CHIEF COMPLAINT: right lower extremity weakness and hypotension

PRESENT ILLNESS: 75yo female with a history of spinal stenosis s/p left
hemilaminectomy spinal surgery (L4-S1) on [**2118-8-22**] with a
post-operative course complicated by PE initially presented for
further evaluation of worsening right lower extremity numbness
and pain. While in the ED, patient developed hypotension and
syncope syncope and was transferred to MICU for further work-up
of hypotension.
.
Patient has a history of L4-S1 spinal stenosis and underwent a
left hemilanectomy on [**2118-8-22**] with significant improvement in
left lower extremity strength and pain; however she has had
persistent back pain. Then one day prior to admission she
noticed the sudden onset of [**9-7**] back pain that radiated to her
right thigh and foot with associated difficulty walking. She
initially presented to [**Hospital6 33**] for further
evaluation with vital signs of temp 99.3, HR 68, BP 115/57, RR
18, and pulse ox 99% on room air. She was transferred to [**Hospital1 18**]
for further MRI evaluation as MRI could not be performed at
[**Hospital6 33**]. She received ativan 1mg PO x 1 and
morphine 2mg x 1.
.
Upon arrival to [**Hospital1 18**] ED temp 99.2, HR 87, BP 85/50, RR 14, and
98% pulse ox. An MRI was performed which demonstrated residual
L5-S1 stenosis. Neurosurgery evaluated the patient and thought
her pain and numbness were likely secondary to residual canal
stenosis and she would benefit from a right hemilanectomy. While
in the ED, BP decreased to 68/26 and she had an episode of
syncope upon standing. She received 3L NS and zofran 4mg IV x 2
and toradol 15mg IV x 1. She reports that her blood pressure is
typically 90/70.

MEDICAL HISTORY: Spinal Stenosis - s/p left hemilaminectomy spinal surgery
(L4-S1) on [**2118-8-22**]
Pulmonary embolus - during post-operative course
Gallstones
Glaucoma
Hypothyroidism

MEDICATION ON ADMISSION: Coumadin 5mg PO qhs
Xalatan drops ou
Levothyroxine 100mcg PO daily
Oxycodone 5mg PO q4-6h prn
Valium
Colace
Senna

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: T 97.9 / BP 103/49 / HR 64 / RR 18 / Pulse ox 100% 2L NC / Wt
73.9 kg
Gen: pleasant, speaking comfortably in full sentences, no acute
distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. trace patellar reflexes
bilateral and symmetric. Babinski sign absent bilaterally. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Home: caregiver for husband with COPD and sister with [**Name (NI) 11964**]
Intervertebral disc disorder with myelopathy, lumbar region,Iatrogenic pulmonary embolism and infarction,Other specified hypotension,Unspecified acquired hypothyroidism,Unspecified glaucoma,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure
Lumb disc dis w myelopat,Iatrogen pulm emb/infarc,Hypotension NEC,Hypothyroidism NOS,Glaucoma NOS,Long-term use anticoagul,Abn react-procedure NEC
Admission Date:  [**2118-9-7**]              Discharge Date:   [**2118-9-10**]

Date of Birth:  [**2043-6-22**]             Sex:   F

Service: MEDICINE

Allergies:
Sulfa (Sulfonamides)

Attending:[**First Name3 (LF) 1973**]
Chief Complaint:
right lower extremity weakness and hypotension

