CHIEF COMPLAINT: neck pain

PRESENT ILLNESS: HPI: Mr. [**Known lastname 41766**] is a 36 yo M who was transferred from an OSH
after
a MCV. Per EMS report, he was unrestrained and found
self-ejected
from the car. He was noted to have + EtOH with slurred speech at
the scene. He was placed in a C-Collar and taken to an OSH where
he was found to have a C7 fracture. He was given Narcan for
drowsiness which improved his mental status. Later in his course
at the ED he was given Ativan 1mg x 2 and then 4 mg of morphine.
He was transferred here for further evaluation.

MEDICAL HISTORY: PMHx:
-polysubstance abuse, IVDU
-denies DT's
-HCV
-Asthma
-Anxiety
-GERD
-HTN

MEDICATION ON ADMISSION: Medications prior to admission:
trazodone, Advair, Claritin, lisinopril, Xopenex, Nasonex,
Zantac

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: AF BP: 104/58  HR: 86  R  18 O2Sats 99% on 15L
Gen: WD/WN, anxious, shaking arms and legs asymmetrically and
requesting Dilaudid
Neck: in hard collar
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, anxious but cooperative with
exam
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5    5     5     5     5     5      5
L     5    5     5    5    5     5     5     5     5      5

FAMILY HISTORY: nc

SOCIAL HISTORY: Social Hx: polysubstance dependance as above but denies ; +
tobacco
Closed fracture of seventh cervical vertebra,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Other, mixed, or unspecified drug abuse, unspecified,Chronic hepatitis C without mention of hepatic coma,Asthma, unspecified type, unspecified,Anxiety state, unspecified,Esophageal reflux,Unspecified essential hypertension
Fx c7 vertebra-closed,Mv coll w oth obj-driver,Drug abuse NEC-unspec,Chrnc hpt C wo hpat coma,Asthma NOS,Anxiety state NOS,Esophageal reflux,Hypertension NOS
Admission Date:  [**2194-5-19**]              Discharge Date:   [**2194-5-26**]

Date of Birth:  [**2158-5-18**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Sulfa (Sulfonamides)

Attending:[**Known firstname 2724**]
Chief Complaint:
neck pain

Major Surgical or Invasive Procedure:
Posterior cervical fusion


History of Present Illness:
HPI: Mr. [**Known lastname 41766**] is a 36 yo M who was transferred from an OSH
after
a MCV. Per EMS report, he was unrestrained and found
self-ejected
from the car. He was noted to have + EtOH with slurred speech at
the scene. He was placed in a C-Collar and taken to an OSH where
he was found to have a C7 fracture. He was given Narcan for
drowsiness which improved his mental status. Later in his course
at the ED he was given Ativan 1mg x 2 and then 4 mg of morphine.
He was transferred here for further evaluation.

In our ED, he was very drowsy and was given Narcan again with
good results. Afterwards, however he stated that he was very
anxious and had pain "all over". He requested Dilaudid as
morphine makes him too sleepy.

Mr. [**Known lastname 41766**] states that he has been in detox for alcohol for the
last 4 days and decided to leave today, prior to discharge
because "I was going crazy". He states that he typically drinks
about 6 beers or 2 "40's" per night as well as a "pint". He is
uncertain of how much he drank this evening. He denies having
taken other drugs tonite but states that he has used heroin in
the past. In the ED, the patient was found to have a small blue
bag with a white power in it. The patient states he is not sure
what is in it, "I don't remember".

Past Medical History:
PMHx:
-polysubstance abuse, IVDU
-denies DT's
-HCV
-Asthma
-Anxiety
-GERD
-HTN

Social History:
Social Hx: polysubstance dependance as above but denies ; +
tobacco

Family History:
nc

Physical Exam:
PHYSICAL EXAM:
O: T: AF BP: 104/58  HR: 86  R  18 O2Sats 99% on 15L
Gen: WD/WN, anxious, shaking arms and legs asymmetrically and
requesting Dilaudid
Neck: in hard collar
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, anxious but cooperative with
exam
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5    5     5     5     5     5      5
L     5    5     5    5    5     5     5     5     5      5

Sensation: pt thinks sensation is intact to light touch but is
very anxious and not certain

Reflexes:  areflexic but very anxious and all muscles are
contracted during exam despite repeated attempts to relax him

Toes downgoing bilaterally

Pertinent Results:
CT C-spine: Nondisplaced fractures through the pedicles at C7
bilaterally, with extension into the transverse processes. No
evidence of vertebral artery or other vascular injury. Recons
are
pending.

