Consider the following medical report that includes the patient's historical health records. Use it to predict the disease that the patient is high likely exposed to. 

 Medical Report: allergies: patient recorded as having no known allergies to drugs attending: addendum: allergies patient recorded as having no known allergies to drugs attending , m.f. service medicine chief complaint back pain major surgical or invasive procedure t12 transpedicular decompression and posterior instrumented fusion t10 to l2 history of present illness 47 yo male with renal cell cancer with intrahepatic and paraspinal metastasis treated with stereotactic body radiotherapy, completed on , who is admitted for pain control. he was doing well after completion of radiotherapy but within a few weeks developed severe left leg pain as well as muscular spasms and areas of numbness. since this weekend, he has developed severe left leg and back pain. however, he denied fecal or urinary incontinence and focalized weakness. because of the pain, on , pt was admitted to local hospital where he received pain medications and mri under anesthesia because of inability to lie flat. the mri revealed " a large mass over the right renal fossa extending to the paraspinal muscle and also there was a tumor involving the thoracic 11 and thoracic 12 vertebral body extending into the spinal canal, cord compression, and also a tumor involving the paraspinous muscle. possible metastatic lesion of cervical 2 vertebral body with possible cord compression. after discussing with his own in , he was transferred to here for further management. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies chest pain or tightness, palpitations. denies cough, shortness of breath, or wheezes. denies nausea, vomiting, diarrhea, constipation. he admitted right side abd pain. no recent change in bowel or bladder habits. no dysuria. denies arthralgias or myalgias. denies rashes or skin breakdown. no numbness/tingling in extremities. no feelings of depression or anxiety. all other review of systems negative. past medical history oncologic history: 1. partial right nephrectomy in after the patient presented with hematuria and flank pain to hospital and was found on ct scan to have a 5.1 x 5.8 right renal mass. 2. resection of recurrent renal cell carcinoma in the right subcostal region and rib in 11/. the pathology of the resected tumor was consistent with the previously resected clear cell primary. 3. posterior cervical fusion, occiput to c5 and left-sided c2 laminectomy and decompression in because of the finding on mri of a 2.5 x 3.2 cm destructive soft tissue mass. this mass had replaced the left side of the c2 vertebral body and extended into the pedicle and neural foramen on the left at the c2-c3 level. 4. postoperative radiation therapy to the cervical spine. 5. one cycle of il-2 as part of the il-2 select trial in 08/. 6. hospitalization in for hypercalcemia. 7. enrolled in sorafenib/bevacizumab phase ii trial on - discontinued as of with development of colonic perforation. 8. readmitted to with contrast nephropathy. status post diverting ileostomy on . 9. begin sutent 37.5 mg on . stopped sutent on (tired of taking it). 10. consideration for the rad-001 biomarker trial. the patient, however, had a nondiagnostic tumor biopsy, and was therefore ineligible. 11. resection of right retroperitoneal tumor, right colectomy, partial liver resection, and ileal transverse colostomy anastomosis on for recurrent renal cell carcinoma in previous right nephrectomy bed with involvement of the liver, right colon and right psoas muscle. 12. started pki-587 (pi3k/mtor inhibitor) on protocol 09-215 13. taken off protocol 09-215 because of disease progression including t11-t12 paraspinal lesion invading spinal canal 14. last zometa 15. srs to right infrahepatic metastasis; srs to paraspinal metastasis past medical history: - renal cell carcinoma (please see below) - h/o rle dvt - colonic perforation - hyponatremia - anemia - cervical surgery with rod-placement due to c2 met - right colectomy, segment vi partial liver resection, resection of retroperitoneal tumor mass; ileal transverse colostomy anastomosis (side to side). social history married. quit drinking alcohol. tobacco and illicit drug use. not currently emplyed, but worked as an electrician. 