CHIEF COMPLAINT: Neck pain

PRESENT ILLNESS: Mr. [**Known lastname 431**] is a 68 year-old man with hx of alcohol abuse,
pancreatic insufficiency, DM, and HTN who was admitted on
[**2185-6-15**] to Ortho-Spine after falling from a 12-foot ladder while
intoxicated. MRI spine at [**Hospital **] Hospital revealed unstable
right C7 facet fracture and C6/7 disc herniation. He was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: DM
HTN
Prostate cancer s/p prostatectomy
Alcohol abuse
Pancreatic insufficiency

MEDICATION ON ADMISSION: Lantus 12 units
Metformin 500 mg [**Hospital1 **]
Lisinopril 30 mg qam
Nifedipine 30 mg qam
Simvastatin 10 mg pm
Pancrease 10 mg TID
Clonazepam 0.5 mg qid
Citalopram 40 mg qam
Albuterol NEB
Prilosec 20 mg pm
Chromium 500 mcg
Fenugreek 600 mg [**Hospital1 **]/meals

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.3   BP 140/80   HR 67   RR 18   O2 sat 96%RA
General: alert and oriented to person but not place or time,
agitated and delirious
CV: RRR, no murmurs/rubs/gallops
Resp: CTAB, no wheezes/crackles/rhonchi
GI: Abd soft NT/ND, bowel sounds present
Extremities: BUE- 4/5 strength at deltoid and biceps, [**5-4**]
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: Lives with wife. [**Name (NI) **] history of tobacco or drug abuse. According
to wife, pt began drinking heavily at age 60 when diagnosed with
prostate cancer. He has been intermittently sober since then. He
has recently been drinking 0.5-1 pint vodka. He often goes
through withdrawal at home which manifests as tremors and
anxiety. He once had hallucinations, but there is no history of
seizures.
Closed fracture of seventh cervical vertebra,Closed dislocation, sixth cervical vertebra,Injury to bladder and urethra, without mention of open wound into cavity,Acute kidney failure, unspecified,Alcohol withdrawal delirium,Closed fracture of head of radius,Degeneration of cervical intervertebral disc,Unspecified essential hypertension,Malnutrition of moderate degree,Other specified diseases of pancreas,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Asthma, unspecified type, unspecified,Alcohol abuse, continuous,Other dysphagia,Anemia, unspecified,Foreign body in respiratory tree, unspecified,Depressive disorder, not elsewhere classified,Personal history of malignant neoplasm of prostate,Long-term (current) use of insulin,Accidental fall from chair,Accidental fall from ladder,Accidents occurring in residential institution,Unspecified accident,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation
Fx c7 vertebra-closed,Disloc 6th cerv vert-cl,Bladder/urethra inj-clos,Acute kidney failure NOS,Delirium tremens,Fx radius head-closed,Cervical disc degen,Hypertension NOS,Malnutrition mod degree,Pancreatic disease NEC,DMII oth uncntrld,Asthma NOS,Alcohol abuse-continuous,Dysphagia NEC,Anemia NOS,FB respiratory tree NOS,Depressive disorder NEC,Hx-prostatic malignancy,Long-term use of insulin,Fall from chair,Fall from ladder,Accid in resident instit,Accident NOS,Resp obstr-inhal obj NEC
Admission Date:  [**2185-6-15**]              Discharge Date:   [**2185-7-2**]

Date of Birth:  [**2116-6-24**]             Sex:   M

Service: MEDICINE

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2181**]
Chief Complaint:
Neck pain

Major Surgical or Invasive Procedure:
ACDF C5-7
Posterior laminectomy and fusion C5-T1


History of Present Illness:
Mr. [**Known lastname 431**] is a 68 year-old man with hx of alcohol abuse,
pancreatic insufficiency, DM, and HTN who was admitted on
[**2185-6-15**] to Ortho-Spine after falling from a 12-foot ladder while
intoxicated. MRI spine at [**Hospital **] Hospital revealed unstable
right C7 facet fracture and C6/7 disc herniation. He was
transferred to [**Hospital1 18**] for further management.

