-24**]
and then posterior fusion on [**8-28**] transferred to medicine for
management of elevated INR and pain.  The patient was diagnosed
with lung cancer in [**2113-11-18**] on work-up for back pain.
Mrs. [**Known lastname **] had wedge resection [**2114-1-18**] foloowed by
XRT/chemo, which ended [**2114-6-8**].  Patient presented to
[**Doctor Last Name 38554**] Hospital with worsening back pain in [**Month (only) 205**] and
underwent hyphoplasty on [**2114-8-7**].  Biopsy was negative at that
time for metastatic disease.  She was transferred to [**Hospital1 18**] with
worsening pain and recieved anterior approach resection/cage on
[**8-24**] with posterior fusion of L1 on [**8-28**].  Imaging at [**Hospital1 18**] is
suspicious for metastatic disease to T10, T11 and L1 on MRI.
Throughout her hospital course here at [**Hospital1 18**], patient has had
pain on her right hip/thigh that has been constant.  She states
no aggravating/relieving factors.  She has been on Dilaudid PCA,
standing MS Contin with dilaudid for breathrough.  The pain has
been treated as neuropathic.  Of note, she has had nausea for
the past 3-4 days limiting her ability to tolerate PO intake.

MEDICAL HISTORY: - Lung adenocarcinoma - metastatic
- Hypercholesterolemia
- s/p hysterectomy, appendectomy, cholecystectomy
- s/p kyphoplasty of L1  ([**2114-7-18**])
- s/p RUL/RML Lobectomies ([**2113-12-18**])

MEDICATION ON ADMISSION: Decadron 4mg PO bid
Lactulose 15 mg PO qday
Prilosec 20 mg PO qday
Senna
Tylenol
MS Contin 15 mg PO bid
Morphine Sulfate IR 30 mg PO q4h: prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ****on transfer to medicine****

FAMILY HISTORY: Uncle with lung cancer. No hx of bleeding/clotting disorders.
Spouse states family history of heart problems.

SOCIAL HISTORY: Lives in [**Location 14663**] with husband, [**Name (NI) 4468**], who is her HCP. [**Name (NI) **]
children. Smoked < 1 ppd x50 years, quit in [**11-25**] upon diagnosis
of lung cancer. Social EtOH. Denies current second hand smoke
exposure,
husband quit smoking 40 years ago. No IVDU or illicits. Worked
as home health aide in the past.
Pathologic fracture of vertebrae,Iatrogenic pulmonary embolism and infarction,Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Acute kidney failure, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypovolemia,Polyneuropathy in malignant disease,Personal history of malignant neoplasm of bronchus and lung,Pure hypercholesterolemia,Neoplasm related pain (acute) (chronic),Other constipation
Path fx vertebrae,Iatrogen pulm emb/infarc,Secondary malig neo bone,Myelopathy in oth dis,Ac posthemorrhag anemia,Urin tract infection NOS,Delirium d/t other cond,Acute kidney failure NOS,Abn react-surg proc NEC,Enterococcus group d,Hypovolemia,Neuropathy in malig dis,Hx-bronchogenic malignan,Pure hypercholesterolem,Neoplasm related pain,Constipation NEC
Admission Date:  [**2114-8-18**]              Discharge Date:   [**2114-9-13**]

Date of Birth:  [**2046-12-30**]             Sex:   F

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5123**]
Chief Complaint:
Lower back and Right hip pain

Major Surgical or Invasive Procedure:
1. Anterior L1 corpectomy.
2. Anterior arthrodesis T12-L2.
3. Application of interbody cage T12-L2.
4. Application of lateral anterior hardware T12-L2 with a screw
rod construct.
5. Application of autograft rib.
6. Posterior arthrodesis T10 to L3.
7. Segmental instrumentation T10 to L3 with pedicle and
    hook constructs.
8. Application of allograft and demineralized bone matrix.

