CHIEF COMPLAINT: Lower back pain

PRESENT ILLNESS: Per the patient, she is a 58 y.o woman named [**Name (NI) 55388**]
[**Name (NI) 79724**]. She states she was riding on a boat near [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 19700**] [**2156-9-29**] when the boat struck a wave and slammed down
causing a strong axial load to her back. She was in a seated
position. There was no fall, but she reports immediate lower
back
pain that is sharp, and non-radiating. It was a [**10-8**]. She was
taken to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] hospital secured on a backboard. She
was
reported and documented to have a resultant L2 burst fracture.
She had not micturated or defecated since the accident. There
was no LOC or seizure activity at the scene.

MEDICAL HISTORY: osteoporosis
Hypothyroidism
Bilateral breast implants

MEDICATION ON ADMISSION: Actonel, Synthroid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 98.5 BP:128/78   HR:68    RR:16   O2Sats:97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA        EOMs full as tested
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Back: There is mild TTP over the spinous processes of L1-L3
Extrem: Warm and well-perfused.
Neuro:
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
R     5    5     5     5    5     5     5     5     5     5
L     5    5     5     5     5    5     5     5     5     5

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Hx: lives at home with husband. Does gardening as a hobby.
occasional ETOH use, no tobacco or illicit drugs.
Closed fracture of lumbar vertebra without mention of spinal cord injury,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Struck accidentally by falling object
Fx lumbar vertebra-close,Hypothyroidism NOS,Osteoporosis NOS,Struck by falling object
Admission Date:  [**2156-9-29**]              Discharge Date:   [**2156-10-3**]

Date of Birth:  [**2097-10-11**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3227**]
Chief Complaint:
Lower back pain

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Per the patient, she is a 58 y.o woman named [**Name (NI) 55388**]
[**Name (NI) 79724**]. She states she was riding on a boat near [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 19700**] [**2156-9-29**] when the boat struck a wave and slammed down
causing a strong axial load to her back. She was in a seated
position. There was no fall, but she reports immediate lower
back
pain that is sharp, and non-radiating. It was a [**10-8**]. She was
taken to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] hospital secured on a backboard. She
was
reported and documented to have a resultant L2 burst fracture.
She had not micturated or defecated since the accident. There
was no LOC or seizure activity at the scene.


Past Medical History:
osteoporosis
Hypothyroidism
Bilateral breast implants

Social History:
Hx: lives at home with husband. Does gardening as a hobby.
occasional ETOH use, no tobacco or illicit drugs.


Family History:
non-contributory

Physical Exam:
T: 98.5 BP:128/78   HR:68    RR:16   O2Sats:97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA        EOMs full as tested
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Back: There is mild TTP over the spinous processes of L1-L3
Extrem: Warm and well-perfused.
Neuro:
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
R     5    5     5     5    5     5     5     5     5     5
L     5    5     5     5     5    5     5     5     5     5

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally. There is no saddle anesthesia.

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

Propioception intact
Toes downgoing bilaterally
Rectal exam: + rectal tone.

Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct
[**2156-10-2**] 07:40AM 9.3 4.19* 13.0 38.5 92 31.0 33.7 12.9 282
  BASIC COAGULATION    PLT
[**2156-10-2**] 07:40AM    282

Chemistry
  RENAL & GLUCOSE Glucose UreaN Creat Na   K   Cl   HCO3 AnGap
[**2156-10-2**] 07:40   93      8    0.6  140 4.0 104    27    13
                          Calcium    Phos      Mg
                             8.6     2.6*     1.8
TOXICOLOGY, SERUM AND OTHER DRUGS ASA Ethanol Acetmnp Bnzodzp
Barbit  Tcl
[**2156-9-28**] 08:25PM               NEG   NEG1    NEG     NEG
NEG   NEG

CT L-spine:
IMPRESSION: Burst fracture of L2, with significant retropulsion
of the
fracture fragments and narrowing of the canal. MR of the lumbar
spine is
recommended to evaluate for cauda equina compression.

MR [**Name13 (STitle) **]:
1. L2 compression fracture with retropulsion of fracture
fragments causing
moderate-to-severe canal stenosis. This is below the level of
the conus;
however, it does cause complete effacement of the thecal sac
surrounding the cauda equina. Clinical correlation is
recommended to determine degree of nerve root compression.
2. Small, likely epidural, hematoma anterior to the cord
superior to the
region of canal stenosis.
3. Apparent discontinuity of the anterior longitudinal ligament
at the L2
level. The posterior longitudinal ligament, supraspinous
ligaments, and
interspinous ligaments appear intact.

