CHIEF COMPLAINT: abnormal gait and numbness on his b/l his lower extremities for
two days

PRESENT ILLNESS: A 65-year-old gentleman with a history of metastatic renal cell

MEDICAL HISTORY: Oncology history:
ONCOLOGIC HISTORY:
[**2-24**] : lower back pain and hematuria &#[**Numeric Identifier 25684**]; CT: 8-cm mass from
the upper pole of the right kidney and compressing the IVC.
[**5-27**]: right radical nephrectomy&#[**Numeric Identifier 25684**];RCC, grade [**1-23**],
clear-cell type with clean margins and no lymphatic invasion.
(stage T2N0M0)
[**9-26**] and [**12-28**]: CT scan:  4-cm right lower lobe nodule
suspicious for metastatic disease. Bronchoscopy and biopsy :
nondiagnostic.
[**1-28**]  PET : nodule was intensely FDG avid&#[**Numeric Identifier 25684**]; open
thoracotomy and wedge resection of  the lung nodule
surveillance CT scan in [**2-26**]: 2.6 x 1.5-cm right paratracheal
lymphadenopathy. Bronchoscopy and EBUS-guided biopsy: renal cell
carcinoma.
[**2125-4-26**]: VATS-assisted mediastinal lymph node dissection by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 2358**].
[**2125-11-30**] CT: progression of disease located in the mediastinum,
right hilum, and in the lung parenchyma bilaterally. A small
pericardial effusion was also noted on this report.
[**2125-12-21**]- [**2126-4-20**]:completed  IL2 therapy
[**2126-7-10**]: Torso CT: decrease in size of mediastinal and hilar
lymphadenopathy. Increase in size of right upper lobe pulmonary
nodule compared to prior.
[**1-/2127**]:new stable adrenal lesion, likely metastatic
[**8-/2127**]: Left laparoscopic adrenalectomy
[**10-31**] - present with back pain - thoracic spinal met, resection
at [**Hospital1 18**]

MEDICATION ON ADMISSION: Lipitor 10 mg Tab
1 Tablet(s) by mouth daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals - T:97 74 118/75 18 99% RA
GENERAL: NAD, lying comfortably on bed
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pale conjunctiva, patent
nares, MMM, nontender supple neck, no LAD, no JVD.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: he was able all extremities, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: 4/5 strength bilaterally throughout. Sensation intact and
symmetric throughout. EOMI. The reflex was hyperactive in the
b/l lower  extremities  . Loss of proprioception in BLE.
.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with his wife and 3 children in [**Location (un) 82229**], [**State 1727**]. His
children are 18, 20 and 21 years of age. He never smoked and
drank alcohol only occasionally.
Secondary malignant neoplasm of brain and spinal cord,Myelopathy in other diseases classified elsewhere,Spinal stenosis, thoracic region,Abnormality of gait,Anemia, unspecified,Other and unspecified hyperlipidemia,Other iatrogenic hypothyroidism,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Personal history of malignant neoplasm of kidney
Sec mal neo brain/spine,Myelopathy in oth dis,Spinal stenosis-thoracic,Abnormality of gait,Anemia NOS,Hyperlipidemia NEC/NOS,Iatrogen hypothyroid NEC,Adv eff antineoplastic,Hx of kidney malignancy
Admission Date:  [**2127-12-2**]              Discharge Date:   [**2127-12-10**]

Date of Birth:  [**2062-4-30**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
abnormal gait and numbness on his b/l his lower extremities for
two days

Major Surgical or Invasive Procedure:
1. Revision T2, T3, T4, T5, T6 bilateral laminectomy,
    medial facetectomy, foraminotomies for removal of
    intraspinal extradural mass, most likely renal cell
    carcinoma.
2. Removal of posterolateral instrumentation and re-
    instrumentation T2 to T7.
3. Primary T7 bilateral laminectomy, medial facetectomy and
    foraminotomy for removal of intraspinal extradural mass,
    most likely renal cell carcinoma.
4. Application of local autograft as well as allograft.


History of Present Illness:
A 65-year-old gentleman with a history of metastatic renal cell

carcinoma to spine presented with abnormal gait and numbness on
his lower extremities for two days.  Because of the metastasis
in the spine, the pt underwent T2-T6 bilateral laminectomy in
[**Month (only) **], he initially felt fine.  However, in the morning of
yesterday, he suddenly had difficulty in walking, which
progressively worse over the past 24 hours.  He denied weakness,
but he had numbness on his B/L lower extremities.  He denied
urine or fecal incontinence although he had constipation that he
attributed to pain medications.  He denied fever, chill, but he
still had back pain around his surgical site, which had not
gotten worse.

In the ED, Orthopedics did consult and recommended " NPO after
midnight, NO ANTICOAGULATION, consider IV dexamethasone. Needs
discussion between radiation vs. surgery in AM"

In an OSH [**Name (NI) **], pt had already received one dose of dexamethasone
at 10 mg.