History of Present Illness:
67 year old female with past medical history of metastatic lung
cancer with spinal metastases had L1 anterior resection on [**8-24**]
and then posterior fusion on [**8-28**] transferred to medicine for
management of elevated INR and pain.  The patient was diagnosed
with lung cancer in [**2113-11-18**] on work-up for back pain.
Mrs. [**Known lastname **] had wedge resection [**2114-1-18**] foloowed by
XRT/chemo, which ended [**2114-6-8**].  Patient presented to
[**Doctor Last Name 38554**] Hospital with worsening back pain in [**Month (only) 205**] and
underwent hyphoplasty on [**2114-8-7**].  Biopsy was negative at that
time for metastatic disease.  She was transferred to [**Hospital1 18**] with
worsening pain and recieved anterior approach resection/cage on
[**8-24**] with posterior fusion of L1 on [**8-28**].  Imaging at [**Hospital1 18**] is
suspicious for metastatic disease to T10, T11 and L1 on MRI.
Throughout her hospital course here at [**Hospital1 18**], patient has had
pain on her right hip/thigh that has been constant.  She states
no aggravating/relieving factors.  She has been on Dilaudid PCA,
standing MS Contin with dilaudid for breathrough.  The pain has
been treated as neuropathic.  Of note, she has had nausea for
the past 3-4 days limiting her ability to tolerate PO intake.


Past Medical History:
- Lung adenocarcinoma - metastatic
- Hypercholesterolemia
- s/p hysterectomy, appendectomy, cholecystectomy
- s/p kyphoplasty of L1  ([**2114-7-18**])
- s/p RUL/RML Lobectomies ([**2113-12-18**])


Social History:
Lives in [**Location 14663**] with husband, [**Name (NI) 4468**], who is her HCP. [**Name (NI) **]
children. Smoked < 1 ppd x50 years, quit in [**11-25**] upon diagnosis
of lung cancer. Social EtOH. Denies current second hand smoke
exposure,
husband quit smoking 40 years ago. No IVDU or illicits. Worked
as home health aide in the past.


Family History:
Uncle with lung cancer. No hx of bleeding/clotting disorders.
Spouse states family history of heart problems.

Physical Exam:
****on transfer to medicine****

Vitals: T: 101.2 BP: 102/62 P: 110 R: 18 O2: 95 RA
General: sedated, arrousable, conversant, pleasant, foley in
place, drain from back in place.
HEENT: Sclera anicteric, MMM, oropharynx clear, tongue red with
marked crevices
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation anteriorly bilaterally, no wheezes,
rales, ronchi, poor respiratory effort
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: soft, tender to deep palpation in LRQ, no reboud
tenderness, non-distended, bowel sounds present, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, pain to palpation on right anterior thigh.
Neuro: CN II-XII intact, strength 5/5 in bilateral upper
extremities, strength 4/5 in R LE and [**5-22**] in L LE.  Intact
sensation to soft touch in all four extremities.  Reflexes
intact in all 4 extremities.
Skin: No rashes


Pertinent Results:
[**2114-8-19**] 04:11AM BLOOD WBC-14.8* RBC-4.20 Hgb-13.2 Hct-39.8
MCV-95 MCH-31.4 MCHC-33.2 RDW-12.8 Plt Ct-382
[**2114-8-31**] 02:55PM BLOOD Hct-25.9*
[**2114-9-4**] 05:46AM BLOOD WBC-3.8* RBC-3.76* Hgb-11.0* Hct-33.8*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.5 Plt Ct-246
[**2114-8-30**] 04:42AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Ellipto-OCCASIONAL
[**2114-8-24**] 09:50AM BLOOD PT-12.1 PTT-22.7 INR(PT)-1.0
[**2114-8-29**] 09:55AM BLOOD PT-19.3* PTT-25.7 INR(PT)-1.8*
[**2114-8-31**] 10:18PM BLOOD PT-13.3 PTT-26.3 INR(PT)-1.1
[**2114-8-30**] 04:42AM BLOOD Fibrino-659*
[**2114-8-19**] 04:11AM BLOOD Glucose-121* UreaN-12 Creat-0.5 Na-142
K-3.6 Cl-99 HCO3-31 AnGap-16
[**2114-9-4**] 05:46AM BLOOD Glucose-106* UreaN-5* Creat-0.5 Na-140
K-4.0 Cl-102 HCO3-30 AnGap-12
[**2114-9-1**] 12:25PM BLOOD LD(LDH)-247 TotBili-0.3
[**2114-8-31**] 10:18PM BLOOD ALT-11 AST-13 AlkPhos-104 TotBili-0.4
[**2114-9-4**] 05:46AM BLOOD Calcium-8.4 Phos-4.0 Mg-1.7
[**2114-8-31**] 04:04AM BLOOD Hapto-393*
[**2114-8-31**] 04:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG

[**2114-9-4**] 05:46AM BLOOD WBC-3.8* RBC-3.76* Hgb-11.0* Hct-33.8*
MCV-90 MCH-29.3 MCHC-32.6 RDW-15.5 Plt Ct-246
[**2114-9-7**] 06:07AM BLOOD WBC-5.3 RBC-3.01* Hgb-8.6* Hct-26.6*
MCV-88 MCH-28.7 MCHC-32.5 RDW-16.5* Plt Ct-317
[**2114-9-9**] 05:51AM BLOOD WBC-5.0 RBC-2.87* Hgb-8.0* Hct-25.5*
MCV-89 MCH-27.9 MCHC-31.5 RDW-15.8* Plt Ct-299
[**2114-9-10**] 03:46AM BLOOD WBC-3.9* RBC-2.59* Hgb-7.5* Hct-23.7*
MCV-91 MCH-28.8 MCHC-31.5 RDW-16.6* Plt Ct-256
[**2114-9-9**] 11:10PM BLOOD Neuts-76.7* Bands-0 Lymphs-16.7*
Monos-5.4 Eos-0.8 Baso-0.4
[**2114-9-10**] 03:46AM BLOOD PT-14.7* PTT-33.4 INR(PT)-1.3*
[**2114-9-4**] 05:46AM BLOOD Glucose-106* UreaN-5* Creat-0.5 Na-140
K-4.0 Cl-102 HCO3-30 AnGap-12
[**2114-9-10**] 03:46AM BLOOD Glucose-109* UreaN-6 Creat-0.6 Na-144
K-3.9 Cl-112* HCO3-25 AnGap-11
[**2114-9-9**] 11:10PM BLOOD CK-MB-NotDone cTropnT-<0.01
[**2114-9-10**] 03:46AM BLOOD proBNP-91
[**2114-9-7**] 06:07AM BLOOD calTIBC-178* Ferritn-453* TRF-137*
[**2114-9-9**] 11:44PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.005
[**2114-9-9**] 11:44PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG

URINE CULTURE (Final [**2114-9-8**]):
      ENTEROCOCCUS SP..    10,000-100,000 ORGANISMS/ML..

                              SENSITIVITIES: MIC expressed in
MCG/ML

_________________________________________________________
                             ENTEROCOCCUS SP.
                             |
AMPICILLIN------------   <=2 S
NITROFURANTOIN--------  <=16 S
TETRACYCLINE----------  =>16 R
VANCOMYCIN------------   <=1 S