2 healthy children. family history mother died of a brain tumor. father diagnosed with prostate cancer in his 70s and is still living. he has 3 siblings and 2 children without medical concerns. maternal aunt with lymphoma. father and sister have had h/o "blood clots." physical exam vs: t 98, bp 120/80, p 91, r 18, sao2 98 @ ra gen: aox3, nad heent: perrla. mmm. no lad. no jvd. neck supple. cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: no dullness to percussion, ctab no crackles or wheezes abd: soft, tender in his right flank and ruq area, +bs. no rebound/guarding. neg hsm. neg sign. extremities: wwp, no edema. dps, pts 2+. skin: no rashes or bruising neuro/psych: cns ii-xii intact. 5/5 strength in u/l extremities. dtrs 2+ bl. sensation intact to lt, cerebellar fxn intact (ftn, hts). gait wnl. upon discharge: t 97.8 120/70 75 16 96ra gen: nad, heent: sclera anicteric. no oral lesions. cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: ctab abd: soft, nt, +bs. no rebound/guarding. extremities: no edema neuro: a&ox3, 5/5 strength in lower extremities back: clean dressing in place, staples, non erythematous pertinent results ct of abd () 1. the paraspinal mass which originates at the lytic lesion of right 12th rib, invades into the spinal canal, is more prominent as compared to the prior studies. spinal cord compression at the level of d12, d11, and d10, mostly from the right side but crossing anteriorly to the left at the level of d11. findings are consistent with spinal cord compression and can be further evaluated by mri. 2. the overall size of the paraspinal lesion is mildly increased, as compared to the prior study. 3. the mass in the right lateral posterior abdominal wall adjacent to the liver now demonstrates small amount of air in it with possible tract into adjacent small bowel loop, suggesting a fistula. 4. increase in size and number of numerous bilateral pulmonary metastases and one of them in the right middle lobe with a cavitation. 5. new small right pleural effusion. ct l spine : impression: 1. extensive fluid surrounding the surgical bed, without definite organization or rim to suggest abscess formation. 2. large, peripherally enhancing fluid collection centered in the right paraspinal location near the level of the liver. this is concerning for a paraspinal abscess. however, given the presence of a lesion near this location on a previous mri, it is unclear if there is also a component of necrotic neoplastic disease. correlation to prior studies, if available, would be helpful. 3. small, rim-enhancing collection in the left paraspinal musculature on the left, also concerning for a paraspinal abscess. 4. numerous pulmonary nodules, the largest of which are described above. . 06:45am blood wbc-10.6 rbc-3.03* hgb-8.5* hct-26.7* mcv-88 mch-28.1 mchc-32.0 rdw-16.7* plt ct-388 05:15am blood wbc-5.8 rbc-4.08* hgb-10.5* hct-33.4* mcv-82 mch-25.7* mchc-31.3 rdw-15.2 plt ct-281 06:45am blood neuts-87.5* lymphs-6.0* monos-4.7 eos-1.6 baso-0.3 05:15am blood neuts-74.7* lymphs-12.5* monos-9.6 eos-2.8 baso-0.2 03:50am blood pt-14.1* ptt-25.5 inr(pt)-1.2* 05:15am blood pt-13.0 ptt-25.2 inr(pt)-1.1 06:10am blood glucose-100 urean-10 creat-0.9 na-143 k-5.7* cl-103 hco3-32 angap-14 05:15am blood glucose-89 urean-10 creat-1.0 na-136 k-4.8 cl-101 hco3-31 angap-9 01:03am blood alt-10 ast-14 alkphos-94 amylase-27 totbili-0.3 05:15am blood alt-16 ast-19 alkphos-109 totbili-0.3 06:10am blood calcium-9.6 phos-4.3 mg-2.2 05:15am blood albumin-3.5 calcium-9.7 phos-3.5 mg-2.2 brief hospital course 47 yo male with renal cell cancer with intrahepatic and paraspinal metastasis treated with stereotactic body radiotherapy, completed on , admitted for pain control s/p t10-l2 fusion and removal of 12th vertebrae. . #back/leg pain secondary to known spinal mets and cord compression seen on imaging without neurological deficits: radiation oncology and neurosurgery were consulted and decided that a surgical approach was best for his management. pain was controlled prior to surgery with fentanyl patch 400 mcg/hr, hydromorphone 1-3 mg every 2-3 hrs iv prn, and gabapentin 300 mg q8. patient underwent surgical decompression on -> he underwent t12 