Past Medical History:
DM
HTN
Prostate cancer s/p prostatectomy
Alcohol abuse
Pancreatic insufficiency


Social History:
Lives with wife. [**Name (NI) **] history of tobacco or drug abuse. According
to wife, pt began drinking heavily at age 60 when diagnosed with
prostate cancer. He has been intermittently sober since then. He
has recently been drinking 0.5-1 pint vodka. He often goes
through withdrawal at home which manifests as tremors and
anxiety. He once had hallucinations, but there is no history of
seizures.

Family History:
N/C

Physical Exam:
Vitals: T 98.3   BP 140/80   HR 67   RR 18   O2 sat 96%RA
General: alert and oriented to person but not place or time,
agitated and delirious
CV: RRR, no murmurs/rubs/gallops
Resp: CTAB, no wheezes/crackles/rhonchi
GI: Abd soft NT/ND, bowel sounds present
Extremities: BUE- 4/5 strength at deltoid and biceps, [**5-4**]
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:
On admission:
[**2185-6-15**] 06:58PM BLOOD WBC-5.8 RBC-3.47* Hgb-10.5* Hct-32.0*
MCV-92 MCH-30.4 MCHC-33.0 RDW-16.7* Plt Ct-128*
[**2185-6-15**] 06:58PM BLOOD Neuts-89.9* Lymphs-6.1* Monos-3.2 Eos-0.7
Baso-0.1
[**2185-6-15**] 06:58PM BLOOD Plt Ct-128*
[**2185-6-15**] 07:41PM BLOOD PT-11.7 PTT-23.0 INR(PT)-1.0
[**2185-6-18**] 01:45PM BLOOD Fibrino-505*
[**2185-6-15**] 06:58PM BLOOD Glucose-129* UreaN-22* Creat-1.2 Na-139
K-5.2* Cl-103 HCO3-20* AnGap-21*
[**2185-6-16**] 06:50AM BLOOD Calcium-7.6* Phos-3.2 Mg-1.2*
[**2185-6-16**] 06:39PM BLOOD Type-ART Temp-37.1 Rates-/40 Tidal V-600
FiO2-40 pO2-155* pCO2-41 pH-7.34* calTCO2-23 Base XS--3
Intubat-INTUBATED Vent-CONTROLLED
[**2185-6-18**] 02:04PM BLOOD Glucose-166* Lactate-0.9 Na-132* K-3.9
Cl-97*
[**2185-6-16**] 06:39PM BLOOD Hgb-9.8* calcHCT-29
[**2185-6-16**] 11:34PM BLOOD freeCa-1.04*
.
On discharge:
[**2185-7-1**] 04:09PM URINE bnzodzp-POS barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
[**2185-7-1**] 12:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-19
Bnzodzp-NEG
.
[**2185-6-29**] and [**2185-6-26**] BLOOD CULTURE-pending
[**2185-6-29**] Ucx neg	
[**2185-6-24**] & [**2185-6-26**] ucx neg
[**2185-7-1**] 06:10AM BLOOD WBC-5.7 RBC-3.01* Hgb-8.7* Hct-26.7*
MCV-89 MCH-28.8 MCHC-32.5 RDW-16.1* Plt Ct-484*
[**2185-7-1**] 06:10AM BLOOD Plt Ct-484*
[**2185-7-1**] 06:10AM BLOOD Glucose-261* UreaN-8 Creat-0.9 Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
[**2185-7-1**] 06:10AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.8
[**2185-7-1**] 12:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-19
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2185-7-2**] 07:35AM BLOOD WBC-5.4 RBC-2.94* Hgb-8.2* Hct-25.7*
MCV-88 MCH-28.0 MCHC-32.0 RDW-16.3* Plt Ct-522*
[**2185-7-2**] 07:35AM BLOOD Glucose-206* UreaN-14 Creat-0.8 Na-137
K-4.1 Cl-101 HCO3-27 AnGap-13
[**2185-7-2**] 07:35AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8