Brief Hospital Course:
67 year old female with PMhx of Lung Cancer, (s/p right upper
lobectomy, middle lobe wedge resection, 4 cycles chemo +
adjuvent radiation) with lower back and right hip pain since
[**6-26**] (s/p kyphoplasty) transferred from OSH for evaluation and
management of lower back pain and possible metastases to the
spinal column at L1.
.
# Lower Back Pain - Mrs. [**Known lastname **] was transferred from
[**Hospital **] hospital for evaluation by Ortho Spine for possible
intervention for her new L1 compression fracture.  Noted on
MRI's in early [**Month (only) 205**], the marrow signal from L1 and possibly from
T11 were suspicious for metastasis, however biopsy in [**Month (only) 205**] at
[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] was negative.  Pateint was initially treated for
her pain with Dilaudid PCA while undergoing evaluation.  MRI and
CT spine at [**Hospital1 18**] confirmed L1 and T11 lesions.  Due to concern
that this was metastatic lung cancer, Heme/Onc and Rad-onc were
consulted, as was palliative care.  Rad-Onc decided that
radiation was not indicated at the time of consult and
recommended following orthopedic's recommendations for extension
brace and further management of pain.  Palliative care was
instrumental in detailing an effective pain management plan.  On
[**8-24**], Mrs. [**Known lastname **] was taken for an anterior L1
corpectomy, anterior arthrodesis T12-L2, application of
interbody cage T12-L2, application of lateral anterior hardware
T12-L2 with a screw rod construct, and application of autograft
rib. Approach for this procedure was through Left thoracotomy
exposed by thoracic surgery.  The procedure did not have any
complications.  She was managed further with a Dilaudid PCA with
activity as tolerated.  Pain was fairly well controlled.  On
post-op day 4, Mrs. [**Known lastname **] underwent a second procedure for
posterior arthrodesis T10 to L3, segmental instrumentation T10
to L3 with pedicle and hook constructs, and application of
allograft and demineralized bone matrix.  Again, there were no
complications with this procedure.  Pain was managed with
dilaudid PCA.  The patients lower back pain gradually improved
after this second procedure.  For her pain, the patient was
ultimately titrated up to MS Contin three times a day, PO
dilaudid for breakthrough pain, neurontin and Lidocaine patches.
 The patient was ultimately given Toradol 30 mg q8h for 2 days
which greatly improved her pain.  Pain regimen was slightly
tweaked her last few days in hospital with MS Contin 30 tid,
dilaudid for breakthrough, neurontin and ibuprofen as final
regimen.  She was discharged to home hospice with a 30-day
supply of these medications.
.
# Right Hip Pain - Mrs. [**Known lastname **] was transferred with another
pain complaint involving her right hip and radiating down her
anterior thigh and into her groin, not travelling below the
knee.  After evaluation by multiple services, the pain was
thought likely to be in the distribution of the lateral femoral
cutaneous nerve. The procedures (as above) did not alleviate the
pain.  Post-op CT did not point to any specific pathology
consistent with her pain distribution but the right psoas muscle
had a fluid collection that could be consistent with post-op
inflammation or infection.  Physical therapy was consulted to
help the patient ambulate.  Initially pain management for this
right hip pain was with dilaudid PCA, as above, with low dose
neurontin.  After her procedures, the right hip pain exceeded
any pain from her back.  Neurontin was titrated up to 300 tid,
Lidocaine patches placed for up to 18 hours per day across her
right hip in the distribution of the nerve and MS Contin
ultimately titrated up to tid dosing.  Chronic pain service was
consulted prior to discharge to consider a nerve block or cryo
to the affected nerve.  LS spine was re-imaged by CT to evaluate
that spinal implants were still in place.  Again, there was
notation that fluid collection near right psoas muscle was
concerning for infection as well as a new tumor that was
infiltrating the right L1/L2 forama, possibly compressing
L1--which more acurately described her L1 distribution pain
syndrome .  Mrs. [**Known lastname **] was scheduled for an intervention by
the pain service after this CT, however she became febrile.
Ultimately, an MRI T- and L-spine with contrast were done to
rule in/out infection.  MRI showed no infection of the psoas,
but instead tumor infiltrating the psoas as well as into the
epidural space with ventral cord compression.  This imaging
clearly identified the source of the pain.  Pain service
cancelled their planned intervention.  Instead, Rad-Onc was
called for possible radiation therapy.  The idea was discussed
with Ortho who agreed to radiation within a 3 week operative
window due to symptoms and good wound healing to date.  The
risks of wound breakdown were explained to the patient and her
husband. Radiation was planned for [**9-11**], however in setting of
possible infection, radiation was not started.  Patient was