transpedicular decompression and posterior fusion t10 to l2 under general anesthesia. had 1500cc ebl. during procedure he was transfused with 2 units of prbc and his pod#1 hematocrit was 32. went to sicu post op and remained intubated overnight as he required nasal intubation. he was extubated pod#1 without difficulty. given his long history of chronic pain, the pain managment team was consulted and recommended a ketamine drip for pain control and dilaudid iv as needed. they continued to follow him post operatively and his ketamine drip was dc'd on pod#4. his jp drain drain was dc'd on pod#4 without difficulties. his hct continued to trend down and on he received 2 units of prbc's for a hct of 21.7. his hematocrits remained stable for the rest of his hospital course. he was transferred to the floor in stable condition although he suffered back pain and intense headache. the pain team continued to follow him on the floor and his pain regimen was optimized. the iv dilaudid was changed to po dilaudid and slowly decreased as tolerated. he was started on methadone 5 mg which was decreased to 2.5 mg . he was given iv caffeine and benadryl for his headache with minimal improvement. indomethacin 25 mg tid in combination with the methadone seemed to help his headache tremendously and he denied headache on day of discharge. he will be discharged on fentanyl patch 400 mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid, tylenol 1000mg tid, methadone 2.5 mg , and prn dilaudid mg po as needed for breakthrough pain. he should f/u with his pcp, , and neurosurgery, and his pain regimen should be adjusted and decreased as tolerated. of note, a ct l-spine was read as concerning for possible paraspinal abscess. this was not clinically correlated as the patient was afebrile without leukocytosis. the neurosurgery team reviewed the ct films and reported that the changes seen were most consistent with post-op surgical changes rather than infection. he will be seen as an outpatient by neurosurgery to follow-up. . #asymptomatic elevated tsh: elevated at 5.5. no symptoms. be elevated due to general illness/hospital stay. will not pursue further workup at this time. consider outpatient work-up after discharge. medications on admission transfer meds: duragesic patch 400mcg q3 days lidoderm patch for 12 hours ativan 1mg daily miralax 17g daily dilaudid 2-3 mg q 2hours prn flexeril 5mg tid ativan 1mg qhs zofran 2mg iv q 6hours prn home meds: ativan prn fentanyl for pain discharge medications 1. lorazepam 1 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 2. acetaminophen 650 mg/20.3 ml solution sig: 1000 (1000) mg po tid (3 times a day) as needed for fever or pain: please do not exceed 4 g in 24 hours. disp:*60 solution* refills:*2* 3. gabapentin 250 mg/5 ml solution sig: three hundred (300) mg po q8h (every 8 hours). disp:*100 ml* refills:*2* 4. indomethacin 25 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 5. fentanyl 100 mcg/hr patch 72 hr sig: four (4) patch 72 hr transdermal q72h (every 72 hours): please do not combine with alcohol or drive while taking this medication. disp:*40 patch 72 hr(s)* refills:*2* 6. hydromorphone 4 mg tablet sig: 1-4 tablets po q3h (every 3 hours) as needed for pain: please do not combine with alcohol or drive while taking this medication. disp:*30 tablet(s)* refills:*2* 7. methadone 5 mg tablet sig: 0.5 tablet po bid (2 times a day): please do not combine with alcohol or drive while taking this medication. disp:*30 tablet(s)* refills:*2* discharge disposition home with service discharge diagnosis t 12 spinal metastasis epidural spinal cord compression seen on imaging with no neurological deficits metastatic renal cell carcinoma, mets to spine, liver, and with pulmonary nodules back/leg pain elevated tsh, asymptomatic discharge condition mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions dear mr. , it was a pleasure participating in your health care. you were admitted to for pain control. your pain was managed with a fentanyl patch, intravenous dilaudid, and gabapentin prior to your operation. after surgery, your pain was controlled with a fentanyl patch, oral dilaudid, gabapentin, indomethacin, tylenol, and methadone. please make the following changes to your medications: stop flexeril 5mg three times daily start fentanyl patch 400 mcg/hr every 72 hours start gabapentin 300 mg every 8 hours start indomethacin 25 mg three times a day start methadone 2.5 m twice a day start hydromorphone (dilaudid) 4-8 mg every 3 hours as needed for uncontrolled pain. start acetaminophen (tylenol) 1000 mg three times a day please work with your physician to reduce the amount of pain medications that you are taking as your pain improves. please continue your other home medications. in addition, please follow the instructions below: ?????? do not smoke ?????? keep wound clean / no tub baths or pools until seen in follow up/ begin 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 ?????? take pain medication as instructed above; ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? clearance to drive and return to work will be addressed at your post-operative office visit followup instructions the following appointments have been made for you: department: hematology/oncology when: wednesday at 4:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: wednesday at 4:00 pm with: , md building: sc clinical ctr campus: east best parking: garage * please return to dr office in days for removal of your staples/suture(clinic days tues or fri). please call to schedule an appointment. * please call to schedule an appointment with dr. to be seen in 6 weeks.you will need xrays prior to this appointment * please arrange an appointment with your primary care physician ,md for 2-3 weeks after discharge. please call to arrange an appointment. chief complaint: back pain major surgical or invasive procedure: t12 transpedicular decompression and posterior instrumented fusion t10 to l2 history of present illness: 47 yo male with renal cell cancer with intrahepatic and paraspinal metastasis treated with stereotactic body radiotherapy, completed on , who is admitted for pain control. he was doing well after completion of radiotherapy but within a few weeks developed severe left leg pain as well as muscular spasms and areas of numbness. since this weekend, he has developed severe left leg and back pain. however, he denied fecal or urinary incontinence and focalized weakness. because of the pain, on , pt was admitted to local hospital where he received pain medications and mri under anesthesia because of inability to lie flat. the mri revealed " a large mass over the right renal fossa extending to the paraspinal muscle and also there was a tumor involving the thoracic 11 and thoracic 12 vertebral body extending into the spinal canal, cord compression, and also a tumor involving the paraspinous muscle. possible metastatic lesion of cervical 2 vertebral body with possible cord compression. after discussing with his own in , he was transferred to here for further management. . review of systems: (+) per hpi (-) denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. denies chest pain or tightness, palpitations. denies cough, shortness of breath, or wheezes. denies nausea, vomiting, diarrhea, constipation. he admitted right side abd pain. no recent change in bowel or bladder habits. no dysuria. denies arthralgias or myalgias. denies rashes or skin breakdown. no numbness/tingling in extremities. no feelings of depression or anxiety. all other review of systems negative. past medical history: oncologic history: 1. partial right nephrectomy in after the patient presented with hematuria and flank pain to and was found on ct scan to have a 5.1 x 5.8 right renal mass. 2. resection of recurrent renal cell carcinoma in the right subcostal region and rib in 11/. the pathology of the resected tumor was consistent with the previously resected clear cell primary. 3. posterior cervical fusion, occiput to c5 and left-sided c2 laminectomy and decompression in because of the finding on mri of a 2.5 x 3.2 cm destructive soft tissue mass. this mass had replaced the left side of the c2 vertebral body and extended into the pedicle and neural foramen on the left at the c2-c3 level. 4. postoperative radiation therapy to the cervical spine. 5. one cycle of il-2 as part of the il-2 select trial in 08/. 6. hospitalization in for hypercalcemia. 7. enrolled in sorafenib/bevacizumab phase ii trial on - discontinued as of with development of colonic perforation. 