CHIEF COMPLAINT: Back pain

PRESENT ILLNESS: Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She is electing to proceed with surgical intervention.

MEDICAL HISTORY: Scoliosis, Liver disease, history of ulcer, mumps, measles,
chicken pox as child, hepatitis A,
PSH: R inguinal hernia repair at age 8, laparoscopic tubal
ligation, R knee arthroscopy, R foot surgery, L 3rd digit cyst
removal, tonsillectomy

MEDICATION ON ADMISSION: tramadol

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/A

SOCIAL HISTORY: Denies tobacco, occassional EtOH; denies illicit drug use
Scoliosis [and kyphoscoliosis], idiopathic,Other and unspecified coagulation defects,Unspecified pleural effusion,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute posthemorrhagic anemia,Lumbosacral spondylosis without myelopathy,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Osteoporosis, unspecified,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Personal history of other infectious and parasitic diseases
Idiopathic scoliosis,Coagulat defect NEC/NOS,Pleural effusion NOS,Accidental op laceration,Ac posthemorrhag anemia,Lumbosacral spondylosis,Iatrogenc hypotnsion NEC,Obstructive sleep apnea,Osteoporosis NOS,Acc cut/hem in surgery,Prsnl hst oth nfct parst
Admission Date:  [**2127-11-24**]              Discharge Date:   [**2127-12-2**]

Date of Birth:  [**2072-11-8**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
No Known Allergies / Adverse Drug Reactions

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

Major Surgical or Invasive Procedure:
Anterior fusion L3-S1
Anterior fusion T11-L3
Posterior fusioin T3-S1

History of Present Illness:
Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She is electing to proceed with surgical intervention.

Past Medical History:
Scoliosis, Liver disease, history of ulcer, mumps, measles,
chicken pox as child, hepatitis A,
PSH: R inguinal hernia repair at age 8, laparoscopic tubal
ligation, R knee arthroscopy, R foot surgery, L 3rd digit cyst
removal, tonsillectomy


Social History:
Denies tobacco, occassional EtOH; denies illicit drug use

Family History:
N/A

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:
[**2127-11-30**] 08:11AM BLOOD WBC-6.6 RBC-3.70*# Hgb-11.2*# Hct-32.5*#
MCV-88 MCH-30.1 MCHC-34.3 RDW-14.5 Plt Ct-189
[**2127-11-29**] 05:24AM BLOOD WBC-6.0 RBC-2.83* Hgb-8.7* Hct-24.7*
MCV-87 MCH-30.7 MCHC-35.1* RDW-14.8 Plt Ct-150#
[**2127-11-28**] 02:32AM BLOOD WBC-5.5 RBC-3.52*# Hgb-10.9*# Hct-30.2*
MCV-86 MCH-31.1 MCHC-36.1* RDW-15.3 Plt Ct-98*
[**2127-11-27**] 02:55PM BLOOD WBC-7.4 RBC-2.43* Hgb-7.5* Hct-21.5*
MCV-89 MCH-30.8 MCHC-34.7 RDW-15.2 Plt Ct-91*
[**2127-11-27**] 11:24AM BLOOD WBC-7.7 RBC-3.13* Hgb-9.4* Hct-27.9*
MCV-89 MCH-30.1 MCHC-33.7 RDW-14.8 Plt Ct-111*
[**2127-11-27**] 01:17AM BLOOD WBC-6.8 RBC-3.54* Hgb-11.3* Hct-31.9*
MCV-90 MCH-31.9 MCHC-35.4* RDW-14.0 Plt Ct-117*

Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2127-11-24**] and taken to the Operating Room for L3-S1 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 she returned to the operating room for a
scheduled T11-L3 anterior fusion through a thoracotomy as part
of a staged 3-part procedure. A chest tube was placed at the
time of this surgery.  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 low and she was
transfused PRBCs with good effect. A bupivicaine epidural pain
catheter placed at the time of the posterior surgery.
she was transfered to the T/SICU for hemodynamic monitoring.
She 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#2
from the third procedure. She was fitted with a TLSO brace for
ambulation. 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:
tramadol

Discharge Medications:
1. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours)
as needed for pain.
5. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. morphine 30 mg Tablet Extended Release Sig: One (1) Tablet
Extended Release PO Q8H (every 8 hours).


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Scoliosis
Acute post-op blood loss anemia

Discharge Condition:
Good

Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar 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
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:  Out of bed w/ assist
 Thoracic lumbar spine:   when OOB

Treatment Frequency:
Please continue to change the dressing daily.

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


Completed by:[**2127-12-1**]
{'Scoliosis [and kyphoscoliosis], idiopathic,Other and unspecified coagulation defects,Unspecified pleural effusion,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute posthemorrhagic anemia,Lumbosacral spondylosis without myelopathy,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Osteoporosis, unspecified,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Personal history of other infectious and parasitic diseases'}


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: Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She is electing to proceed with surgical intervention.

MEDICAL HISTORY: Scoliosis, Liver disease, history of ulcer, mumps, measles,
chicken pox as child, hepatitis A,
PSH: R inguinal hernia repair at age 8, laparoscopic tubal
ligation, R knee arthroscopy, R foot surgery, L 3rd digit cyst
removal, tonsillectomy

MEDICATION ON ADMISSION: tramadol

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/A

SOCIAL HISTORY: Denies tobacco, occassional EtOH; denies illicit drug use 

### Response:
{'Scoliosis [and kyphoscoliosis], idiopathic,Other and unspecified coagulation defects,Unspecified pleural effusion,Accidental puncture or laceration during a procedure, not elsewhere classified,Acute posthemorrhagic anemia,Lumbosacral spondylosis without myelopathy,Other iatrogenic hypotension,Obstructive sleep apnea (adult)(pediatric),Osteoporosis, unspecified,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Personal history of other infectious and parasitic diseases'}
