CHIEF COMPLAINT: status post fall

PRESENT ILLNESS: This is a 68 year old male who fell backwards at home on [**2130-2-2**]
and presented to the mergency department.There was no loss of
conciousness. At the time of admission he complained of pain
in his neck and back after this fall. He came to the emergency
[**Hospital1 **] and was evaluated with a head CT and Cspine CT. A
intercranial hemorhage was ruled out. A cervical spine CT showed
pre-vertebral swelling. He was completely neurologically intact,
and has no pain to palpation of his c-spine, he denied
difficulty breathing,and was
saturating appropriately on room air. Of note, he had spine
surgery in [**Month (only) 1096**](1 year ago) at [**Hospital6 **] hopsital.
The patientdoes not remember what type of surgery he had,
however, based onthe MRI and scar in posterior neck, he must
have had posterior
laminectomies. MRI cspine was done to evaluate this injury and
it just
re-confirmed the pre-vertebral swelling.

MEDICAL HISTORY: DM2 with neuropathy
Prostate cancer s/p prostatectomy
IgA gammopathy
Carcinoid s/p colectomy
Cervical spondylosis s/p C4-5 fusion and posterior
laminectomies.

MEDICATION ON ADMISSION: dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).

ALLERGIES: Penicillins / Shellfish

PHYSICAL EXAM: 99.3 80 159/80 16 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERLLA   EOMs Intact
Neck: No murmurs heard. Posterior neck scar is clean dry and
intact
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
5/5 strength BUE: deltoid, biceps, triceps, ECR,FCR,intrinsic
hand muscles.
5/5 strength BLE: hip flexors/extensors, knee flexors/extensors,
ankle plantarflexio/dorsiflexion.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: The patient is retired auto worker.  He says he
does use alcohol.  He has four children and four grandchildren.
C1-C4 level with unspecified spinal cord injury,Acute venous embolism and thrombosis of internal jugular veins,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of prostate,Arthrodesis status,Accidental fall on or from other stairs or steps
C1-c4 spin cord inj NOS,Ac embl internl jug vein,DMII neuro nt st uncntrl,Neuropathy in diabetes,Acquire absnce intestine,Hx-prostatic malignancy,Arthrodesis status,Fall on stair/step NEC
Name:  [**Known lastname 1923**],[**Known firstname 672**]                 Unit No:   [**Numeric Identifier 15724**]

Admission Date:  [**2130-2-3**]              Discharge Date:   [**2130-2-7**]

Date of Birth:  [**2061-7-28**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins / Shellfish

Attending:[**First Name3 (LF) 1698**]
Addendum:
Please call [**Telephone/Fax (1) 10038**] to schedule an appointment with ENT in
two weeks for further follow up.

Discharge Disposition:
Home With Service

Facility:
VNA of [**Location (un) 42**]

                             [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]

Completed by:[**2130-2-7**]

Admission Date:  [**2130-2-3**]              Discharge Date:   [**2130-2-7**]

Date of Birth:  [**2061-7-28**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins / Shellfish

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
status post fall

Major Surgical or Invasive Procedure:
none


History of Present Illness:
This is a 68 year old male who fell backwards at home on [**2130-2-2**]
and presented to the mergency department.There was no loss of
conciousness. At the time of admission he complained of pain
in his neck and back after this fall. He came to the emergency
[**Hospital1 **] and was evaluated with a head CT and Cspine CT. A
intercranial hemorhage was ruled out. A cervical spine CT showed
pre-vertebral swelling. He was completely neurologically intact,
and has no pain to palpation of his c-spine, he denied
difficulty breathing,and was
saturating appropriately on room air. Of note, he had spine
surgery in [**Month (only) 1096**](1 year ago) at [**Hospital6 **] hopsital.
The patientdoes not remember what type of surgery he had,
however, based onthe MRI and scar in posterior neck, he must
have had posterior
laminectomies. MRI cspine was done to evaluate this injury and
it just
re-confirmed the pre-vertebral swelling.


Past Medical History:
DM2 with neuropathy
Prostate cancer s/p prostatectomy
IgA gammopathy
Carcinoid s/p colectomy
Cervical spondylosis s/p C4-5 fusion and posterior
laminectomies.


Social History:
The patient is retired auto worker.  He says he
does use alcohol.  He has four children and four grandchildren.


Family History:
non contributory

Physical Exam:
99.3 80 159/80 16 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERLLA   EOMs Intact
Neck: No murmurs heard. Posterior neck scar is clean dry and
intact
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
5/5 strength BUE: deltoid, biceps, triceps, ECR,FCR,intrinsic
hand muscles.
5/5 strength BLE: hip flexors/extensors, knee flexors/extensors,
ankle plantarflexio/dorsiflexion.