.
CT C-Spine w/o contrast [**2185-6-15**]:
IMPRESSION: Fracture of right superior articulating facet of C7
with anterior subluxation of C6 inferior facet. C6-C7 disc space
widening, concerning for ligamentous injury; posterior
osteophyte disc complex at C5-C6 that narrows the canal;
Recommend MRI to further assess.
.
MR [**First Name (Titles) 11598**] [**Last Name (Titles) 1093**] w/o contrast [**2185-6-16**]:
IMPRESSION:
1. Disruption of the anterior and posterior longitudinal
ligaments and the ligamentum flavum at the level of C6/7, with
adjacent soft tissue
abnormalities, compatible with highly unstable extension-type
fracture injury.
2. Right C7 facet fracture with impaction of the C6 inferior
facet into the fracture site. This has not significantly changed
since the CT examination from the prior day.
3. Acute C6/7 posterior disc herniation resulting in moderate
stenosis of the spinal canal at this level. Signal abnormalities
within the cord are
suggestive of contusion. No hematoma is seen.
.
C-SPINE (PORTABLE); SPINAL FLUORO [**2185-6-16**]:
IMPRESSION: There is an anterior plate at the C5 through C7
levels with
normal alignment at this time.
.
Portable CXR [**2185-6-16**]:
IMPRESSION: AP chest reviewed in the absence of prior chest
radiographs:
Tip of the endotracheal tube is substantially above the upper
margin of the clavicles, at least 9 cm above the carina, 6 cm
above optimal placement.  Subsequent chest radiograph, 6:05 a.m.
on [**6-17**] available at the time of this review showed no change
in this malposition.

