CHIEF COMPLAINT: fall, arm weakness/tingling

PRESENT ILLNESS: Asked to see this 51 year old white female for possible central
cord syndrome after a fall at home this evening. She is
hypotensive in the ED. She reports that she had a mechanical
fall at home today at 10pm.  Her mom (70 yrs old)
found her and called EMS. SHe thinks she may have lost
consciousness after the fall briefly.  Currently she admits to
tingling in the upper extremities.  She denies nausea vomiting
visual changes.

MEDICAL HISTORY: PE  / "almost killed me"
HTN

MEDICATION ON ADMISSION: COUMADIN
lisinopril 10 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: T: 96.3 BP: 119/ 76        HR:68    R  16     O2Sats99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-1**]        EOMis / 1cm laceration to chin /
abrasion and swelling to left forehead
Neck: in cervical collar
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives at home with her mom / not married / no children / works
in
a bank / [**12-4**] ppd tobacco x 20 yrs / dialy ETOH
C5-C7 level with central cord syndrome,Other and unspecified coagulation defects,Fall from other slipping, tripping, or stumbling,Closed dislocation, multiple cervical vertebrae,Alcohol abuse, continuous,Open wound of jaw, without mention of complication,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants
Central cord synd/c5-c7,Coagulat defect NEC/NOS,Fall from slipping NEC,Disloc mult cerv vert-cl,Alcohol abuse-continuous,Open wound of jaw,Hypertension NOS,Hx-ven thrombosis/embols,Long-term use anticoagul
Admission Date:  [**2169-1-10**]              Discharge Date:   [**2169-1-13**]

Date of Birth:  [**2117-11-13**]             Sex:   F

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
fall, arm weakness/tingling

Major Surgical or Invasive Procedure:
[**1-11**]: ACDF C4-5 C5-6


History of Present Illness:
Asked to see this 51 year old white female for possible central
cord syndrome after a fall at home this evening. She is
hypotensive in the ED. She reports that she had a mechanical
fall at home today at 10pm.  Her mom (70 yrs old)
found her and called EMS. SHe thinks she may have lost
consciousness after the fall briefly.  Currently she admits to
tingling in the upper extremities.  She denies nausea vomiting
visual changes.

Past Medical History:
PE  / "almost killed me"
HTN


Social History:
lives at home with her mom / not married / no children / works
in
a bank / [**12-4**] ppd tobacco x 20 yrs / dialy ETOH


Family History:
non-contributory

Physical Exam:
O: T: 96.3 BP: 119/ 76        HR:68    R  16     O2Sats99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-1**]        EOMis / 1cm laceration to chin /
abrasion and swelling to left forehead
Neck: in cervical collar
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3to2
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor:
UE's  grips [**1-7**], delt's [**4-6**], bicep [**4-6**], tricep 0/5
LE's 4+/5 throughout

Sensation: Intact to light touch, propioception.

On Discharge:
Motor: D B T IP Q H AT [**Last Name (un) **] [**Last Name (un) 938**]
     R 5 5 3  5 5 5  5  5    5
     L 5 5 3  5 5 5  5   5   5
Incision: c/d/i, steri strips in place and patient in c-collar.

Pertinent Results:
[**1-10**] CT Head: no acute pathology

[**1-10**] CT C-Spine:Reversal of the cervical kyphosis angled at C4-C5
with large disc-osteophyte complex causing severe narrowing of
the canal and predisposing the patient to cord injury in the
setting of trauma. Hyperdensity in the canal at this level
likely due to artifact rather than epidural collection/hematoma.
Grade I retrolisthesis of C5 on C6 with fractured osteophytes
concerning for acute subluxation. Slight widening of the
anterior C5-C6 and C6-C7 disc spaces raises concern for ALL
injury. MRI recommended for further evaluation as clinically
indicated.1 cm spiculated mass in the right lung apex. Could
represent scarring, but 3
month CT follow up recommended.

[**1-10**] C-spine MRI:
Grade 1 retrolisthesis of C4 on C5 with severe spinal canal
narrowing and spinal cord edema. This is likely a combination of
degenerative changes with superimposed trauma. Adjacent signal
changes could represent acute tear or sprain of the ALL, PLL and
posterior ligamentous complex. However, degenerative changes can
have similar appearance.