5.6\ 12.7 /273
     36.4

Tox screen + benzos, opiates and EtOH

PT: 12.1  PTT: 24.7  INR: 1.0
Fibrinogen: 212

Na:141 K:4.2 Cl:104 TCO2:22 Glu:76 Lactate:1.4


Brief Hospital Course:
Pt was admitted to the trauma service and monitored closely in
the ICU.  MRI of c-spine showed ligamentous injury.  He was kept
in a hard collar at all times.  On HD#2 he was transferred to
neurosurgery service and the floor.  He was pre-oped for the OR.
On [**2194-5-22**] he was brought to the OR where under general
anesthesia a posterior cervical fusion was performed. He
tolerated this procedure well, was extubated, transferred PACU
and then to floor when stable. He was given pain medication by
PCA and ultimately transitioned to PO. Diet and activity were
advanced. Foley was removed. Drain was removed POD#2. Staples
were clean/dry/intact. He remained in Aspen collar.He was
evaluated by PT and was cleared for discharge to home. Pt agreed
with this plan.

Medications on Admission:
Medications prior to admission:
trazodone, Advair, Claritin, lisinopril, Xopenex, Nasonex,
Zantac


Discharge Medications:
1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

2. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig:
[**1-22**] Disk with Devices Inhalation [**Hospital1 **] (2 times a day).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): take while on pain med.
Disp:*60 Capsule(s)* Refills:*1*
6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
7. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-22**]
Inhalation q4-6h prn ().
8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1)
Spray Nasal [**Hospital1 **] (2 times a day).
9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 5 days.
Disp:*10 Tablet(s)* Refills:*0*
10. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed.
Disp:*80 Tablet(s)* Refills:*0*
11. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) for 2 weeks: 1 [**Hospital1 **] for 1 week, then 1 qd for 1 week then
dc.
Disp:*21 Tablet(s)* Refills:*0*
12. Methocarbamol 750 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*1*


Discharge Disposition:
Home

Discharge Diagnosis:
bilateral C7 facet fracture


Discharge Condition:
neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES

??????        Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up / begin daily showers [**2194-5-26**].
??????        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 cervical collar as instructed
??????        You may shower briefly without the collar
??????        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
* You may not drive while in cervical collar.

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

Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**7-31**] DAYS FOR REMOVAL OF YOUR
STAPLES

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



Completed by:[**2194-5-26**]
{'Closed fracture of seventh cervical vertebra,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Other, mixed, or unspecified drug abuse, unspecified,Chronic hepatitis C without mention of hepatic coma,Asthma, unspecified type, unspecified,Anxiety state, unspecified,Esophageal reflux,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: neck pain

PRESENT ILLNESS: HPI: Mr. [**Known lastname 41766**] is a 36 yo M who was transferred from an OSH
after
a MCV. Per EMS report, he was unrestrained and found
self-ejected
from the car. He was noted to have + EtOH with slurred speech at
the scene. He was placed in a C-Collar and taken to an OSH where
he was found to have a C7 fracture. He was given Narcan for
drowsiness which improved his mental status. Later in his course
at the ED he was given Ativan 1mg x 2 and then 4 mg of morphine.
He was transferred here for further evaluation.

MEDICAL HISTORY: PMHx:
-polysubstance abuse, IVDU
-denies DT's
-HCV
-Asthma
-Anxiety
-GERD
-HTN

MEDICATION ON ADMISSION: Medications prior to admission:
trazodone, Advair, Claritin, lisinopril, Xopenex, Nasonex,
Zantac

ALLERGIES: Sulfa (Sulfonamides)

PHYSICAL EXAM: PHYSICAL EXAM:
O: T: AF BP: 104/58  HR: 86  R  18 O2Sats 99% on 15L
Gen: WD/WN, anxious, shaking arms and legs asymmetrically and
requesting Dilaudid
Neck: in hard collar
Lungs: CTA bilaterally anteriorly
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, anxious but cooperative with
exam
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5    5     5     5     5     5      5
L     5    5     5    5    5     5     5     5     5      5

FAMILY HISTORY: nc

SOCIAL HISTORY: Social Hx: polysubstance dependance as above but denies ; +
tobacco 

### Response:
{'Closed fracture of seventh cervical vertebra,Other motor vehicle traffic accident involving collision on the highway injuring driver of motor vehicle other than motorcycle,Other, mixed, or unspecified drug abuse, unspecified,Chronic hepatitis C without mention of hepatic coma,Asthma, unspecified type, unspecified,Anxiety state, unspecified,Esophageal reflux,Unspecified essential hypertension'}