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right     2 2 2  2   2
Left      2 2 2  2   2

Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control

exam upon discharge:

Pertinent Results:
[**2130-2-3**] 08:19PM   CRP-17.2*
[**2130-2-3**] 08:19PM   SED RATE-20*
[**2130-2-3**] 03:37PM   COMMENTS-GREEN TOP
[**2130-2-3**] 03:37PM   GLUCOSE-131* LACTATE-1.2 NA+-141 K+-4.3
CL--99* TCO2-28
[**2130-2-3**] 03:20PM   UREA N-19 CREAT-1.1
[**2130-2-3**] 03:20PM   WBC-5.4 RBC-4.40* HGB-13.3* HCT-38.3* MCV-87
MCH-30.2 MCHC-34.7 RDW-13.7
[**2130-2-3**] 03:20PM   NEUTS-53.9 LYMPHS-38.1 MONOS-5.9 EOS-1.5
BASOS-0.6
[**2130-2-3**] 03:20PM   PLT COUNT-168
[**2130-2-2**] 10:30AM   GLUCOSE-145* UREA N-21* CREAT-1.1 SODIUM-136
POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-23 ANION GAP-18
[**2130-2-2**] 10:30AM   estGFR-Using this
[**2130-2-2**] 10:30AM   WBC-7.1# RBC-4.86 HGB-14.3 HCT-41.8 MCV-86#
MCH-29.4 MCHC-34.2 RDW-13.6
[**2130-2-2**] 10:30AM   NEUTS-72.7* LYMPHS-21.2 MONOS-4.8 EOS-1.0
BASOS-0.2
[**2130-2-2**] 10:30AM   PLT COUNT-146*
[**2130-2-2**] 10:30AM   PT-12.8 PTT-25.7 INR(PT)-1.1

CT C-SPINE W/O CONTRAST Study Date of [**2130-2-2**] 10:17 AM
IMPRESSION:

1. Abnormal prevertebral soft tissue swelling extending from C2
through
C7-T1. There is also soft tissue stranding of the right neck
with associated
loss of fat planes. Recommend further evaluation of the neck
with MR.

2. Multilevel degenerative changes of the cervical spine
including
moderate-to-severe narrowing of the spinal canal at C5-6
secondary to a
bulging disc. Narrowing of the canal is also seen at C3-4 and
C6-7. In the
setting of trauma, narrowing of the central spinal canal can
predispose to
spinal cord injury.

3. Slight rotation of the C1 vertebral body on the C2 vertebral
body is
likely positional, although rotatory subluxation cannot be
excluded.

4. No evidence of fracture.

CT HEAD W/O CONTRAST Study Date of [**2130-2-2**] 10:17 AM
IMPRESSION: No acute intracranial process.

CHEST (PA & LAT) Study Date of [**2130-2-2**] 10:38 AM

IMPRESSION: No acute cardiopulmonary process.

MR CERVICAL SPINE W/O CONTRAST Study Date of [**2130-2-2**] 4:12 PM

IMPRESSION:
1. Extensive fluid signal and edema in the prevertebral space,
and involving
the right greater than left soft tissues of the neck, extending
inferiorly
below the level covered by this MRI. These findings are
concerning for an
acute process, such as infection or hematoma. The ALL is not
well seen
(artifact from the plate and screws limits evaluation) and may
be torn. CT
chest with contrast is suggested to assess the inferior extent
of this
process.

2. Interval increase in kyphotic angulation at C5-C6 with
moderate spinal
canal narrowing, worse compared to [**2128-11-14**]. This could
represent interval
worsening of degenerative disease, or acute injury.

3. Interval (when compared to [**2128-11-14**]) C3 and C4 laminectomy.
The
posterior paraspinal edematous changes could be residual
post-operative
changes, although acute traumatic injury to the structure is
possible as well.

4. Remote anterior fusion of C4 and C5, with underlying
degenerative changes
with a chronic myelomalacia changes at that level.


CTA NECK W&W/OC & RECONS Study Date of [**2130-2-3**] 5:23 PM

IMPRESSION:
1. No change in the size of the prevertebral soft tissue
swelling since the
previous cervical spine CT.
2. Compression of the left jugular vein with a small thrombus
identified as
described above.
3. No evidence of arterial injury seen or extravasation of
contrast in
relation with the veins identified.
4. Small metallic fragment is seen in the cervical spine, of
uncertain
significance, likely from previous surgical instrumentation.
5. Post-surgical changes in the region of cervical spondylosis.

CT CHEST W/CONTRAST Study Date of [**2130-2-3**] 5:23 PMIMPRESSION:
Soft tissue stranding and fluid of intermediate density
extending
from prevertebral space of the neck into the upper mediastinum
and right
supraclavicular fat. This is likely edema and hemorrhage
tracking inferiorly
from the cervical surgery but infection of it cannot be
excluded, though there
is no abnormal enhancement to suggest it.

Multiple lung nodules unchanged from [**2123**], benign.

MR THORACIC SPINE W/O CONTRAST Study Date of [**2130-2-4**] 12:18 AM
IMPRESSION: No evidence of fracture or intraspinal hematoma in
the thoracic region. No abnormal signal is seen within the
spinal cord. Upper thoracic prevertebral soft tissue swelling,
likely from extension from the cervical region.