discharged on [**9-13**] to hospice with instructions to follow-up
with oncologist re: palliative radiation.
.
# Metastatic Lung Cancer - Patient was treated for primary lung
cancer from [**Month (only) 404**]-[**2114-5-18**].  After admission to [**Hospital1 18**], the
results of OSH's biopsy of pt's Left Iliac Crest indicated
adenocarcinoma consistent with primary lung.  The patient was
seen by heme/onc during her admission.  Due to quick failure s/p
chemo and poor functional status during this admission, the
patient was not considered for further chemotherapy.  MRI TL
spine showed tumor infiltrating the psoas as well as into the
epidural space with ventral cord compression.  This imaging
clearly identified the source of the pain.  The patient is to
follow-up as an outpatient with her oncologist.  Palliative care
was following Mrs. [**Known lastname **] throughout her admission. Rad-Onc
was consulted for radiation therapy, pt was evaluated and
planned to start radiation while she was inpatient (risk of
wound breakdown explained to patient and husband).  Through many
discussions, Mrs. [**Known lastname **] and her husband ultimately decided
on hospice.  On [**9-13**], she was discharged to home hospice with
follow-up planned with her outpatient oncologist for management
of possible palliative radiation.
.
# Pulmonary Embolism - After Mrs.[**Known lastname 82814**] first surgery, she
was noted to be tachycardic.  She had some low-grade fevers, but
no signs of infection.   She was never hypoxic.  Initially, she
was treated for her sinus tachycardia with a beta-blocker.
After her second procedure on [**8-28**], she remained tachycardic and
was transferred to the Internal Medicine service for an
unrelated elevated INR.  At this time, her standing tylenol and
beta-blocker were stopped.  She continued to be tachycardic and
it was attributed to pain.  Due to the tachycardia and fever,
bilateral LENI's were done, which were negative for DVT.  3 days
post-operatively from her second procedure, patient became
tachycardic into 150's and triggered.  At this time hematocrit
was also noted to be dropping and the patient was acting
confused and becoming delerius.  Out of concern for acute
hemorrhage, CT head, abdomen, pelvis and chest (PE protocol)
were ordered.  The patient was transferred to the MICU out of
caution, which she stayed in for 1 night.  Blood and urine
cultures were drawn, which were negative.  CTA chest showed
subsegmental PE bilaterally.  Heparin drip was initiated and
target PTT was maintained.  Prior to discharge, heparin was
switched to Lovenox SC 1 mg/kg [**Hospital1 **] for continued anticoagulation
in the setting of malignancy.  Patient was discharged to hospice
on the Lovenox.
.
# Fever - Patient had intermittent low-grade fever throughout
her admission after her operative procedures.  Likely
multifactorial, but include PE, malignancy, post-operative
atelectasis or infection.  On [**9-8**], patient had  fever of 102
and was started on Levoquin for empiric coverage due to no
identified source of infection.   At that time, all blood and
urine cultures to date were negative.  Additionally, CXR had no
acute changes and CT spine showed right paraspinal mass and not
psoas infection.  MRI TL-spine was doen and showed no infection,
but instead rapidly progressive tumor.  On [**9-10**], patient spiked
to 104 and was transferred to MICU.   She also became
hypotensive, requiring Levophed for a brief time until
resuscitated with fluids.  She was started on Vanc and Cefepime.
 She quickly stabilized and defervesced and was switched to
Vancomcin and Zosyn.  Mrs. [**Known lastname **] was transferred to the
floor on [**9-11**] stable.  She was continued on Vancomycin and Zosyn
until discharge and was sent home with 10 day course of Bactrim
DS PO bid.
.
# Tachycardia - Patient remained tachycardic after initial
procedure on [**8-24**].  Tachycardia was felt to be multi-factorial
due to poorly controlled pain, PE, and possible hypovolemia due
to poor PO intake.  Tachycardia did not respond to IV fluids.
Tachycardia improved after initiation of heparin for PE with
intermittant elevation in heart rate when pain was not
controlled. Patient remained mildly tachycardic throughout her
admission.  She was discharged to hospice asymptommatic in this
matter.
.
# Rising INR: Patient with acute change in INR from [**8-28**] to
[**8-29**].  Possibility for nutritional deficiency given poor PO
intake, intermittent Abx for periop PPx, low albumin, low BUN.
Although low suspicion for DIC, work-up was initiated and were
negative.  INR returned to [**Location 213**] within 48 hours and was normal
on discharge.
.
# Anemia - Patient admitted with normal Hct, however in light of
two surgeries, patient developed a mild anemia.  Due to
operative blood loss on [**8-28**], patient was transfused 2 units
PRBC's. Hematocrit was followed daily to monitor for worsening
anemia.  Hemolysis labs were normal.  All imaging throughout
admission was negative for acute hemorrhage.  Patient was
discharged with mild, stable anemia.