Lungs are low in volume but aside from mild left basal
atelectasis, clear.  Heart size normal. No pleural abnormality.
.
ECG [**2185-6-21**]:
Sinus rhythm. Consider left atrial abnormality. Left anterior
fascicular block. Delayed R wave progression is non-specific but
clinical correlation is suggested. No previous tracing available
for comparison.
.
CT Head w/o contrast [**2185-6-23**]:
IMPRESSION:
1. No acute hemorrhage or fracture is detected.
2. Fluid in the paranasal sinuses, may be secondary to recent
intubation/surgery.
.
Right Elbow Xray [**2185-6-23**]:
IMPRESSION:
1. Slight irregularity at the radial head suspicious for an
occult fracture.  Small joint effusion.
2. Enthesopathy at medial and lateral epicondyles of distal
humerus and
triceps insertion on the olecranon.
.
Portable CXR [**2185-6-18**]:
FINDINGS: Endotracheal tube is in a proximal location, 9.5 cm
above the
carina. New nasogastric tube terminates within the stomach with
side port
near the GE junction. Dr. [**Last Name (STitle) 85028**] has been paged with these
results. Exam is otherwise remarkable for worsening atelectasis
at the left lung base, with no other relevant short interval
changes.
.
Portable CXR [**2185-6-26**]:
FINDINGS: The feeding tube has been removed. The lungs are
grossly clear
without focal consolidation. Hardware within the lower cervical
spine is
seen.
.
OROPHARYNGEAL VIDEOFLUOROSCOPIC SWALLOWING EVALUATION [**2185-6-28**]:
EVALUATION:
An oral and pharyngeal swallowing videofluoroscopy was performed
today in collaboration with Radiology.  Nectar-thick liquid
(tspn, cup) and pureed consistency barium (1 tspn only) were
administered. Results follow:
.
ORAL PHASE:
Oral phase was most remarkable for moderately reduced bolus
control resulting in premature spillover of nectar thick liquid
to the valleculae and airway before the swallow.  Mild-moderate
tongue weakness (specifically base of tongue) contributed to
pharyngeal residue.  Oral transit time for individual swallows
was WNL.
.
PHARYNGEAL PHASE:
Swallow was initiated in a timely manner, however pt presented
with severely reduced hyolaryngeal excursion, moderately reduced
laryngeal valve closure, and near absent epiglottic deflection.
Pt had at least moderately reduced bolus propulsion and apparent
edema near the level of the UES (in line with new cervical
spinal
hardware).  Deficits in combination with oral phase deficits
resulted in moderate to severe vallecular and pyriform sinus
residue after [**5-5**] swallows per bolus.
.
ASPIRATION/PENETRATION:
Pt demonstrated penetration before and during the swallow which
resulted in aspiration after the swallow with both nectar thick
liquids and purees.  Pt had spontaneous throat clear which
temporarily would improve the amount of aspiration or
penetration, however it did not fully clear and thus the
material
would be re-aspirated.  Cued cough was also ineffective at fully
eliminating aspirated material.
.
TREATMENT TECHNIQUES:
Pt benefits partially but not fully from spontaneous repeat
swallows (5-6 per bite/sip) and cued swallow-cough-swallow
maneuver.  There is no strategy, however, which eliminates
aspiration or pharyngeal residue.
.
SUMMARY:
Pt, currently POD #[**8-9**] from anterior and posterior cervical
spinal surgeries with hardware, demonstrates severe
oropharyngeal
dysphagia as described above most notable for reduced movement
of
the pharyngeal swallow mechanism and swelling at the level of
the
cervical hardware.  Deficits result in significant pharyngeal
residue and aspiration across all consistencies assessed.  Based
on the results of today's evaluation, he does not appear safe
for
PO intake and should remain fully NPO at this time including no
Dobbhoff today.  Given the length of time pt will require to
recover from his current deficits and his propensity to self-d/c
NGTs despite our efforts otherwise, MD team may wish to consider
longer term means of nutritional support such as PEG.  If we can
be of further assistance with discussion regarding plan of care,
please contact us.  Otherwise, we will f/u in approximately 1
week's time for reassessment, if he remains at this facility.
Alternatively, pt could have swallow f/u in a rehab setting.
.
RECOMMENDATIONS:
1. NPO, no ice chips, no oral meds
2. Q4 oral care while NPO.
3. Support non-oral means of nutrition, hydration, and
medication
4. Consider longer term means of non-oral nutrition.
5. Repeat swallowing evaluation in 1 week's time.
Page/reconsult
if we can be of further assistance prior to that f/u.
6. Pt will benefit from intensive swallow therapy and
cognitive-linguistic dx/tx in a rehab setting upon d/c.
.
NG tube placement [**2185-6-30**]:
IMPRESSION: Successful placement of a nasointestinal tube into
the
post-pyloric position. The tube is ready to use.
.
Ct head [**2185-6-29**] non contrast:
There is no acute hemorrhage, edema, mass effect or acute major
vascular
territorial infarction. Global, predominantly central
parenchymal atrophy is likely age-related. Periventricular white
matter hypodensities are most likely the sequelae of chronic
small vessel ischemic disease. There is minimal fluid in ethmoid
air cells and frontal sinuses, bilaterally. The remainder of the
paranasal sinuses and mastoid air cells appear clear. Surgical
clips and post-surgical changes are noted in the scalp overlying
the left occipital bone.
IMPRESSION: No acute intracranial abnormality.
.
CXR [**2185-6-29**]:
FINDINGS: Small retrocardiac opacity, could be atelectasis.
There is no
pneumonia. There is no pleural effusion, or pneumothorax. Hilar,
mediastinal, and cardiac silhouette are within normal limits.
There is mild
rightward scoliosis in the thoracic spine. Anterior posterior
cervical fusion at the lower C-spine.
IMPRESSION:
1. No pneumonia.
2. Small retrocardiac opacity, could be atelectasis.

