CHIEF COMPLAINT: Back pain

PRESENT ILLNESS: Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She elects 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: vicodin 7.5/750 one tab daily
fosamax
diltiazem 120mg qd

ALLERGIES: Codeine / morphine

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
Other mechanical complication of other internal orthopedic device, implant, and graft,Acute posthemorrhagic anemia,Other acquired deformity of back or spine,Lumbosacral spondylosis without myelopathy,Scoliosis [and kyphoscoliosis], idiopathic,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other iatrogenic hypotension
Mech com orth dev NEC,Ac posthemorrhag anemia,Other acq back deformity,Lumbosacral spondylosis,Idiopathic scoliosis,Abn react-artif implant,Iatrogenc hypotnsion NEC
Admission Date:  [**2128-3-29**]              Discharge Date:   [**2128-4-2**]

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

Service: ORTHOPAEDICS

Allergies:
Codeine / morphine

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

Major Surgical or Invasive Procedure:
T9-S1 posterior fusion


History of Present Illness:
Ms. [**Known lastname **] has a long history of back pain due to scoliosis.
She elects 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:
[**2128-4-1**] 06:30AM BLOOD WBC-4.8 RBC-3.29* Hgb-10.1* Hct-30.9*
MCV-94 MCH-30.7 MCHC-32.7 RDW-14.9 Plt Ct-130*
[**2128-3-31**] 05:20AM BLOOD WBC-5.8 RBC-3.35* Hgb-10.3* Hct-31.6*
MCV-94 MCH-30.7 MCHC-32.5 RDW-15.4 Plt Ct-101*
[**2128-3-30**] 06:00AM BLOOD WBC-5.7 RBC-2.70* Hgb-8.4* Hct-26.2*
MCV-97 MCH-31.2 MCHC-32.2 RDW-14.0 Plt Ct-102*
[**2128-3-29**] 05:19PM BLOOD WBC-7.7 RBC-3.25* Hgb-10.2* Hct-30.9*
MCV-95# MCH-31.5 MCHC-33.1 RDW-14.2 Plt Ct-112*
[**2128-3-31**] 05:20AM BLOOD Glucose-108* UreaN-4* Creat-0.5 Na-142
K-3.4 Cl-109* HCO3-29 AnGap-7*
[**2128-3-29**] 05:19PM BLOOD Glucose-162* UreaN-8 Creat-0.6 Na-140
K-3.8 Cl-109* HCO3-24 AnGap-11

Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for
a posterior thoracolumbar fusion with instrumentation.  She was
informed and consented and elected to proceed.  Please see
Operative Note for procedure in detail.
Post-operatively she was given antibiotics and pain medication.
An epidural was placed intraoperatively and this was removed POD
1.  A hemovac drain was placed intra-operatively and this was
removed POD 2.  Her bladder catheter was removed POD 3 and her
diet was advanced without difficulty.  She was able to work with
physical therapy for strength and balance.  She was discharged
in good condition and will follow up in the Orthopaedic Spine
clinic.


Medications on Admission:
vicodin 7.5/750 one tab daily
fosamax
diltiazem 120mg qd


Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
2. 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*
3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO DAILY (Daily).
4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours).
Disp:*8 Tablet(s)* Refills:*0*
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
7. zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for sleep.
Disp:*60 Tablet(s)* Refills:*0*
8. diazepam 5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for spasm.
Disp:*90 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Scoliosis and kyphosis
Acute post-op blood loss anemia


Discharge Condition:
Good


Discharge Instructions:
You have undergone the following operation: Posterior
thoracolumbar fusion T9-S1


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.



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



Completed by:[**2128-4-15**]
{'Other mechanical complication of other internal orthopedic device, implant, and graft,Acute posthemorrhagic anemia,Other acquired deformity of back or spine,Lumbosacral spondylosis without myelopathy,Scoliosis [and kyphoscoliosis], idiopathic,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other iatrogenic hypotension'}


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 elects 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: vicodin 7.5/750 one tab daily
fosamax
diltiazem 120mg qd

ALLERGIES: Codeine / morphine

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:
{'Other mechanical complication of other internal orthopedic device, implant, and graft,Acute posthemorrhagic anemia,Other acquired deformity of back or spine,Lumbosacral spondylosis without myelopathy,Scoliosis [and kyphoscoliosis], idiopathic,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Other iatrogenic hypotension'}