8. readmitted to with contrast nephropathy. status post diverting ileostomy on . 9. begin sutent 37.5 mg on . stopped sutent on (tired of taking it). 10. consideration for the rad-001 biomarker trial. the patient, however, had a nondiagnostic tumor biopsy, and was therefore ineligible. 11. resection of right retroperitoneal tumor, right colectomy, partial liver resection, and ileal transverse colostomy anastomosis on for recurrent renal cell carcinoma in previous right nephrectomy bed with involvement of the liver, right colon and right psoas muscle. 12. started pki-587 (pi3k/mtor inhibitor) on protocol 09-215 13. taken off protocol 09-215 because of disease progression including t11-t12 paraspinal lesion invading spinal canal 14. last zometa 15. srs to right infrahepatic metastasis; srs to paraspinal metastasis past medical history: - renal cell carcinoma (please see below) - h/o rle dvt - colonic perforation - hyponatremia - anemia - cervical surgery with rod-placement due to c2 met - right colectomy, segment vi partial liver resection, resection of retroperitoneal tumor mass; ileal transverse colostomy anastomosis (side to side). social history: married. quit drinking alcohol. tobacco and illicit drug use. not currently emplyed, but worked as an electrician. 2 healthy children. family history: mother died of a brain tumor. father diagnosed with prostate cancer in his 70s and is still living. he has 3 siblings and 2 children without medical concerns. maternal aunt with lymphoma. father and sister have had h/o "blood clots." physical exam: vs: t 98, bp 120/80, p 91, r 18, sao2 98 @ ra gen: aox3, nad heent: perrla. mmm. no lad. no jvd. neck supple. cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: no dullness to percussion, ctab no crackles or wheezes abd: soft, tender in his right flank and ruq area, +bs. no rebound/guarding. neg hsm. neg sign. extremities: wwp, no edema. dps, pts 2+. skin: no rashes or bruising neuro/psych: cns ii-xii intact. 5/5 strength in u/l extremities. dtrs 2+ bl. sensation intact to lt, cerebellar fxn intact (ftn, hts). gait wnl. upon discharge: t 97.8 120/70 75 16 96ra gen: nad, heent: sclera anicteric. no oral lesions. cards: rrr s1/s2 normal. no murmurs/gallops/rubs. pulm: ctab abd: soft, nt, +bs. no rebound/guarding. extremities: no edema neuro: a&ox3, 5/5 strength in lower extremities back: clean dressing in place, staples, non erythematous pertinent results: ct of abd () 1. the paraspinal mass which originates at the lytic lesion of right 12th rib, invades into the spinal canal, is more prominent as compared to the prior studies. spinal cord compression at the level of d12, d11, and d10, mostly from the right side but crossing anteriorly to the left at the level of d11. findings are consistent with spinal cord compression and can be further evaluated by mri. 2. the overall size of the paraspinal lesion is mildly increased, as compared to the prior study. 3. the mass in the right lateral posterior abdominal wall adjacent to the liver now demonstrates small amount of air in it with possible tract into adjacent small bowel loop, suggesting a fistula. 4. increase in size and number of numerous bilateral pulmonary metastases and one of them in the right middle lobe with a cavitation. 5. new small right pleural effusion. ct l spine : impression: 1. extensive fluid surrounding the surgical bed, without definite organization or rim to suggest abscess formation. 2. large, peripherally enhancing fluid collection centered in the right paraspinal location near the level of the liver. this is concerning for a paraspinal abscess. however, given the presence of a lesion near this location on a previous mri, it is unclear if there is also a component of necrotic neoplastic disease. correlation to prior studies, if available, would be helpful. 3. small, rim-enhancing collection in the left paraspinal musculature on the left, also concerning for a paraspinal abscess. 4. numerous pulmonary nodules, the largest of which are described above. . 