Brief Hospital Course:
Mr. [**Known lastname 431**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2185-6-15**] and taken to the Operating Room for a cervical fusion
through an anterior approach C5-7. Please refer to the dictated
operative note for further details. The surgery was without
complication and the patient was transferred to the PACU in
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.
Post-operatively he was noticed to be confused and withdrawing
from alcohol.  He was transfered to the T/SICU for further
management.  On HD#3 he returned to the operating room for a
scheduled posterior cervical fusion 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 returned to the T/SICU intubated.
.
He was subsequently extubated without difficulty but failed a
speech and swallow likely secondary to soft tissue swelling from
his surgeries.  A Dobhoff was placed and he was given tubefeeds.
His further withdrawal symptoms were managed with ativan and
valium. He pulled out his Dobhoff tube on [**6-21**]. He was
transfered to the medical service for further management.
.
On the medical service, he failed a second speech and swallow
evaluation on [**6-22**] and another Dobhoff tube was placed on [**6-23**].
We started him on thiamine and a multivitamin and continued his
folate. It was felt that his altered mental status was largely
due to delirium and not alcohol or benzodiazepine withdrawal,
and we thus sought to minimize use of narcotics and
benzodiazepines.
.
On [**6-23**], Mr. [**Known lastname 431**] [**Last Name (Titles) 18095**] an unfortunate fall to the floor
as he was getting out of his chair. He had a CT scan of his head
and complete spine, which showed no acute intracranial process
and no fractures. An x-ray of his right elbow showed a tiny
non-displaced fracture of his radial head. His right arm was put
in a sling, and on discahrge was recommended for full [**Last Name (un) **] of
motion, non weight bearing, and sling for comfort.
Subsequently, he was kept with a 1:1 sitter until his transfer
to an outside hospital.
.
The patient had several aspiration events associated with a
brief desaturation and occasional fever. The differential for
these fevers included aspiration pneumonitis vs. neuroleptic
malignant syndrome.  His CXRs did not demonstrate a
consolidation and making pneumonia less likely although he
certainally is at risk for developing a true aspiration PNA.
All psych meds were stopped due to concern of NMS and he
remained afebrile without leukocytosis throughout rest of
hospital stay. While at [**Hospital 26260**] hospital these psych meds
should be restarted soon after arrival. He was re-evaluated by
Speech and Swallow on [**6-27**] and again failed a bedside speech and
swallow exam.  On [**6-28**] he underwent a video swallow study that
showed mild-moderate tongue weakness, near absent epiglottic
deflection, and edema near the level of the UES in line with new
cervical spinal hardware.  These defects resulted in aspiration
with both nectar thick liquids and purees.  Based on these
results, it was recommended that patient be kept NPO without
oral meds.  A dobhoff was placed for nutrition but he pulled it
out the same day before it could be utilized for tube feeds.
The next day, another dobhoff was attempted and patient was kept
on restraints so as not to pull it out.  Tube feeds were started
on [**6-30**].
.
Given that he does not tolerate [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-gastric tube well, a more
long-term means of non-oral nutrition should be pursued,
possibly with a PEG tube.  We discussed the issue of the PEG
tube with the patient and his wife on [**6-28**].  However, his wife
expressed her desire for the patient to be transferred to [**Hospital 85029**] Center to be under the care of his primary care
physician.  [**Name10 (NameIs) **] patient should continue this discussion on a
means for long-term nutrition at his outside hospital.  If he is
discharged to a rehab facility without a PEG tube in place, he
should continue to be kept NPO until re-evaluation one week
later with a repeat swallow study.  He should receive intensive
swallow therapy and cognitive-linguistic treatment in a rehab
setting.  He should also receive q4h oral care while NPO.  He
also had episodes of oxygen desaturations to the high 80s that
improved to the high 90s with both oxygen via nasal cannula and
with suctioning of oral secretions.  By discharge, his oxygen
saturation was stable in the mid to high 90s on room air.
Please note: blood cultures were still pending on discharge.
.
Of note, patient continued to show signs of sun-downing until
the 2 days before transfer. Delirium persisted despite the fact
that he was ostensibly taken off all possible sedatives,
including benzos and his psychiatric medications.  Patient
periodically agitated, often requiring restraints.  He was
combative off restraints and received one dose of 5mg zyprexa IM
which did not alleviate symptoms.  Psych consult was obtained to
evaluate and recommended starting 1mg haldol standing and 1mg
qhs prn on [**6-30**]. QTC was mildly prolonged to 455 and thus he was
changed to liquid haldol. His psych meds were so far in the
hospitalization but citalopram was started at low dose and
should be titrated up. Patient's mental status improved after
the haldol; he was alert and oriented x 3 the next morning [**7-1**].
CXR, UA, and blood cx were unremarkable.  TSH, B12, folate, and
RPR were checked as part of delirium work up and were pending on
discharge.
.
However, throughout the day, he  became more somnolent and
lethargic, out of proportion to the amount of haloperidol he was
receiving.  A urine toxicology returned on [**7-1**] positive for
benzos in the urine which had been discontinued since [**6-23**].  It
is unclear why he had benzos in the urine at that time. Blood
toxicology was negative.