Brief Hospital Course:
This is a 68 year old male who fell backwards at home on
[**2130-2-3**]. There was no loss of consiousness. He initially
complained of pain in his neck and back after this fall. He came
to the emergency [**Hospital1 **] and was evaluated with a head CT and
Cspine CT. Head bleed was ruled out. Cspine CT showed
pre-vertebral swelling.  On [**2-3**] he was admitted to the trauma
SICU with a hard cervical collar to be worn at all times.  A CTA
of the neck was performed which revealed compression of the left
jugular vein with a small thrombus.After discussion with
vascular surgery and trauma surgery, it was decided that you did
not need anticoagulation was not needed for this clot. You had a
repeat CT done that showed interval improvement in the
pre-vertebral swelling. Your condition is at baseline now and
your vitals are stable.


Medications on Admission:
dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).

latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2
times a day).
niacin 100 mg Tablet Sig: Five (5) Tablet PO BID (2 times a
day).
bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day).



Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
3. dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at
bedtime).
5. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
6. niacin 100 mg Tablet Sig: Five (5) Tablet PO BID (2 times a
day).
7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).


Discharge Disposition:
Home With Service

Facility:
VNA of [**Location (un) 86**]

Discharge Diagnosis:
prevertebral edema
left internal jugular thrombus


Discharge Condition:
AAO X 3
regular diet
baseline ambulation


Discharge Instructions:
??????	No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
??????	Wear your cervical collar at all times as instructed.
??????	You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
??????	Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
??????	Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
??????CALL IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING:

??????	Pain that is continually increasing or not relieved by pain
medicine.
??????	Any weakness, numbness, tingling in your extremities.
??????	Any change in your bowel or bladder habits (such as loss of
bowl or urine control).


Followup Instructions:
Follow Up Instructions/Appointments

??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 4 weeks.
??????You will/will not need x-rays/CT-scan prior to your
appointment.


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2130-2-7**]

Name:  [**Known lastname 1923**],[**Known firstname 672**]                 Unit No:   [**Numeric Identifier 15724**]

Admission Date:  [**2130-2-3**]              Discharge Date:   [**2130-2-7**]

Date of Birth:  [**2061-7-28**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins / Shellfish

Attending:[**First Name3 (LF) 1698**]
Addendum:
Patient was discharged home with services.

Discharge Disposition:
Home With Service

Facility:
VNA of [**Location (un) 42**]

                             [**Name6 (MD) **] [**Name8 (MD) 1041**] MD [**MD Number(2) 1709**]

Completed by:[**2130-2-7**]
{'C1-C4 level with unspecified spinal cord injury,Acute venous embolism and thrombosis of internal jugular veins,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of prostate,Arthrodesis status,Accidental fall on or from other stairs or steps'}


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: status post fall

PRESENT ILLNESS: This is a 68 year old male who fell backwards at home on [**2130-2-2**]
and presented to the mergency department.There was no loss of
conciousness. At the time of admission he complained of pain
in his neck and back after this fall. He came to the emergency
[**Hospital1 **] and was evaluated with a head CT and Cspine CT. A
intercranial hemorhage was ruled out. A cervical spine CT showed
pre-vertebral swelling. He was completely neurologically intact,
and has no pain to palpation of his c-spine, he denied
difficulty breathing,and was
saturating appropriately on room air. Of note, he had spine
surgery in [**Month (only) 1096**](1 year ago) at [**Hospital6 **] hopsital.
The patientdoes not remember what type of surgery he had,
however, based onthe MRI and scar in posterior neck, he must
have had posterior
laminectomies. MRI cspine was done to evaluate this injury and
it just
re-confirmed the pre-vertebral swelling.

MEDICAL HISTORY: DM2 with neuropathy
Prostate cancer s/p prostatectomy
IgA gammopathy
Carcinoid s/p colectomy
Cervical spondylosis s/p C4-5 fusion and posterior
laminectomies.

MEDICATION ON ADMISSION: dronabinol 2.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily).

ALLERGIES: Penicillins / Shellfish

PHYSICAL EXAM: 99.3 80 159/80 16 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:PERLLA   EOMs Intact
Neck: No murmurs heard. Posterior neck scar is clean dry and
intact
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
5/5 strength BUE: deltoid, biceps, triceps, ECR,FCR,intrinsic
hand muscles.
5/5 strength BLE: hip flexors/extensors, knee flexors/extensors,
ankle plantarflexio/dorsiflexion.

FAMILY HISTORY: non contributory

SOCIAL HISTORY: The patient is retired auto worker.  He says he
does use alcohol.  He has four children and four grandchildren. 

### Response:
{'C1-C4 level with unspecified spinal cord injury,Acute venous embolism and thrombosis of internal jugular veins,Diabetes with neurological manifestations, type II or unspecified type, not stated as uncontrolled,Polyneuropathy in diabetes,Acquired absence of intestine (large) (small),Personal history of malignant neoplasm of prostate,Arthrodesis status,Accidental fall on or from other stairs or steps'}