06:45am blood wbc-10.6 rbc-3.03* hgb-8.5* hct-26.7* mcv-88 mch-28.1 mchc-32.0 rdw-16.7* plt ct-388 05:15am blood wbc-5.8 rbc-4.08* hgb-10.5* hct-33.4* mcv-82 mch-25.7* mchc-31.3 rdw-15.2 plt ct-281 06:45am blood neuts-87.5* lymphs-6.0* monos-4.7 eos-1.6 baso-0.3 05:15am blood neuts-74.7* lymphs-12.5* monos-9.6 eos-2.8 baso-0.2 03:50am blood pt-14.1* ptt-25.5 inr(pt)-1.2* 05:15am blood pt-13.0 ptt-25.2 inr(pt)-1.1 06:10am blood glucose-100 urean-10 creat-0.9 na-143 k-5.7* cl-103 hco3-32 angap-14 05:15am blood glucose-89 urean-10 creat-1.0 na-136 k-4.8 cl-101 hco3-31 angap-9 01:03am blood alt-10 ast-14 alkphos-94 amylase-27 totbili-0.3 05:15am blood alt-16 ast-19 alkphos-109 totbili-0.3 06:10am blood calcium-9.6 phos-4.3 mg-2.2 05:15am blood albumin-3.5 calcium-9.7 phos-3.5 mg-2.2 brief hospital course: 47 yo male with renal cell cancer with intrahepatic and paraspinal metastasis treated with stereotactic body radiotherapy, completed on , admitted for pain control s/p t10-l2 fusion and removal of 12th vertebrae. . #back/leg pain secondary to known spinal mets and cord compression seen on imaging without neurological deficits: radiation oncology and neurosurgery were consulted and decided that a surgical approach was best for his management. pain was controlled prior to surgery with fentanyl patch 400 mcg/hr, hydromorphone 1-3 mg every 2-3 hrs iv prn, and gabapentin 300 mg q8. patient underwent surgical decompression on -> he underwent t12 transpedicular decompression and posterior fusion t10 to l2 under general anesthesia. had 1500cc ebl. during procedure he was transfused with 2 units of prbc and his pod#1 hematocrit was 32. went to sicu post op and remained intubated overnight as he required nasal intubation. he was extubated pod#1 without difficulty. given his long history of chronic pain, the pain managment team was consulted and recommended a ketamine drip for pain control and dilaudid iv as needed. they continued to follow him post operatively and his ketamine drip was dc'd on pod#4. his jp drain drain was dc'd on pod#4 without difficulties. his hct continued to trend down and on he received 2 units of prbc's for a hct of 21.7. his hematocrits remained stable for the rest of his hospital course. he was transferred to the floor in stable condition although he suffered back pain and intense headache. the pain team continued to follow him on the floor and his pain regimen was optimized. the iv dilaudid was changed to po dilaudid and slowly decreased as tolerated. he was started on methadone 5 mg which was decreased to 2.5 mg . he was given iv caffeine and benadryl for his headache with minimal improvement. indomethacin 25 mg tid in combination with the methadone seemed to help his headache tremendously and he denied headache on day of discharge. he will be discharged on fentanyl patch 400 mcg/hr q72 hrs, gabapentin 300 mg q8, indomethacin 25 mg tid, tylenol 1000mg tid, methadone 2.5 mg , and prn dilaudid mg po as needed for breakthrough pain. he should f/u with his pcp, , and neurosurgery, and his pain regimen should be adjusted and decreased as tolerated. of note, a ct l-spine was read as concerning for possible paraspinal abscess. this was not clinically correlated as the patient was afebrile without leukocytosis. the neurosurgery team reviewed the ct films and reported that the changes seen were most consistent with post-op surgical changes rather than infection. he will be seen as an outpatient by neurosurgery to follow-up. . #asymptomatic elevated tsh: elevated at 5.5. no symptoms. be elevated due to general illness/hospital stay. will not pursue further workup at this time. consider outpatient work-up after discharge. medications on admission: transfer meds: duragesic patch 400mcg q3 days lidoderm patch for 12 hours ativan 1mg daily miralax 17g daily dilaudid 2-3 mg q 2hours prn flexeril 5mg tid ativan 1mg qhs zofran 2mg iv q 6hours prn home meds: ativan prn fentanyl for pain discharge medications: 1. lorazepam 1 mg tablet sig: one (1) tablet po hs (at bedtime) as needed for insomnia. 