CHIEF COMPLAINT: neck pain

PRESENT ILLNESS: Mr. [**Known lastname **] is a 71M brought ot [**Hospital1 18**] ED s/p restrained driver of
a car vs. semi-truck.  The patient presented with head trauma,
and had been transferred from [**Hospital 8641**] Hospital with a C1/C2 burst
fracture.  The patient remaine AAOx3 throughout.  Steering wheel
intact and airbags not deployed
during the accident.  Pt reports neck pain as well as voice
changes.  Pt denies any SOB or pain with swallowing, and
reports improvement in his voice since admission though it is
not
back to normal yet.

MEDICAL HISTORY: PMHx: HTN
PSH: appendectomy, inguinal hernia repair

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Lying flat, hard collar intact, NAD
HEENT: Pupils:  [**4-7**]   EOMs intact,  no nasal drainage, left
lateral/proximal tongue with lacerated skin flap, ?rt upper
palate/gum fx at molar aspect
Neck: Hard collar intact
Extrem: Warm and well-perfused.
Neuro: Awake, cooperative with exam, speech fluent/conversant
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: retired, separated, denies tobacco/etoh/drug use
4 children
Closed fracture of C1-C4 level with unspecified spinal cord injury,Pneumonia, organism unspecified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Unspecified essential hypertension
C1-c4 fx-cl/cord inj NOS,Pneumonia, organism NOS,Ocl crtd art wo infrct,Mv collision NOS-driver,Hypertension NOS
Admission Date:  [**2130-12-19**]              Discharge Date:   [**2130-12-26**]

Date of Birth:  [**2059-10-27**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
neck pain

Major Surgical or Invasive Procedure:
Halo placement


History of Present Illness:
Mr. [**Known lastname **] is a 71M brought ot [**Hospital1 18**] ED s/p restrained driver of
a car vs. semi-truck.  The patient presented with head trauma,
and had been transferred from [**Hospital 8641**] Hospital with a C1/C2 burst
fracture.  The patient remaine AAOx3 throughout.  Steering wheel
intact and airbags not deployed
during the accident.  Pt reports neck pain as well as voice
changes.  Pt denies any SOB or pain with swallowing, and
reports improvement in his voice since admission though it is
not
back to normal yet.


Past Medical History:
PMHx: HTN
PSH: appendectomy, inguinal hernia repair


Social History:
retired, separated, denies tobacco/etoh/drug use
4 children

Family History:
non-contributory


Physical Exam:
Gen: Lying flat, hard collar intact, NAD
HEENT: Pupils:  [**4-7**]   EOMs intact,  no nasal drainage, left
lateral/proximal tongue with lacerated skin flap, ?rt upper
palate/gum fx at molar aspect
Neck: Hard collar intact
Extrem: Warm and well-perfused.
Neuro: Awake, cooperative with exam, speech fluent/conversant
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G

Sensation: Intact to light touch, propioception bilaterally.

No clonus

Propioception intact
Toes downgoing bilaterally


Pertinent Results:
[**2130-12-19**] 08:44PM BLOOD WBC-13.4* RBC-4.95 Hgb-16.0 Hct-43.9
MCV-89 MCH-32.2* MCHC-36.3* RDW-12.8 Plt Ct-166
[**2130-12-22**] 02:57AM BLOOD WBC-9.6 RBC-3.88* Hgb-12.5* Hct-34.8*
MCV-90 MCH-32.3* MCHC-36.0* RDW-13.1 Plt Ct-119*
[**2130-12-25**] 09:30AM BLOOD WBC-13.1* RBC-4.60 Hgb-14.8 Hct-40.7
MCV-88 MCH-32.1* MCHC-36.3* RDW-13.4 Plt Ct-157
[**2130-12-24**] 08:00AM BLOOD WBC-15.0*# RBC-4.66 Hgb-15.3 Hct-41.7
MCV-90 MCH-32.9* MCHC-36.7* RDW-12.6 Plt Ct-175
[**2130-12-19**] 08:44PM BLOOD PT-12.2 PTT-25.6 INR(PT)-1.0
[**2130-12-21**] 02:43AM BLOOD Glucose-145* UreaN-26* Creat-1.1 Na-140
K-4.4 Cl-104 HCO3-26 AnGap-14
[**2130-12-21**] 02:43AM BLOOD CK(CPK)-99
[**2130-12-25**] 07:15AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.6

CT C-Spine [**12-19**]:
1. [**Location (un) 5621**]-type fracture of C1.
2. Type III comminuted fracture of C2 with posterior angulation
of the superior fracture fragment and likely epidural hematoma
narrowing the spinal canal, likely compressing the spinal cord.
Extension of fracture lines into the transverse foramen
bilaterally.

MRA [**12-20**]: IMPRESSION: No evidence of arterial dissection.
Atherosclerotic plaque causing more than 90% stenosis at the
origin of left internal carotid artery.
MR [**Name13 (STitle) 76090**] [**12-20**]: IMPRESSION:
1. [**Location (un) 5621**] type C1 fracture and comminuted type III C2
fracture as described above.
2. Prevertebral swelling from C2-C4.
3. No evidence of cord signal abnormalities or cord compression.

[**12-24**] CT Chest IMPRESSION:
1. Predominantly left lower lobe pneumonia with small RLL
component and scattered peribronchovascular ground-glass
opacities within the remaining lobes likely also
infectious/inflammatory in etiology. Presence of secretions
within the distal trachea and proximal mainstem bronchi raises
suspicion for aspiration as the underlying etiology.