Of note Mrs. [**Known lastname 431**] was updated daily by several members of the
medical team including Dr. [**Last Name (STitle) **] (attending), Dr. [**Last Name (STitle) 3315**] (pgy3),
and Dr. [**Last Name (STitle) **] (pgy1).  She repeatedly expressed concern that we
were not caring for her husband well. [**Name2 (NI) **] was transferred to
[**Hospital 26260**] Hospital on [**2185-7-2**] per the wishes of his wife.


Medications on Admission:
Lantus 12 units
Metformin 500 mg [**Hospital1 **]
Lisinopril 30 mg qam
Nifedipine 30 mg qam
Simvastatin 10 mg pm
Pancrease 10 mg TID
Clonazepam 0.5 mg qid
Citalopram 40 mg qam
Albuterol NEB
Prilosec 20 mg pm
Chromium 500 mcg
Fenugreek 600 mg [**Hospital1 **]/meals


Discharge Medications:
1. Lipase-Protease-Amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Lisinopril 20 mg Tablet Sig: 1.5 Tablets PO QAM (once a day
(in the morning)).
4. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. Multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).

9. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1)  PO BID (2
times a day).
10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection three times a day.
11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
12. Insulin
per attached sliding sclae
13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed for constipation.
14. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours).
15. Haloperidol Lactate 2 mg/mL Concentrate Sig: o.5  PO BID (2
times a day).
16. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
17. Ondansetron 4 mg IV Q6H:PRN nausea


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Primary diagnosis: C7 superior facet fracture and C6 perched
right inferior facet with C6-7 disc injury, delirium, ?NMS,
failed speech and swallow
Secondary diagnoses: Diabetes mellitus type 2, hypertension,
alcohol abuse, pancreatic insufficiency, history of prostate
cancer s/p prostatectomy


Discharge Condition:

Discharge Instructions:
You were admitted after falling off a ladder and fracturing a
cervical vertebra (a part of your spine). Our surgeons performed
anterior and posterior fusion of your cervical spine. You
[**Hospital1 18095**] a fall while you were in the hospital. CT scans of
your head and spine showed no acute bleeding in your head and no
disruption of your spine. An elbow x-ray showed a tiny
nondisplaced fracture of your right radius (one of the bones in
your forearm), and you were given a sling. It was not possible
to tell the age of that fracture.
.
You were very confused at the hospital and psychiatry was
consulted.  You are now on haldol. Your confusion is getting
better.
.
You also showed symptoms of alcohol withdrawal which was treated
with medications. You should abstain from alcohol in the future.
You also had some confusion due to sedating medications which
slowly improved. You had some fevers that were thought to be due
to neuroleptic malignant syndrome (in which patients develop
high temperatures due to psychiatric medications) or aspiration
pneumonia.  However, your chest x ray was clear, making
pneumonia less likely.  Your fevers resolved when your
psychiatric medications were stopped, your psych medications
will be restarted after transfer to your new hospital but they
may be restarted slowly. We started your citalopram at a low
dose on [**2185-7-1**].
.
You had persistent difficulty with swallowing, as shown by
several swallowing tests in the hospital.  As a result of your
swallowing difficulties, you like aspirated while in the
hospital. We tried to give you nutrition through a tube that
goes through your nose into your stomach but you pulled it out
several times.  You will likely need a more long-term source of
nutrition such as a PEG tube, which is a tube that goes into
your stomach and attaches to the outside.  You will be
transferred to an outside hospital as you and your family
requested.  There, this issue of the feeding tube should be
addressed further.  For now you have a tube through your nose.
.
Post op instructions from our surgeons:
-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: 2-3 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. Limit any kind of lifting.
-Brace: You have been given a collar. This is to be worn for
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 once you
are taking things by mouth. No NSAIDs (ibuprofen, aleve).
-Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
.
We will send the doctors at your [**Name5 (PTitle) **] hospital a list of your
medications on transfer.