Major Surgical or Invasive Procedure:
none

History of Present Illness:
75yo female with a history of spinal stenosis s/p left
hemilaminectomy spinal surgery (L4-S1) on [**2118-8-22**] with a
post-operative course complicated by PE initially presented for
further evaluation of worsening right lower extremity numbness
and pain. While in the ED, patient developed hypotension and
syncope syncope and was transferred to MICU for further work-up
of hypotension.
.
Patient has a history of L4-S1 spinal stenosis and underwent a
left hemilanectomy on [**2118-8-22**] with significant improvement in
left lower extremity strength and pain; however she has had
persistent back pain. Then one day prior to admission she
noticed the sudden onset of [**9-7**] back pain that radiated to her
right thigh and foot with associated difficulty walking. She
initially presented to [**Hospital6 33**] for further
evaluation with vital signs of temp 99.3, HR 68, BP 115/57, RR
18, and pulse ox 99% on room air. She was transferred to [**Hospital1 18**]
for further MRI evaluation as MRI could not be performed at
[**Hospital6 33**]. She received ativan 1mg PO x 1 and
morphine 2mg x 1.
.
Upon arrival to [**Hospital1 18**] ED temp 99.2, HR 87, BP 85/50, RR 14, and
98% pulse ox. An MRI was performed which demonstrated residual
L5-S1 stenosis. Neurosurgery evaluated the patient and thought
her pain and numbness were likely secondary to residual canal
stenosis and she would benefit from a right hemilanectomy. While
in the ED, BP decreased to 68/26 and she had an episode of
syncope upon standing. She received 3L NS and zofran 4mg IV x 2
and toradol 15mg IV x 1. She reports that her blood pressure is
typically 90/70.


Past Medical History:
Spinal Stenosis - s/p left hemilaminectomy spinal surgery
(L4-S1) on [**2118-8-22**]
Pulmonary embolus - during post-operative course
Gallstones
Glaucoma
Hypothyroidism


Social History:
Home: caregiver for husband with COPD and sister with [**Name (NI) 11964**]

Tobacco: quit 30 years ago
EtOH: drinks [**11-30**] glasses of wine/day
Drugs: Denies


Family History:
noncontributory

Physical Exam:
T 97.9 / BP 103/49 / HR 64 / RR 18 / Pulse ox 100% 2L NC / Wt
73.9 kg
Gen: pleasant, speaking comfortably in full sentences, no acute
distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. trace patellar reflexes
bilateral and symmetric. Babinski sign absent bilaterally. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant



Pertinent Results:
[**2118-9-7**] 09:16AM   LACTATE-1.2
[**2118-9-7**] 09:00AM   CK(CPK)-34
[**2118-9-7**] 09:00AM   cTropnT-<0.01
[**2118-9-7**] 09:00AM   CK-MB-NotDone
[**2118-9-7**] 09:00AM   HCT-34.5*
[**2118-9-7**] 01:35AM   GLUCOSE-101 UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-30 ANION GAP-11
[**2118-9-7**] 01:35AM   CK(CPK)-23*
[**2118-9-7**] 01:35AM   CK-MB-4 cTropnT-<0.01
[**2118-9-7**] 01:35AM   WBC-8.2 RBC-3.76* HGB-12.3 HCT-35.7* MCV-95
MCH-32.7* MCHC-34.4 RDW-13.6
[**2118-9-7**] 01:35AM   PT-23.4* PTT-48.4* INR(PT)-2.3*
------------------
[**2118-9-7**] - CXR - Findings at the left CP angle, which could
represent small pulmonary infarct with effusion in this patient
with apparently known pulmonary embolism.
--------------------
[**2118-9-7**] - MR L spine - CONCLUSION: Apparent residual stenosis
at the L4-5 operative site with cauda equina compression is seen
at this locale. There is extensive residual degenerative disease
of multiple lumbar intervertebral discs. Superimposed infection,
as also stated in the preliminary [**Location (un) 1131**] of Dr. [**Last Name (STitle) **], cannot
be excluded radiographically.

ADDENDUM: Also noted is moderately prominent degenerative
disease of the L4-5 and L5-S1 facet joint complexes.
[**2118-9-7**] - ECG - Sinus rhythm. First degree atrio-ventricular
conduction delay. Otherwise,
no significant abnormalities. No previous tracing available for
comparison.
[**2118-9-9**] - Echo - Normal global and regional biventricular
systolic function. No pulmonary hypertension seen.


