CHIEF COMPLAINT: Back pain

PRESENT ILLNESS: Mr. [**Known lastname 79613**] has a long history of back pain.  He has attempted
conservative therapy but has failed.  He now presents for
surgical intervention.

MEDICAL HISTORY: Hypertension, history of constipation
secondary to medications, and ulnar nerve neuropathy on the
right.

MEDICATION ON ADMISSION: cymbalta, HCTZ, lisinopril, morphine, trazodone

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies
Obesity, unspecified,Lumbosacral spondylosis without myelopathy,Other digestive system complications,Delirium due to conditions classified elsewhere,Paralytic ileus,Acute posthemorrhagic anemia,Degeneration of lumbar or lumbosacral intervertebral disc,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Other acute postoperative pain,Alcohol abuse, unspecified,Opioid type dependence, in remission,Lesion of ulnar nerve,Arthrodesis status
Obesity NOS,Lumbosacral spondylosis,Oth digestv system comp,Delirium d/t other cond,Paralytic ileus,Ac posthemorrhag anemia,Lumb/lumbosac disc degen,Abn react-surg proc NEC,Hypertension NOS,Acute postop pain NEC,Alcohol abuse-unspec,Opioid dependence-remiss,Ulnar nerve lesion,Arthrodesis status
Admission Date:  [**2187-12-11**]              Discharge Date:   [**2187-12-18**]

Date of Birth:  [**2124-4-8**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain

Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation L3-5


History of Present Illness:
Mr. [**Known lastname 79613**] has a long history of back pain.  He has attempted
conservative therapy but has failed.  He now presents for
surgical intervention.

Past Medical History:
Hypertension, history of constipation
secondary to medications, and ulnar nerve neuropathy on the
right.

Past Surgical History: Fusion x2 to his neck, bilateral rotator

cuff repairs multiple, prostate surgery, and tonsillectomy


Social History:
Denies

Family History:
N/C

Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles


Pertinent Results:
[**2187-12-16**] 12:15PM BLOOD WBC-13.5* RBC-3.38* Hgb-10.5* Hct-30.7*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.5 Plt Ct-387
[**2187-12-15**] 04:15AM BLOOD WBC-14.4* RBC-3.27* Hgb-10.2* Hct-29.6*
MCV-91 MCH-31.1 MCHC-34.3 RDW-13.1 Plt Ct-285
[**2187-12-14**] 05:16AM BLOOD WBC-17.8*# RBC-3.32* Hgb-10.3* Hct-30.1*
MCV-91 MCH-31.0 MCHC-34.2 RDW-13.2 Plt Ct-230
[**2187-12-13**] 05:42AM BLOOD WBC-11.2* RBC-2.69* Hgb-8.4* Hct-24.4*
MCV-91 MCH-31.3 MCHC-34.5 RDW-12.7 Plt Ct-219
[**2187-12-16**] 12:15PM BLOOD Glucose-137* UreaN-15 Creat-0.9 Na-140
K-4.2 Cl-107 HCO3-23 AnGap-14
[**2187-12-15**] 12:17AM BLOOD Glucose-133* UreaN-12 Creat-0.9 Na-140
K-3.5 Cl-102 HCO3-32 AnGap-10
[**2187-12-14**] 01:05PM BLOOD Glucose-146* UreaN-11 Creat-1.0 Na-142
K-3.9 Cl-102 HCO3-36* AnGap-8

Brief Hospital Course:
Mr. [**Known lastname 79613**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2187-12-11**] and taken to the Operating Room for L3-5 interbody
fusion through an anterior approach. Please 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
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#2 he returned to the operating room for a
scheduled L3-5 decompression with PSIF as part of a staged
2-part procedure. Please refer to the dictated operative note
for further details. The second surgery was also without
complication and the patient was transferred to the PACU in a
stable condition. Postoperative HCT was 37.1. A bupivicaine
epidural pain catheter placed at the time of the posterior
surgery remained in place until postop day one.
Post-operatively he developed a severe post-operative ileus.  An
NGT was placed which the patient subsequently discontinued.  His
physical exam was concerning for an abdominal compartment
syndrome and he was transfered to the SICU for close monitoring.
He was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#4
from the second procedure. He was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. 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.

Medications on Admission:
cymbalta, HCTZ, lisinopril, morphine, trazodone

Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
Disp:*100 Tablet(s)* Refills:*0*
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).

4. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasms.
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
1-2 Puffs Inhalation Q6H (every 6 hours) as needed for asthma.
7. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).


Discharge Disposition:
Home With Service

Facility:
Bayada Nurses, Inc.

Discharge Diagnosis:
Lumbar stenosis and disc degeneration
Post-op ileus
Acute post-op blood loss anemia
Abdominal compartment syndrome


Discharge Condition:
Good


Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion



Immediately after the operation:



-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.



-Rehabilitation/ Physical Therapy:

o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.


oLimit 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.



-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.



-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. Call the
office.



-You should resume taking your normal home medications. No
NSAIDs.



-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.



Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.


Physical Therapy:
Activity:   Activity:  Out of bed w/ assist
LSO for ambulation; may be out of bed to chair without.

Treatments Frequency:
Please continue to change the dressing

Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days



Completed by:[**2187-12-27**]
{'Obesity, unspecified,Lumbosacral spondylosis without myelopathy,Other digestive system complications,Delirium due to conditions classified elsewhere,Paralytic ileus,Acute posthemorrhagic anemia,Degeneration of lumbar or lumbosacral intervertebral disc,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Other acute postoperative pain,Alcohol abuse, unspecified,Opioid type dependence, in remission,Lesion of ulnar nerve,Arthrodesis status'}


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: Back pain

PRESENT ILLNESS: Mr. [**Known lastname 79613**] has a long history of back pain.  He has attempted
conservative therapy but has failed.  He now presents for
surgical intervention.

MEDICAL HISTORY: Hypertension, history of constipation
secondary to medications, and ulnar nerve neuropathy on the
right.

MEDICATION ON ADMISSION: cymbalta, HCTZ, lisinopril, morphine, trazodone

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies 

### Response:
{'Obesity, unspecified,Lumbosacral spondylosis without myelopathy,Other digestive system complications,Delirium due to conditions classified elsewhere,Paralytic ileus,Acute posthemorrhagic anemia,Degeneration of lumbar or lumbosacral intervertebral disc,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Unspecified essential hypertension,Other acute postoperative pain,Alcohol abuse, unspecified,Opioid type dependence, in remission,Lesion of ulnar nerve,Arthrodesis status'}
