CHIEF COMPLAINT: renal cell carcinoma

PRESENT ILLNESS: This 58-year-old gentleman has a history of renal cell
carcinoma.  He experienced cerebral metastasis and a T5
metastasis with significant spinal cord compression and
resultant instability of the thoracic spine.

MEDICAL HISTORY: renal cell carcinoma s/p L nephrectomy in [**2129**], no xrt/chemo

MEDICATION ON ADMISSION: decadron
dilantin
ranitidine

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: NAD, WDWN
Ht: RRR, nl S1,S2
Lungs: CTA
Abd: soft, nt
ext: no cce
neuro: aox3
motor full
sensation intact
dtr 2+

FAMILY HISTORY: negative for past malignancies

SOCIAL HISTORY: lives with his daughter. Infrequent EtOH use. Quit smoking
25yrs ago. No IVDU
Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Other specified intestinal obstruction,Bacteremia,Personal history of malignant neoplasm of renal pelvis,Urinary tract infection, site not specified,Disruption of external operation (surgical) wound,Peripheral vascular complications, not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension
Secondary malig neo bone,Myelopathy in oth dis,Ac DVT/emb prox low ext,Intestinal obstruct NEC,Bacteremia,Hx malig renal pelvis,Urin tract infection NOS,Disrup-external op wound,Surg comp-peri vasc syst,Abn react-surg proc NEC,Hypertension NOS
Admission Date:  [**2138-5-14**]              Discharge Date:   [**2138-6-6**]

Date of Birth:  [**2080-9-7**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 8790**]
Chief Complaint:
renal cell carcinoma

Major Surgical or Invasive Procedure:
spinal emolization
T5 vertebrectomy, T2-7 laminectomy and instrumented fusion


History of Present Illness:
This 58-year-old gentleman has a history of renal cell
carcinoma.  He experienced cerebral metastasis and a T5
metastasis with significant spinal cord compression and
resultant instability of the thoracic spine.

Past Medical History:
renal cell carcinoma s/p L nephrectomy in [**2129**], no xrt/chemo


Social History:
lives with his daughter. Infrequent EtOH use. Quit smoking
25yrs ago. No IVDU


Family History:
negative for past malignancies


Physical Exam:
NAD, WDWN
Ht: RRR, nl S1,S2
Lungs: CTA
Abd: soft, nt
ext: no cce
neuro: aox3
motor full
sensation intact
dtr 2+

Pertinent Results:
[**2138-5-14**] 03:41PM   GLUCOSE-99 UREA N-14 CREAT-1.2 SODIUM-143
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-27 ANION GAP-15
[**2138-5-14**] 03:41PM   CALCIUM-9.7 PHOSPHATE-3.6 MAGNESIUM-2.0
[**2138-5-14**] 03:41PM   PT-12.8 PTT-24.1 INR(PT)-1.1


Brief Hospital Course:
Pt was admitted to the hospital [**5-14**] and underwent embolization
to T5 lesion pre-op. He tolerated this well and was brought to
OR [**5-15**] where under general anesthesia he underwent T5
vertebrectomy/reconstruction and T2-7 instrumented fusion.  He
had EBL of over 2 l, received 4uPRBC intraop but was
hemodynamically stable, tolerated procedure was transferred to
TICU and then extubated shortly thereafter.  He was moving
extremities but left quadriceps was slightly weak.  MRI was
obtained that showed no compression of nerve roots, good
hardware placement. His strength improved.  He received more
transfusions for low hematocrit.  His diet and acvtivity were
increased.  Drains that were placed intraop were removed on
POD#2.  He was transferred to the floor.  His hematocrit was
followed throughout the hospitalization.  His was fit with TLSO
brace.  Incision was clean and dry with staples.  He developed
post op ileus and was seen in consultation by general surgery.
rectal tube was placed with large output of air and relief of
symptoms. His decadron which he came into the hospital on for
brain mets s/p craniotomy were weaned.  His dilantin level was
followed and therapeutic. He developed abdominal distention and
pain and KUB showed dilated loops of bowel.  He was made NPO and
seen by general surgery and GI.  Rectal tube did help initially
but pt was unable to tolerate and it was removed.  Ambulation
was encouraged - he did need TLSO brace whenever out of bed.  He
was seen by PT/OT who recommended rehab but was unable to go due
to insurance reasons. He had lower extremity doplers for left
leg pain which showed a left leg DVT. In discussion with
Neurosurgery, he was started on lovenox, for which he will
continue at least 6 months. He was reevaluated by PT who cleared
the patient for home discharge. However just prior to discharge
he developed a fever and subsequently became hypotensive. He was
then transferred to the ICU for further care.

ICU course: Patient was transferred to ICU service with fevers,
hypotension and diarrhea. Cultures grew out GNRs initially.
Patient was started on broad spectrum antibiotics including
Vancomycin, Cefepime, flagyl. Patient remained normotensive
while in the unit. His abdomen was soft but distended. CT scan
was read as consistent with C diff infection. Surgery was
consulted and felt his presentation was more consistent with his
prior diagnosis of [**Last Name (un) 3696**] syndrome and that his distended
bowel loops had decreased in size. Serial abdominal exams were
performed with no change. Daily KUB's were performed and a
rectal tube was place for decompression with initially good
results. Team was concerned about perforation given degree of
distention and that his course of steroids may mask his
presentation. However, he became afebrile and normotensive, and
was transferred back to the floor.