2. Hypoattenuating right thyroid lesion likely represents a
benign nodule. This can be evaluated with a dedicated ultrasound
on non-emergent basis.

3. Mild atherosclerotic disease within the left coronary
circulation.

Brief Hospital Course:
The patient was admitted to the Trauma ICU under the trauma
team.  He was evaluated with CT of the head adn torso for
further injuries.  The patient was found to have a C1-2 fracture
(for more details, see report), for which neurosurgery was
consulted.   The patient received dexamethasone, and had
frequent neurochecks for evaluation of any changes in his
neurological status.  The patient's blood pressure was
controlled on lopressor, and his oxygenation status was
constantly monitored.

On [**12-20**], otolaryngology was consulted to evaluate the patient's
airway, as the patient began experiencing changes in his voice
with copious secretions.  After fiberoptic examination, it was
felt that the patient's airway must be secured by intubation as
the patient had pooling of secretions, and pharyngeal wall
edema.
Anesthesia was called for nasopharyngeal fiberoptic intubation,
which was completed without complication.  The patient was
extubated on [**12-21**], and did well without any difficulty
protecting his airway.  The patient was noted, however to have a
pneumonia prior to discharge for which he was put on
levofloxacin for a 2 week course; a CT of the chest.  The
patient remained afebrile, with adequate cough, and was stable
for discharge to rehab with continued antibiotics.

As for the patient's neurologic status, a CT c-spine was
repeated, and and MRI/MRV/MRA was performed to evaluate for
epidural hematoma, cord contusion, and vascular injury.
Neurosurgery recommended a Halo, which was subsequently placed
at the bedside without further complications on [**12-21**].  The
patient was evaluated radiographically and found to have good
head alignment.

When appropriate followin extubation, the patient's diet was
advanced, his oxygen was weaned, and the patient was evaluated
and treated by physical and occupational therapy.   He also had
a nutrition consult for proper supplementation if necessary.
The patient was put on DVT and GI prophylaxis throughout his
stay.

Medications on Admission:
none

Discharge Medications:
1. Insulin Regular Human 100 unit/mL Solution Sig: One (1) vial
Injection ASDIR (AS DIRECTED). vial
2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q6H (every 6 hours) as needed for pain.
4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for fever: Max dosage is 4g/day (please be
careful with the use of percocet in addition) .
6. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 weeks.
Disp:*14 Tablet(s)* Refills:*0*
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
11. Pneumococcal 23-ValPS Vaccine 25 mcg/0.5 mL Injectable Sig:
One (1) vial Injection ASDIR8 (ASDIR): Pt may refuse if
previously vaccinated.
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) vial
Injection TID (3 times a day).
13. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
[**Location (un) 5621**] type fracture of C1, Type III comminuted fracture of
C2 with posterior angulation of the superior fracture fragment,
90% stenosis of left internal carotid artery


Discharge Condition:
good


Discharge Instructions:
Please call your doctor or return to the ER for any of the
following:
*New weakness, numbness or tingling in your extremities
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* Your pain is not improving within 8-12 hours or not gone
within 24 hours. Call or return immediately if your pain is
getting worse or is changing location or moving to your chest or

back.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
* Continue to ambulate several times per day.

Followup Instructions:
Please follow up with vascular surgery in [**2-7**] weeks for your
left internal carotid artery stenosis; all [**Telephone/Fax (1) 1237**] to make
an appointment.

Please follow up with trauma surgery in [**2-7**] weeks; call
[**Telephone/Fax (1) 6429**] to make an appointment.

Please follow up with Neurosurgery (Dr. [**Last Name (STitle) 548**] in [**5-12**] weeks (you
must wear your Halo for about 12 weeks); call [**Telephone/Fax (1) 1669**] to
schedule an appointment.

Please follow up with your PCP [**Last Name (NamePattern4) **] [**2-7**] weeks.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]
{'Closed fracture of C1-C4 level with unspecified spinal cord injury,Pneumonia, organism unspecified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,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: Mr. [**Known lastname **] is a 71M brought ot [**Hospital1 18**] ED s/p restrained driver of
a car vs. semi-truck.  The patient presented with head trauma,
and had been transferred from [**Hospital 8641**] Hospital with a C1/C2 burst
fracture.  The patient remaine AAOx3 throughout.  Steering wheel
intact and airbags not deployed
during the accident.  Pt reports neck pain as well as voice
changes.  Pt denies any SOB or pain with swallowing, and
reports improvement in his voice since admission though it is
not
back to normal yet.

MEDICAL HISTORY: PMHx: HTN
PSH: appendectomy, inguinal hernia repair

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: Lying flat, hard collar intact, NAD
HEENT: Pupils:  [**4-7**]   EOMs intact,  no nasal drainage, left
lateral/proximal tongue with lacerated skin flap, ?rt upper
palate/gum fx at molar aspect
Neck: Hard collar intact
Extrem: Warm and well-perfused.
Neuro: Awake, cooperative with exam, speech fluent/conversant
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: retired, separated, denies tobacco/etoh/drug use
4 children 

### Response:
{'Closed fracture of C1-C4 level with unspecified spinal cord injury,Pneumonia, organism unspecified,Occlusion and stenosis of carotid artery without mention of cerebral infarction,Other motor vehicle traffic accident involving collision with motor vehicle injuring driver of motor vehicle other than motorcycle,Unspecified essential hypertension'}