Followup Instructions:
Please schedule a follow-up appointment with Dr. [**Last Name (STitle) 363**] in 10
days at ([**Telephone/Fax (1) 11061**].



Completed by:[**2185-8-11**]
{'Closed fracture of seventh cervical vertebra,Closed dislocation, sixth cervical vertebra,Injury to bladder and urethra, without mention of open wound into cavity,Acute kidney failure, unspecified,Alcohol withdrawal delirium,Closed fracture of head of radius,Degeneration of cervical intervertebral disc,Unspecified essential hypertension,Malnutrition of moderate degree,Other specified diseases of pancreas,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Asthma, unspecified type, unspecified,Alcohol abuse, continuous,Other dysphagia,Anemia, unspecified,Foreign body in respiratory tree, unspecified,Depressive disorder, not elsewhere classified,Personal history of malignant neoplasm of prostate,Long-term (current) use of insulin,Accidental fall from chair,Accidental fall from ladder,Accidents occurring in residential institution,Unspecified accident,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation'}


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: Mr. [**Known lastname 431**] is a 68 year-old man with hx of alcohol abuse,
pancreatic insufficiency, DM, and HTN who was admitted on
[**2185-6-15**] to Ortho-Spine after falling from a 12-foot ladder while
intoxicated. MRI spine at [**Hospital **] Hospital revealed unstable
right C7 facet fracture and C6/7 disc herniation. He was
transferred to [**Hospital1 18**] for further management.

MEDICAL HISTORY: DM
HTN
Prostate cancer s/p prostatectomy
Alcohol abuse
Pancreatic insufficiency

MEDICATION ON ADMISSION: Lantus 12 units
Metformin 500 mg [**Hospital1 **]
Lisinopril 30 mg qam
Nifedipine 30 mg qam
Simvastatin 10 mg pm
Pancrease 10 mg TID
Clonazepam 0.5 mg qid
Citalopram 40 mg qam
Albuterol NEB
Prilosec 20 mg pm
Chromium 500 mcg
Fenugreek 600 mg [**Hospital1 **]/meals

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Vitals: T 98.3   BP 140/80   HR 67   RR 18   O2 sat 96%RA
General: alert and oriented to person but not place or time,
agitated and delirious
CV: RRR, no murmurs/rubs/gallops
Resp: CTAB, no wheezes/crackles/rhonchi
GI: Abd soft NT/ND, bowel sounds present
Extremities: BUE- 4/5 strength at deltoid and biceps, [**5-4**]
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: Lives with wife. [**Name (NI) **] history of tobacco or drug abuse. According
to wife, pt began drinking heavily at age 60 when diagnosed with
prostate cancer. He has been intermittently sober since then. He
has recently been drinking 0.5-1 pint vodka. He often goes
through withdrawal at home which manifests as tremors and
anxiety. He once had hallucinations, but there is no history of
seizures. 

### Response:
{'Closed fracture of seventh cervical vertebra,Closed dislocation, sixth cervical vertebra,Injury to bladder and urethra, without mention of open wound into cavity,Acute kidney failure, unspecified,Alcohol withdrawal delirium,Closed fracture of head of radius,Degeneration of cervical intervertebral disc,Unspecified essential hypertension,Malnutrition of moderate degree,Other specified diseases of pancreas,Diabetes with other specified manifestations, type II or unspecified type, uncontrolled,Asthma, unspecified type, unspecified,Alcohol abuse, continuous,Other dysphagia,Anemia, unspecified,Foreign body in respiratory tree, unspecified,Depressive disorder, not elsewhere classified,Personal history of malignant neoplasm of prostate,Long-term (current) use of insulin,Accidental fall from chair,Accidental fall from ladder,Accidents occurring in residential institution,Unspecified accident,Inhalation and ingestion of other object causing obstruction of respiratory tract or suffocation'}