Brief Hospital Course:
The patient was transferred to the [**Hospital1 18**] from [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**]
Hospital. She arrived in the ED and a Neurosurgery Consult was
obtained. Repeat CT of her T and L-spines were obtained
confirming her diagnosis of an L2 burst fracture with
retropulsion. An MRI was obtained for assessment of cord
compression and/or ligamentous injury.

After reviewing this case with several spine surgeons, a
spectrum of management options were discussed.  Ultimately, it
was felt that the patient can try a short course of lumbar
bracing -- reserving anterior stabilization should she fail
bracing challenge.  She was fitted  and recieved a TLSO brace
which should be worn at all times when up and out of bed.

While she had suffer some pain during initial attempts at
sitting, this pain improved significantly in subsequent days.
She was able to tolerate sitting, standing, and walking with the
help of PT.  Given her significant improvement, the patient was
discharged on [**2156-10-4**].

Medications on Admission:
Actonel, Synthroid

Discharge Medications:
1. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed.
3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-31**]
Drops Ophthalmic PRN (as needed).
4. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000
Injection TID (3 times a day).
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for Pain.
10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q3H (every 3 hours) as needed.
12. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed.
13. Ondansetron 4 mg IV Q8H:PRN


Discharge Disposition:
Extended Care

Facility:
[**Doctor First Name **] medical center

Discharge Diagnosis:
Lumbar 2 vertebral body burst fracture with retropulsion


Discharge Condition:
Stable


Discharge Instructions:
Spine Diagnosis Based Education:

1.  You should not over-exert yourself for the first few weeks
home.  Make sure you walk every day whatever distance is
comfortable. If your back or legs start to hurt, you have gone
too far. There is no stair climbing restriction but make sure to
use available hand rails.
2.  AVOID vigorous activities such as heavy house or yard work.
This also includes raking, shoveling and mowing the lawn.
3.  Do not lift greater than 10 lbs which is about one gallon of
milk.
4.  Do not sit upright in a straight chair for longer than 2
hours at a time. You may be more comfortable on a recliner,
couch or bed.  You must wear your brace when upright either
sitting or standing. Do not wear the brace in bed as it could
cause blistering or sores.
5.  Your travel will be limited. You cannot sit or stand longer
than two hours at a time.
6.  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.
     Do not take any anti-inflammatory medications such as
Motrin, Advil, Aspirin, and Ibuprofen etc. unless directed by
your doctor.
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 your surgeon or go to the nearest ER if you have:
Leg pain that is continually increasing or not relieved by pain
medications.
Call for any new weakness, numbness, tingling in your
extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness,drainage or if you develop a fever greater than or
equal to 101?????? F.
Any change in your bowel or bladder habits (such as loss of bowl
or urine control).

Followup Instructions:
Call Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] next week [**Telephone/Fax (1) 1669**] to update your
progress.



Completed by:[**2156-10-3**]
{'Closed fracture of lumbar vertebra without mention of spinal cord injury,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Struck accidentally by falling object'}


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: Lower back pain

PRESENT ILLNESS: Per the patient, she is a 58 y.o woman named [**Name (NI) 55388**]
[**Name (NI) 79724**]. She states she was riding on a boat near [**Initials (NamePattern4) **]
[**Last Name (NamePattern4) 19700**] [**2156-9-29**] when the boat struck a wave and slammed down
causing a strong axial load to her back. She was in a seated
position. There was no fall, but she reports immediate lower
back
pain that is sharp, and non-radiating. It was a [**10-8**]. She was
taken to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] hospital secured on a backboard. She
was
reported and documented to have a resultant L2 burst fracture.
She had not micturated or defecated since the accident. There
was no LOC or seizure activity at the scene.

MEDICAL HISTORY: osteoporosis
Hypothyroidism
Bilateral breast implants

MEDICATION ON ADMISSION: Actonel, Synthroid

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: 98.5 BP:128/78   HR:68    RR:16   O2Sats:97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA        EOMs full as tested
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Back: There is mild TTP over the spinous processes of L1-L3
Extrem: Warm and well-perfused.
Neuro:
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
R     5    5     5     5    5     5     5     5     5     5
L     5    5     5     5     5    5     5     5     5     5

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Hx: lives at home with husband. Does gardening as a hobby.
occasional ETOH use, no tobacco or illicit drugs. 

### Response:
{'Closed fracture of lumbar vertebra without mention of spinal cord injury,Unspecified acquired hypothyroidism,Osteoporosis, unspecified,Struck accidentally by falling object'}