Medications on Admission:
Decadron 4mg PO bid
Lactulose 15 mg PO qday
Prilosec 20 mg PO qday
Senna
Tylenol
MS Contin 15 mg PO bid
Morphine Sulfate IR 30 mg PO q4h: prn


Discharge Medications:
1. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q8H (every 8 hours) for 30 days.
Disp:*90 Tablet Sustained Release(s)* Refills:*0*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for breakthrough pain for 30 days.
Disp:*200 Tablet(s)* Refills:*0*
3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) for 30
days: Apply for 12 hours to area of pain then remove for 12
hours.
Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0*
4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day) for 30 days.
Disp:*90 Capsule(s)* Refills:*0*
5. Reglan 5 mg Tablet Sig: 1-2 Tablets PO with meals and at
bedtime as needed for nausea for 30 days: give 30 minutes before
meals.
Disp:*120 Tablet(s)* Refills:*0*
6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 30 days.
Disp:*90 Tablet(s)* Refills:*0*
7. Lovenox 60 mg/0.6 mL Syringe Sig: 0.5 mL Subcutaneous twice a
day for 30 days.
Disp:*60 * Refills:*0*
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 30 days.
Disp:*60 Capsule(s)* Refills:*0*
9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours) for
30 days.
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) for 30 days.
Disp:*60 Tablet(s)* Refills:*0*
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation for 30 days.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
12. Lactulose 10 gram/15 mL Syrup Sig: Fifteen (15) ML PO DAILY
(Daily) as needed for constipation for 30 days.
Disp:*300 ML(s)* Refills:*0*
13. Morphine Concentrate 20 mg/mL Solution Sig: Five (5) mg PO
every four (4) hours as needed for severe pain or
breathlessness.
Disp:*30 mL* Refills:*0*
14. Lorazepam 2 mg/mL Concentrate Sig: One (1) mg PO every six
(6) hours as needed for anxiety or agitation.
Disp:*30 mL* Refills:*0*
15. Atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four
(4) hours as needed for secretions: place 2 drops S/L.
Disp:*5 mL* Refills:*0*
16. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a
day for 10 days.
Disp:*20 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Company 1519**]

Discharge Diagnosis:
Primary Diagnosis:
1. Metastatic Lung Adenocarcinoma
2. Pathologic compression fracture of L1 with significant spinal
stenosis.
3. Pulmonary Embolism
4. Anemia
5. Neuropathic Pain (Lateral Femoral Cutaneous Nerve)


Discharge Condition:
Stable.  Pain well controlled.


Discharge Instructions:
You were transferred from and outside hospital for further
evaluation and management of your lower back and right hip pain.
 You had two surgeries on your back.  You required two units of
blood for low blood counts during your second surgery.  You were
given medication to control your pain.  You worked with physical
therapy to help regain some of your strength.  Please follow-up
with the appointments that have been arranged for you once you
leave the hospital (listed below).

Medication Changes:

If you experience Fever > 102, chest pain, shortness of breath,
pain/pus/discharge from incision site, uncontrollable pain,
bowel or bladder incontinence, loss of function/sensation in
your legs or any other symptom that concerns you, please contact
your PCP or go to the nearest emergency room for treatment.