Review of Systems:
(+) Per HPI.
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations, lower extremity edema. Denies cough,
shortness of breath, or wheezes. Denies nausea, vomiting,
diarrhea,  abdominal pain, melena, hematemesis, hematochezia.
Denies dysuria, stool or urine incontinence. Denies arthralgias
or myalgias. Denies rashes or skin breakdown. All other systems
negative.


Past Medical History:
Oncology history:
ONCOLOGIC HISTORY:
[**2-24**] : lower back pain and hematuria &#[**Numeric Identifier 25684**]; CT: 8-cm mass from
the upper pole of the right kidney and compressing the IVC.
[**5-27**]: right radical nephrectomy&#[**Numeric Identifier 25684**];RCC, grade [**1-23**],
clear-cell type with clean margins and no lymphatic invasion.
(stage T2N0M0)
[**9-26**] and [**12-28**]: CT scan:  4-cm right lower lobe nodule
suspicious for metastatic disease. Bronchoscopy and biopsy :
nondiagnostic.
[**1-28**]  PET : nodule was intensely FDG avid&#[**Numeric Identifier 25684**]; open
thoracotomy and wedge resection of  the lung nodule
surveillance CT scan in [**2-26**]: 2.6 x 1.5-cm right paratracheal
lymphadenopathy. Bronchoscopy and EBUS-guided biopsy: renal cell
carcinoma.
[**2125-4-26**]: VATS-assisted mediastinal lymph node dissection by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 2358**].
[**2125-11-30**] CT: progression of disease located in the mediastinum,
right hilum, and in the lung parenchyma bilaterally. A small
pericardial effusion was also noted on this report.
[**2125-12-21**]- [**2126-4-20**]:completed  IL2 therapy
[**2126-7-10**]: Torso CT: decrease in size of mediastinal and hilar
lymphadenopathy. Increase in size of right upper lobe pulmonary
nodule compared to prior.
[**1-/2127**]:new stable adrenal lesion, likely metastatic
[**8-/2127**]: Left laparoscopic adrenalectomy
[**10-31**] - present with back pain - thoracic spinal met, resection
at [**Hospital1 18**]

Other PMH:
Hyperlipidemia
Recent hypothyroid after IL2

PSH;
T3 to T5 laminectomy and posterior fusion from T2 to T7 on
[**2127-10-18**]
Left laparoscopic adrenalectomy on [**2127-9-2**]


Social History:
Lives with his wife and 3 children in [**Location (un) 82229**], [**State 1727**]. His
children are 18, 20 and 21 years of age. He never smoked and
drank alcohol only occasionally.


Family History:
non-contributory

Physical Exam:
Vitals - T:97 74 118/75 18 99% RA
GENERAL: NAD, lying comfortably on bed
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pale conjunctiva, patent
nares, MMM, nontender supple neck, no LAD, no JVD.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: he was able all extremities, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: 4/5 strength bilaterally throughout. Sensation intact and
symmetric throughout. EOMI. The reflex was hyperactive in the
b/l lower  extremities  . Loss of proprioception in BLE.
.


Pertinent Results:
[**2127-12-2**] 04:33PM   LACTATE-1.4
[**2127-12-2**] 04:20PM   GLUCOSE-134* UREA N-22* CREAT-1.0 SODIUM-134
POTASSIUM-4.7 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
[**2127-12-2**] 04:20PM   WBC-7.8 RBC-4.67 HGB-12.6* HCT-39.1* MCV-84
MCH-27.0 MCHC-32.3 RDW-13.3
[**2127-12-2**] 04:20PM   NEUTS-94.1* LYMPHS-4.9* MONOS-0.5* EOS-0.3
BASOS-0.1
[**2127-12-2**] 04:20PM   PLT COUNT-318

MRI of the spine:
T2-T7 posterior fusion with postop artifact in spinal canal
which obscures
evaluation.
Within surgical bed, there is heterogeneous appearnce within
spinal canal
which may represent susceptilibity +/- residual/recurrent tumor
or
postsurgical fibrosis.
Canal and foramina patent in lower T- and L/S-spine. Cord has
normal signal at these levels.

Brief Hospital Course:
Patient was transferred from OMED 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 PACU in a stable condition.  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.  Foley was removed on POD#2.  Physical
therapy was consulted for mobilization OOB to ambulate with
support.  Hospital course was otherwise unremarkable.  On the
day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet. Patient will require rehabilitation considering his
neurological status. He will also need adjuvant therapy for
control of local recurrence in the future.