C-SPINE [**2169-1-10**]
AP and cross-table lateral supine images of the cervical spine.
Since
intraoperative exam six hours earlier on same day, the anterior
fusion of C4 through C6 has been completed with corresponding
anterior plate and C4-5 and C5-6 interbody graft. There is
associated prevertebral soft tissue swelling. Slight loss of
anterior superior height of C4 body. Visualized upper lungs
clear.


Brief Hospital Course:
Pre-Operative:
Patinet status post fall [**2169-1-9**]. C-spine MRI was obtained in the
emergency [**Hospital1 **] and revealed subluxation at C5-6 with cord
contusion at C4-5, C5-6. Radiological findings confirmed with
clinical evidence suggestive of central cord synrome. She was
put in a cervical collar and admitted to the ICU for close
neurological monitoring (Q2hr neuro checks). Additionally, she
was kept on pressors to keep pressures >120 SBP. Coagulopathy
corrected with vitamin K. She was taken to the OR for
stabilization via ACDF.

Operative:
Patient was taken to the Operating Room for ACDF on [**2169-1-10**].

Post-Operative:
Patient was taken to the ICU for blood pressure monitoring. On
[**1-11**], strength was improved as well as numbness and tingling.
Patient was transferred to the floor. PT was consulted. On [**1-12**],
it was determined that she needs rehab and on [**1-13**] patient was
discharged to rehab.

Medications on Admission:
COUMADIN
lisinopril 10 mg daily


Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain fever.
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet
PO Q4H (every 4 hours) as needed for pain fever.
4. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
5. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
6. Famotidine 20 mg IV Q12H
7. HYDROmorphone (Dilaudid) 0.5 mg IV Q4H:PRN pain
8. Metoclopramide 10 mg IV Q6H
9. Lorazepam 0.5-1 mg IV Q4H:PRN ciwa>10


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] Hispital

Discharge Diagnosis:
C5-6 Subluxation, central cord syndrome


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.


Discharge Instructions:
??????       *****You may restart your coumadin in 3 weeks
([**2169-2-3**])******
??????	Do not smoke.
??????	Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
??????	If you have steri-strips in place, you must keep them dry for
72 hours.  Do not pull them off. They will fall off on their own
or be taken off in the office.  You may trim the edges if they
begin to curl.
??????	No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
??????	Limit your use of stairs to 2-3 times per day.
??????	Have a friend or family member check your incision daily for
signs of infection.
??????	If you are required to wear one, wear your cervical collar or
back brace 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.
??????	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.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.


Followup Instructions:
Follow Up Instructions/Appointments

??????Please return to the office in [**6-11**] days (from date of surgery)
for removal of your sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner.  Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) 739**] to be seen in 4 weeks.
??????You will need AP/LAT c-spine images prior to your appointment.


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

Completed by:[**2169-1-13**]
{'C5-C7 level with central cord syndrome,Other and unspecified coagulation defects,Fall from other slipping, tripping, or stumbling,Closed dislocation, multiple cervical vertebrae,Alcohol abuse, continuous,Open wound of jaw, without mention of complication,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}


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: fall, arm weakness/tingling

PRESENT ILLNESS: Asked to see this 51 year old white female for possible central
cord syndrome after a fall at home this evening. She is
hypotensive in the ED. She reports that she had a mechanical
fall at home today at 10pm.  Her mom (70 yrs old)
found her and called EMS. SHe thinks she may have lost
consciousness after the fall briefly.  Currently she admits to
tingling in the upper extremities.  She denies nausea vomiting
visual changes.

MEDICAL HISTORY: PE  / "almost killed me"
HTN

MEDICATION ON ADMISSION: COUMADIN
lisinopril 10 mg daily

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: T: 96.3 BP: 119/ 76        HR:68    R  16     O2Sats99
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**2-1**]        EOMis / 1cm laceration to chin /
abrasion and swelling to left forehead
Neck: in cervical collar
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: lives at home with her mom / not married / no children / works
in
a bank / [**12-4**] ppd tobacco x 20 yrs / dialy ETOH 

### Response:
{'C5-C7 level with central cord syndrome,Other and unspecified coagulation defects,Fall from other slipping, tripping, or stumbling,Closed dislocation, multiple cervical vertebrae,Alcohol abuse, continuous,Open wound of jaw, without mention of complication,Unspecified essential hypertension,Personal history of venous thrombosis and embolism,Long-term (current) use of anticoagulants'}