Followup Instructions:
MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**]
Specialty: Orthopedics
Date and time: Thursday, [**9-20**], 8:40am
Location: Spine Center - [**Hospital Ward Name 23**] Building, [**Location (un) 453**]
Phone number: [**Telephone/Fax (1) 3736**]

Please call Dr. [**Last Name (STitle) 31966**] at [**Telephone/Fax (1) 82815**] to schedule a follow up
appointment with him.
{'Pathologic fracture of vertebrae,Iatrogenic pulmonary embolism and infarction,Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Acute kidney failure, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypovolemia,Polyneuropathy in malignant disease,Personal history of malignant neoplasm of bronchus and lung,Pure hypercholesterolemia,Neoplasm related pain (acute) (chronic),Other constipation'}


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: Lower back and Right hip pain

PRESENT ILLNESS: 67 year old female with past medical history of metastatic lung
cancer with spinal metastases had L1 anterior resection on [**8-24**]
and then posterior fusion on [**8-28**] transferred to medicine for
management of elevated INR and pain.  The patient was diagnosed
with lung cancer in [**2113-11-18**] on work-up for back pain.
Mrs. [**Known lastname **] had wedge resection [**2114-1-18**] foloowed by
XRT/chemo, which ended [**2114-6-8**].  Patient presented to
[**Doctor Last Name 38554**] Hospital with worsening back pain in [**Month (only) 205**] and
underwent hyphoplasty on [**2114-8-7**].  Biopsy was negative at that
time for metastatic disease.  She was transferred to [**Hospital1 18**] with
worsening pain and recieved anterior approach resection/cage on
[**8-24**] with posterior fusion of L1 on [**8-28**].  Imaging at [**Hospital1 18**] is
suspicious for metastatic disease to T10, T11 and L1 on MRI.
Throughout her hospital course here at [**Hospital1 18**], patient has had
pain on her right hip/thigh that has been constant.  She states
no aggravating/relieving factors.  She has been on Dilaudid PCA,
standing MS Contin with dilaudid for breathrough.  The pain has
been treated as neuropathic.  Of note, she has had nausea for
the past 3-4 days limiting her ability to tolerate PO intake.

MEDICAL HISTORY: - Lung adenocarcinoma - metastatic
- Hypercholesterolemia
- s/p hysterectomy, appendectomy, cholecystectomy
- s/p kyphoplasty of L1  ([**2114-7-18**])
- s/p RUL/RML Lobectomies ([**2113-12-18**])

MEDICATION ON ADMISSION: Decadron 4mg PO bid
Lactulose 15 mg PO qday
Prilosec 20 mg PO qday
Senna
Tylenol
MS Contin 15 mg PO bid
Morphine Sulfate IR 30 mg PO q4h: prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: ****on transfer to medicine****

FAMILY HISTORY: Uncle with lung cancer. No hx of bleeding/clotting disorders.
Spouse states family history of heart problems.

SOCIAL HISTORY: Lives in [**Location 14663**] with husband, [**Name (NI) 4468**], who is her HCP. [**Name (NI) **]
children. Smoked < 1 ppd x50 years, quit in [**11-25**] upon diagnosis
of lung cancer. Social EtOH. Denies current second hand smoke
exposure,
husband quit smoking 40 years ago. No IVDU or illicits. Worked
as home health aide in the past. 

### Response:
{'Pathologic fracture of vertebrae,Iatrogenic pulmonary embolism and infarction,Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Delirium due to conditions classified elsewhere,Acute kidney failure, unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Streptococcus infection in conditions classified elsewhere and of unspecified site, streptococcus, group D [Enterococcus],Hypovolemia,Polyneuropathy in malignant disease,Personal history of malignant neoplasm of bronchus and lung,Pure hypercholesterolemia,Neoplasm related pain (acute) (chronic),Other constipation'}