Brief Hospital Course:
75 yo female with past medical history of spinal stenosis s/p
left hemilaminectomy was admitted for evaluation of hypotension
with an episode of syncope in the setting of recurrent back and
right lower extremity pain.  Hospital course by problem below:
.
1. Hypotension
The patient was hypotensive in the ED with an episode of syncope
and she was admitted to the MICU initially for closer
monitoring.  Differential diagnosis included decreased PO intake
and medication effects in the setting of increased narcotics.
Sepsis was thought much less likely given lack of
fever/leukocytosis and quick resolution of blood pressure with
IVF. Echo and [**Last Name (un) 104**] stim test were both unremarkable.  While in
the MICU her SBP ranged from 70-90s, compared to her baseline
SBP 90.  She was fluid resuscitated with improvement in her
blood pressure.  Her pain regimen was modified from prn
narcotics to scheduled tylenol with prn NSAIDs.  Her blood
pressure improved with these interventions and she was then
transferred to the floor.  On the floor her blood pressure was
stable.  She was advised to take only 5 mg of oxycodone every 5
hours.
.
2. Right Lower extremity weakness
The patient's right lower extremity and back pain was thought
most likely to be secondary to residual spinal stenosis.   She
was evaluated by neurosurgery and they recommended right
hemi-laminectomy once her acute medical issues have resolved.
Neurosurgery evaluated her MRI and thought changes were most
consistent post-surgical change.  Her pain improved
significantly shortly after admission with minimal medications
as above.  Physical therapy assessed her and recommended home
physical therapy.  She was advised to call Neurosurgery within
the next 2 weeks to discuss surgery.
.
3. Hypothyroidism
Stable.  The patient continued levothyroxine 100mcg daily per
home regimen.
.
4. Pulmonary Embolus
She patient was recently diagnosed with PE on [**2118-8-30**] in the
post-operative course of recent neurosurgical procedure.  Upon
admission, she was switched from coumadin to lovenox in
preparation for possible procedures.  On discharge she was
subtherapeutic on coumadin and was discharged on lovenox as
bridging therapy.  VNA will perform INR recheck 2 days after
discharge.
.
5. Anemia
She was found to have a normocytic anemia on admission.  This
remained stable during her stay.  PCP [**Name9 (PRE) 702**] was recommended.


Medications on Admission:
Coumadin 5mg PO qhs
Xalatan drops ou
Levothyroxine 100mcg PO daily
Oxycodone 5mg PO q4-6h prn
Valium
Colace
Senna


Discharge Medications:
1. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
2. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
Disp:*30 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
5. Enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 ml Subcutaneous Q12H
(every 12 hours).
Disp:*12 syringes* Refills:*0*
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six
(6) hours as needed for pain.
7. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day.
10. Ibuprofen 200 mg Tablet Sig: Two (2) Tablet PO three times a
day for 1 weeks.
11. Outpatient Lab Work
Draw PTT (INR) on Monday, [**9-12**].  Fax results to Dr.
[**Last Name (STitle) 32467**] at ([**Telephone/Fax (1) 32468**].


Discharge Disposition:
Home With Service

Facility:
[**Location (un) 2203**] VNA

Discharge Diagnosis:
medication-induced hypotension
Spinal Stenosis
.
Pulmonary embolus
Anemia
Hypothyroidism

Discharge Condition:
stable, normotensive.  able to ambulate with pain control.

Discharge Instructions:
You were hospitalized for low blood pressure and right-sided
back pain.  You were seen by the surgeons, who feel that you
need a right-sided laminectomy in the future.

Please take all medications as directed.  Your pain medications
were decreased while here.  You will need to take Lovenox until
your INR is in the desired range.

Please seek immediate medical attention if you experience
dizziness, chest pain, shortness of breath, leg weakness or
numbness, or worsened back pain.

Followup Instructions:
You should follow-up with Dr. [**Last Name (STitle) 32467**] within the week.  You will
need to have blood tests done on Monday to check your INR.  Your
coumadin and Lovenox dosing may be adjusted accordingly.