Patient was also seen by neurosurgery as he was noted to have
small wound at surgical site. Per neurosurgery, this was not
consistent with wound infection, but only small serosanguinous
drainage. He was evaluated by the wound nurse who recommended
local wound care.

After transfer back to the floor, his blood and urine cultures
grew pan-sensitive E.coli. He was transitioned to PO cipro and
remained afebrile and hemodynamically stable. His diarrhea
resolved and c.diff was negative x 3 so flagyl and PO vancomycin
were discontinued. He was evaluated again by GI who felt that
since his symptoms were improving, there was no call for
neostigmine or colonoscopy.  His abdominal distension worsened
with a rectal tube in place and after it was removed he had a
large amount of stool and gas. His abdominal exam continued to
improve and his diet was advanced. He was tolerating a full diet
by discharge. He was given prescriptions for colace, senna, and
dulcolax with instructions to contact his doctor or the [**Name (NI) **] if he
does not have a BM in [**1-26**] with these medications.

He began his cyberknife and radiation therapy treatments to his
brain and spine while in house. He had received [**2-26**] of his
cyberknife treatments prior to discharge. He will return next
week to continue these treatments. He will follow up with his
primary oncologist, his neuro-oncologist and his spinal surgeon.


Medications on Admission:
decadron
dilantin
ranitidine

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day).

6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
Disp:*60 Tablet(s)* Refills:*2*
7. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H () as needed
for pain.
Disp:*20 Tablet(s)* Refills:*0*
9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
10. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1)  Subcutaneous
Q12H (every 12 hours).
Disp:*14 Syringes* Refills:*0*
11. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for nausea.
Disp:*20 Tablet(s)* Refills:*0*
12. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a
day for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
14. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
Disp:*60 Tablet(s)* Refills:*0*
15. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
Disp:*60 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Metastatic renal cell carcinoma to T5
ileus
anemia


Discharge Condition:
neurologically stable, all vital signs stable.


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES
?????? Do not smoke
?????? Keep wound clean / No tub baths or pools until seen in follow
up/take daily showers
?????? No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
?????? Limit your use of stairs to 2-3 times per day
?????? Have a family member check your incision daily for signs of
infection
?????? You are required to wear a back brace whenever out of bed.
?????? You may shower briefly without the back brace unless
instructed otherwise
?????? Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
??????  Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. for 3 months.
??????  Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

?????? Pain that is continually increasing or not relieved by pain
medicine
?????? Any weakness, numbness, tingling in your extremities
?????? Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
?????? Fever greater than or equal to 101?????? F
?????? Any change in your bowel or bladder habits

You were also found to have a blood clot in your left leg. You
were started on a blood thinning medication called Lovenox
(enoxaparin) that you will continue for 3 months.

You were also found have an infection in your bladder. This was
treated with antibiotics called ciprofloxacin which you will
continue at home.

You have had difficulties having bowel movements. We will give
you prescriptions for medications to help you have bowel
movements, including suppositories. If you have not had a bowel
movement in 2 days, even after taking your medications, you
should call your doctor or return to the emergency room. If you
have worsening abdominal pain, you should return to the
emergency room

Please take all your medications as prescribed.

Please attend all of your follow up appointment

Followup Instructions:
You will need to return to [**Hospital Ward Name 332**] Building basement this Friday
at 1pm to begin your radiation treatment. They will tell you the
schedule for further treatments.

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED XRAYS PRIOR TO YOUR APPOINMENT

You have an appointment with Dr, [**Name6 (MD) 5005**] [**Last Name (NamePattern4) 5342**], MD
Phone:[**Telephone/Fax (1) 44**] on [**2138-6-16**] at 4:00pm.

You have an appointment with Dr. [**Last Name (STitle) **] on [**6-16**] at 3pm
in the [**Hospital Ward Name 23**] building. ([**Telephone/Fax (1) 16668**]

Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2138-7-14**]
9:15
{'Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Other specified intestinal obstruction,Bacteremia,Personal history of malignant neoplasm of renal pelvis,Urinary tract infection, site not specified,Disruption of external operation (surgical) wound,Peripheral vascular complications, not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension'}


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: renal cell carcinoma

PRESENT ILLNESS: This 58-year-old gentleman has a history of renal cell
carcinoma.  He experienced cerebral metastasis and a T5
metastasis with significant spinal cord compression and
resultant instability of the thoracic spine.

MEDICAL HISTORY: renal cell carcinoma s/p L nephrectomy in [**2129**], no xrt/chemo

MEDICATION ON ADMISSION: decadron
dilantin
ranitidine

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: NAD, WDWN
Ht: RRR, nl S1,S2
Lungs: CTA
Abd: soft, nt
ext: no cce
neuro: aox3
motor full
sensation intact
dtr 2+

FAMILY HISTORY: negative for past malignancies

SOCIAL HISTORY: lives with his daughter. Infrequent EtOH use. Quit smoking
25yrs ago. No IVDU 

### Response:
{'Secondary malignant neoplasm of bone and bone marrow,Myelopathy in other diseases classified elsewhere,Acute venous embolism and thrombosis of deep vessels of proximal lower extremity,Other specified intestinal obstruction,Bacteremia,Personal history of malignant neoplasm of renal pelvis,Urinary tract infection, site not specified,Disruption of external operation (surgical) wound,Peripheral vascular complications, not elsewhere classified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension'}