2. acetaminophen 650 mg/20.3 ml solution sig: 1000 (1000) mg po tid (3 times a day) as needed for fever or pain: please do not exceed 4 g in 24 hours. disp:*60 solution* refills:*2* 3. gabapentin 250 mg/5 ml solution sig: three hundred (300) mg po q8h (every 8 hours). disp:*100 ml* refills:*2* 4. indomethacin 25 mg capsule sig: one (1) capsule po tid (3 times a day). disp:*90 capsule(s)* refills:*2* 5. fentanyl 100 mcg/hr patch 72 hr sig: four (4) patch 72 hr transdermal q72h (every 72 hours): please do not combine with alcohol or drive while taking this medication. disp:*40 patch 72 hr(s)* refills:*2* 6. hydromorphone 4 mg tablet sig: 1-4 tablets po q3h (every 3 hours) as needed for pain: please do not combine with alcohol or drive while taking this medication. disp:*30 tablet(s)* refills:*2* 7. methadone 5 mg tablet sig: 0.5 tablet po bid (2 times a day): please do not combine with alcohol or drive while taking this medication. disp:*30 tablet(s)* refills:*2* discharge disposition: home with service facility: vna, discharge diagnosis: t 12 spinal metastasis epidural spinal cord compression seen on imaging with no neurological deficits metastatic renal cell carcinoma, mets to spine, liver, and with pulmonary nodules back/leg pain elevated tsh, asymptomatic discharge condition: mental status: clear and coherent. level of consciousness: alert and interactive. activity status: ambulatory - independent. discharge instructions: dear mr. , it was a pleasure participating in your health care. you were admitted to for pain control. your pain was managed with a fentanyl patch, intravenous dilaudid, and gabapentin prior to your operation. after surgery, your pain was controlled with a fentanyl patch, oral dilaudid, gabapentin, indomethacin, tylenol, and methadone. please make the following changes to your medications: stop flexeril 5mg three times daily start fentanyl patch 400 mcg/hr every 72 hours start gabapentin 300 mg every 8 hours start indomethacin 25 mg three times a day start methadone 2.5 m twice a day start hydromorphone (dilaudid) 4-8 mg every 3 hours as needed for uncontrolled pain. start acetaminophen (tylenol) 1000 mg three times a day please work with your physician to reduce the amount of pain medications that you are taking as your pain improves. please continue your other home medications. in addition, please follow the instructions below: ?????? do not smoke ?????? keep wound clean / no tub baths or pools until seen in follow up/ begin 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 ?????? take pain medication as instructed above; ?????? increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? clearance to drive and return to work will be addressed at your post-operative office visit followup instructions: the following appointments have been made for you: department: hematology/oncology when: wednesday at 4:00 pm with: , md building: sc clinical ctr campus: east best parking: garage department: hematology/oncology when: wednesday at 4:00 pm with: , md building: sc clinical ctr campus: east best parking: garage * please return to dr office in days for removal of your staples/suture(clinic days tues or fri). please call to schedule an appointment. * please call to schedule an appointment with dr. to be seen in 6 weeks.you will need xrays prior to this appointment * please arrange an appointment with your primary care physician ,md for 2-3 weeks after discharge. please call to arrange an appointment. md procedure: dorsal and dorsolumbar fusion of the posterior column, posterior technique lumbar and lumbosacral fusion of the posterior column, posterior technique insertion of interbody spinal fusion device fusion or refusion of 4-8 vertebrae diagnoses: malignant neoplasm of liver, secondary acute posthemorrhagic anemia secondary malignant neoplasm of other specified sites hypopotassemia other nervous system complications secondary malignant neoplasm of brain and spinal cord personal history of malignant neoplasm of bladder personal history of malignant neoplasm of large intestine other constipation personal history of venous thrombosis and embolism surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation secondary malignant neoplasm of lung personal history of malignant neoplasm of kidney secondary malignant neoplasm of bone and bone marrow personal history of antineoplastic chemotherapy personal history of irradiation, presenting hazards to health leukocytosis, unspecified neoplasm related pain (acute) (chronic) arthrodesis status myelopathy in other diseases classified elsewhere acquired absence of intestine (large) (small) other acute postoperative pain 

Answer: The patient is high likely exposed to