Your blood count was low while in the hospital.  You should
discuss this with Dr. [**Last Name (STitle) 32467**].

Please call Dr. [**Last Name (STitle) **] at ([**Telephone/Fax (1) 88**] to arrange your back
surgery.
{'Intervertebral disc disorder with myelopathy, lumbar region,Iatrogenic pulmonary embolism and infarction,Other specified hypotension,Unspecified acquired hypothyroidism,Unspecified glaucoma,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}


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: right lower extremity weakness and hypotension

PRESENT ILLNESS: 75yo female with a history of spinal stenosis s/p left
hemilaminectomy spinal surgery (L4-S1) on [**2118-8-22**] with a
post-operative course complicated by PE initially presented for
further evaluation of worsening right lower extremity numbness
and pain. While in the ED, patient developed hypotension and
syncope syncope and was transferred to MICU for further work-up
of hypotension.
.
Patient has a history of L4-S1 spinal stenosis and underwent a
left hemilanectomy on [**2118-8-22**] with significant improvement in
left lower extremity strength and pain; however she has had
persistent back pain. Then one day prior to admission she
noticed the sudden onset of [**9-7**] back pain that radiated to her
right thigh and foot with associated difficulty walking. She
initially presented to [**Hospital6 33**] for further
evaluation with vital signs of temp 99.3, HR 68, BP 115/57, RR
18, and pulse ox 99% on room air. She was transferred to [**Hospital1 18**]
for further MRI evaluation as MRI could not be performed at
[**Hospital6 33**]. She received ativan 1mg PO x 1 and
morphine 2mg x 1.
.
Upon arrival to [**Hospital1 18**] ED temp 99.2, HR 87, BP 85/50, RR 14, and
98% pulse ox. An MRI was performed which demonstrated residual
L5-S1 stenosis. Neurosurgery evaluated the patient and thought
her pain and numbness were likely secondary to residual canal
stenosis and she would benefit from a right hemilanectomy. While
in the ED, BP decreased to 68/26 and she had an episode of
syncope upon standing. She received 3L NS and zofran 4mg IV x 2
and toradol 15mg IV x 1. She reports that her blood pressure is
typically 90/70.

MEDICAL HISTORY: Spinal Stenosis - s/p left hemilaminectomy spinal surgery
(L4-S1) on [**2118-8-22**]
Pulmonary embolus - during post-operative course
Gallstones
Glaucoma
Hypothyroidism

MEDICATION ON ADMISSION: Coumadin 5mg PO qhs
Xalatan drops ou
Levothyroxine 100mcg PO daily
Oxycodone 5mg PO q4-6h prn
Valium
Colace
Senna

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: T 97.9 / BP 103/49 / HR 64 / RR 18 / Pulse ox 100% 2L NC / Wt
73.9 kg
Gen: pleasant, speaking comfortably in full sentences, no acute
distress
HEENT: Clear OP, dry mucous membranes
NECK: Supple, No LAD, No JVD
CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops
LUNGS: CTA, BS BL, No W/R/C
ABD: Soft, NT, ND. NL BS. No HSM
EXT: No edema. 2+ DP pulses BL
SKIN: No lesions
NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation
throughout. 5/5 strength throughout. trace patellar reflexes
bilateral and symmetric. Babinski sign absent bilaterally. Gait
assessment deferred
PSYCH: Listens and responds to questions appropriately, pleasant

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Home: caregiver for husband with COPD and sister with [**Name (NI) 11964**] 

### Response:
{'Intervertebral disc disorder with myelopathy, lumbar region,Iatrogenic pulmonary embolism and infarction,Other specified hypotension,Unspecified acquired hypothyroidism,Unspecified glaucoma,Long-term (current) use of anticoagulants,Other specified procedures as the cause of abnormal reaction of patient, or of later complication, without mention of misadventure at time of procedure'}
