CHIEF COMPLAINT: 33M s/p 15' fall, unwitnessed, c ?SDH, small scattered bifrontal
SAH, T8-T9 fx

PRESENT ILLNESS: Pt sp unwitnessed [**2089**]5' from deck.  GCS on arrival to [**Hospital **]
Hospital 13-14.  Intubated [**2-6**] pt unable to follow commands.
Report of no LE movement but intact UE movement.

MEDICAL HISTORY: denies

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: pt arrived from outside hospital medically sedated and intubated
chest clear
heart regular
neck supple, no deformity
abdomen soft
spine:  palpable stepoff mid thoracic area
neuro:  sedated and intubated
vascular intact

FAMILY HISTORY: non contributory

SOCIAL HISTORY: ETOH
Tobacco
Marijuana
Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute posthemorrhagic anemia,Other accidental fall from one level to another
Fx dorsal vertebra-close,Subdural hem w/o coma,Ac posthemorrhag anemia,Fall-1 level to oth NEC
Admission Date:  [**2123-1-1**]              Discharge Date:   [**2123-1-8**]

Date of Birth:  [**2089-6-9**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
33M s/p 15' fall, unwitnessed, c ?SDH, small scattered bifrontal
SAH, T8-T9 fx

Major Surgical or Invasive Procedure:
Open reduction of T8-9 dislocation, instrumented spinal fusion
for T8 fracture.

History of Present Illness:
Pt sp unwitnessed [**2089**]5' from deck.  GCS on arrival to [**Hospital **]
Hospital 13-14.  Intubated [**2-6**] pt unable to follow commands.
Report of no LE movement but intact UE movement.

Past Medical History:
denies

Social History:
ETOH
Tobacco
Marijuana

Family History:
non contributory

Physical Exam:
pt arrived from outside hospital medically sedated and intubated
chest clear
heart regular
neck supple, no deformity
abdomen soft
spine:  palpable stepoff mid thoracic area
neuro:  sedated and intubated
vascular intact

Pertinent Results:
[**2123-1-1**] 08:12PM   GLUCOSE-133* UREA N-8 CREAT-0.9 SODIUM-136
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-22 ANION GAP-14
[**2123-1-1**] 08:12PM   WBC-10.5 RBC-3.11* HGB-9.6* HCT-28.2* MCV-91
MCH-31.0 MCHC-34.2 RDW-13.2
[**2123-1-1**] 08:12PM   PT-12.1 PTT-25.9 INR(PT)-1.0
[**2123-1-1**] 06:24PM   TYPE-ART PO2-112* PCO2-44 PH-7.35 TOTAL
CO2-25 BASE XS--1 INTUBATED-INTUBATED
[**2123-1-5**] 07:30AM BLOOD WBC-6.5 RBC-3.01* Hgb-9.1* Hct-26.6*
MCV-88 MCH-30.2 MCHC-34.3 RDW-12.9 Plt Ct-308
[**2123-1-5**] 07:30AM BLOOD PT-11.6 PTT-22.0 INR(PT)-1.0
[**2123-1-5**] 07:30AM BLOOD Glucose-125* UreaN-12 Creat-0.8 Na-134
K-4.0 Cl-97 HCO3-28 AnGap-13
[**2123-1-5**] 07:30AM BLOOD Calcium-8.8 Phos-2.0* Mg-2.3

Brief Hospital Course:
[**2123-1-1**]

CT HEAD: 1.  Small SAH and a 6-mm IPH/SAH within the left
parietal lobe.  No mass effect or midline shift.  The findings
are roughly stable compared to outside hospital CT taken one
hour prior.
.
CT TORSO: T8 3 colulmn injury with inevitable ligamentous
injury. T8 fx include: anterior superior corner, through
vertbral body, through left posterior costo-vertebral joint,
with perched facets (T8 on T9) bilaterally, anterolisthesis of
T8 on T9, T8 spinous process fx.  Bony fragments abut left side
of thecal sac at T8, with likely small epidural hematoma and no
obvious cord compression- to be evaluated by MRI. T9 fractures
include anterior superior corner --> through vertebral body -->
Left T9 transverse process.

Pt to OR with Ortho Spine for open redution and instrumented
fusion with no complication.

He tolerated the procedure well and returned to the ICU.  On POD
2, he was transferred to the spine service and the regular
hospital floor.

A TLSO brace was obtained for use with ambulation.

He remained medically stable with no complications of the
hospital stay.

A ambulated safely and was cleared by physical and occupational
therapy.

He was discharged to home in stable condition.


Medications on Admission:
none

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 10 mg Suppository Sig: One (1) Suppository Rectal
DAILY (Daily) as needed.
Disp:*10 Suppository(s)* Refills:*0*
3. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
4. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
Disp:*90 Tablet Sustained Release 12 hr(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
HomeHealth VNA

Discharge Diagnosis:
Thoracic spine fracture T8

Discharge Condition:
Good

Discharge Instructions:
Keep the incision dry.   You may shower as long as you cover the
incisions with Band-aids.  Do not take a bath or submerge the
incision under water.  You need to wear the brace whenever you
are out of bed.  You do not need the brace when you are in bed.

Do not lift anything heavier than a gallon of milk.  do not bend
or twist from the lower back.

Do not smoke.

call the office if you have a fever over 101F or if you have an
increase in pain or discharge from the incisions.


Physical Therapy:
Activity:  Out of bed to chair [**Hospital1 **]
 Thoracic lumbar spine:   when ambulating
pt may be OOB to chair without brace.

Treatment Frequency:
Please continue to change the dressings daily with dry sterile
gauze.

Followup Instructions:
Dr. [**Last Name (STitle) 363**] in 2 weeks, call the office for an appointment:  [**Telephone/Fax (1) 18552**]
{'Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute posthemorrhagic anemia,Other accidental fall from one level to another'}


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: 33M s/p 15' fall, unwitnessed, c ?SDH, small scattered bifrontal
SAH, T8-T9 fx

PRESENT ILLNESS: Pt sp unwitnessed [**2089**]5' from deck.  GCS on arrival to [**Hospital **]
Hospital 13-14.  Intubated [**2-6**] pt unable to follow commands.
Report of no LE movement but intact UE movement.

MEDICAL HISTORY: denies

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: pt arrived from outside hospital medically sedated and intubated
chest clear
heart regular
neck supple, no deformity
abdomen soft
spine:  palpable stepoff mid thoracic area
neuro:  sedated and intubated
vascular intact

FAMILY HISTORY: non contributory

SOCIAL HISTORY: ETOH
Tobacco
Marijuana 

### Response:
{'Closed fracture of dorsal [thoracic] vertebra without mention of spinal cord injury,Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Acute posthemorrhagic anemia,Other accidental fall from one level to another'}