Medications on Admission:
Lipitor 10 mg Tab
1 Tablet(s) by mouth daily

 Sutent 50 mg Cap
1 Capsule(s) by mouth once per day for 28 days, then 14 days off

 fludrocortisone 0.1 mg Tab
1 tablet by mouth daily

 prednisone 2.5 mg Tab
3 tablets by mouth daily and increase if sick or surgery

 oxycodone-acetaminophen 5 mg-325 mg Tab
[**12-22**] Tablet(s) by mouth every four (4) hours as needed for pain

 levothyroxine 75 mcg Tab
1 Tablet(s) by mouth daily



Discharge Medications:
1. fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for fever or pain.
5. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. prednisone 2.5 mg Tablet Sig: Three (3) Tablet PO once a day.
Disp:*90 Tablet(s)* Refills:*2*
10. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed
for indigestion.
11. Heparin 5000sc tid

Discharge Disposition:
Extended Care

Facility:
[**Hospital3 12564**] hospital

Discharge Diagnosis:
1. Recurrent intraspinal extradural tumor, most likely
    renal cell carcinoma, T2 to C7.
2. Thoracic stenosis.
3. Recurrent thoracic myelopathy.


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
Immediately after the operation:

-        Activity: As tolerated

-        Rehabilitation/ Physical Therapy:
 You can walk as much as you can tolerate. 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.

-        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 and 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:
see discharge instructions. Activity as tolerated. No
restrictions except for bending forward, and lifting.
Treatments Frequency:
see discharge instructions

Followup Instructions:
You follow up visit at the spine center is scheduled for the [**2127-12-23**] at 1 pm with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please call Spine center
to confirm appointment.

Also please schedule an appointment with Dr [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] for
radiation in the first week of [**Month (only) 404**] (after the Spine center
appointment on 3rd). Dr[**Name (NI) 82230**] office number is [**Numeric Identifier 82231**]

Please schedule an appointment with Dr [**Last Name (STitle) **] 4 weeks from
the day of the surgery for systemic therapy.
{'Secondary malignant neoplasm of brain and spinal cord,Myelopathy in other diseases classified elsewhere,Spinal stenosis, thoracic region,Abnormality of gait,Anemia, unspecified,Other and unspecified hyperlipidemia,Other iatrogenic hypothyroidism,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Personal history of malignant neoplasm of kidney'}


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: abnormal gait and numbness on his b/l his lower extremities for
two days

PRESENT ILLNESS: A 65-year-old gentleman with a history of metastatic renal cell

MEDICAL HISTORY: Oncology history:
ONCOLOGIC HISTORY:
[**2-24**] : lower back pain and hematuria &#[**Numeric Identifier 25684**]; CT: 8-cm mass from
the upper pole of the right kidney and compressing the IVC.
[**5-27**]: right radical nephrectomy&#[**Numeric Identifier 25684**];RCC, grade [**1-23**],
clear-cell type with clean margins and no lymphatic invasion.
(stage T2N0M0)
[**9-26**] and [**12-28**]: CT scan:  4-cm right lower lobe nodule
suspicious for metastatic disease. Bronchoscopy and biopsy :
nondiagnostic.
[**1-28**]  PET : nodule was intensely FDG avid&#[**Numeric Identifier 25684**]; open
thoracotomy and wedge resection of  the lung nodule
surveillance CT scan in [**2-26**]: 2.6 x 1.5-cm right paratracheal
lymphadenopathy. Bronchoscopy and EBUS-guided biopsy: renal cell
carcinoma.
[**2125-4-26**]: VATS-assisted mediastinal lymph node dissection by Dr.
[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital3 2358**].
[**2125-11-30**] CT: progression of disease located in the mediastinum,
right hilum, and in the lung parenchyma bilaterally. A small
pericardial effusion was also noted on this report.
[**2125-12-21**]- [**2126-4-20**]:completed  IL2 therapy
[**2126-7-10**]: Torso CT: decrease in size of mediastinal and hilar
lymphadenopathy. Increase in size of right upper lobe pulmonary
nodule compared to prior.
[**1-/2127**]:new stable adrenal lesion, likely metastatic
[**8-/2127**]: Left laparoscopic adrenalectomy
[**10-31**] - present with back pain - thoracic spinal met, resection
at [**Hospital1 18**]

MEDICATION ON ADMISSION: Lipitor 10 mg Tab
1 Tablet(s) by mouth daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Vitals - T:97 74 118/75 18 99% RA
GENERAL: NAD, lying comfortably on bed
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, anicteric sclera, pale conjunctiva, patent
nares, MMM, nontender supple neck, no LAD, no JVD.
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: he was able all extremities, no cyanosis, clubbing or
edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: 4/5 strength bilaterally throughout. Sensation intact and
symmetric throughout. EOMI. The reflex was hyperactive in the
b/l lower  extremities  . Loss of proprioception in BLE.
.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives with his wife and 3 children in [**Location (un) 82229**], [**State 1727**]. His
children are 18, 20 and 21 years of age. He never smoked and
drank alcohol only occasionally. 

### Response:
{'Secondary malignant neoplasm of brain and spinal cord,Myelopathy in other diseases classified elsewhere,Spinal stenosis, thoracic region,Abnormality of gait,Anemia, unspecified,Other and unspecified hyperlipidemia,Other iatrogenic hypothyroidism,Antineoplastic and immunosuppressive drugs causing adverse effects in therapeutic use,Personal history of malignant neoplasm of kidney'}
