CHIEF COMPLAINT: Neck Pain and Decreased Extremity Movement

PRESENT ILLNESS: 24M with no significant PMH presents after cocaine use and
diving head-first off a dock into a [**Doctor Last Name **] with 2ft water.
Immediate decreased movement of upper and lower ext. No LOC, GCS
15, transferred from [**Hospital 46**] Hosp after receiving decadron.
Imaging revealed a C5 burst fracture.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: AVSS
Gen: WD/WN young male strapped to spine board
HEENT: laceration over right anterior scalp
Neck: TTP over C6-C7
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:
      D    B     T    WE   WF    IP    Q  H     AT    [**Last Name (un) 938**]    G
R     4    5     0    0    3     0     3  3     3     3      3

FAMILY HISTORY: N/C

SOCIAL HISTORY: + cocaine
Closed fracture of C5-C7 level with central cord syndrome,Other respiratory complications,Pulmonary collapse,Purulent endophthalmitis, unspecified,Accident from diving or jumping into water [swimming pool],Open wound of forehead, without mention of complication,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution,Retention of urine, unspecified
C5-c7 fx-cl/cen cord syn,Respiratory comp NEC,Pulmonary collapse,Purulent endophthalm NOS,Diving accident,Open wound of forehead,Abn react-artif implant,Accid in resident instit,Retention urine NOS
Admission Date:  [**2155-9-13**]              Discharge Date:   [**2155-9-20**]

Date of Birth:  [**2131-4-27**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Neck Pain and Decreased Extremity Movement

Major Surgical or Invasive Procedure:
Anterior corpectomy at C5 with C4-6 anterior/posterior fusion
with instrumentation and bone grafting


History of Present Illness:
24M with no significant PMH presents after cocaine use and
diving head-first off a dock into a [**Doctor Last Name **] with 2ft water.
Immediate decreased movement of upper and lower ext. No LOC, GCS
15, transferred from [**Hospital 46**] Hosp after receiving decadron.
Imaging revealed a C5 burst fracture.

Past Medical History:
None

Social History:
+ cocaine

Family History:
N/C

Physical Exam:
AVSS
Gen: WD/WN young male strapped to spine board
HEENT: laceration over right anterior scalp
Neck: TTP over C6-C7
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:
      D    B     T    WE   WF    IP    Q  H     AT    [**Last Name (un) 938**]    G
R     4    5     0    0    3     0     3  3     3     3      3

L     4    5     0    0    3     0     3  3     3     3      3

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

Reflexes: B T Br Pa
Right     0 0 0  2
Left      0 0 0  2

Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control
[**Doctor Last Name 937**] negative
No Clonus


Pertinent Results:
[**2155-9-15**] 05:17AM BLOOD WBC-13.8* RBC-3.90* Hgb-11.9* Hct-34.8*
MCV-89 MCH-30.6 MCHC-34.3 RDW-12.6 Plt Ct-189
[**2155-9-14**] 02:47AM BLOOD WBC-11.3* RBC-3.83* Hgb-11.6* Hct-34.5*
MCV-90 MCH-30.3 MCHC-33.7 RDW-13.0 Plt Ct-214
[**2155-9-13**] 11:51AM BLOOD WBC-11.1* RBC-4.26* Hgb-13.2* Hct-38.5*
MCV-91 MCH-30.9 MCHC-34.1 RDW-13.0 Plt Ct-259
[**2155-9-13**] 03:21AM BLOOD WBC-12.0* RBC-4.33* Hgb-13.2* Hct-38.3*
MCV-88 MCH-30.4 MCHC-34.5 RDW-13.0 Plt Ct-226
[**2155-9-14**] 02:47AM BLOOD Glucose-114* UreaN-12 Creat-0.9 Na-138
K-3.8 Cl-102 HCO3-28 AnGap-12
[**2155-9-13**] 11:51AM BLOOD Glucose-128* UreaN-8 Creat-1.0 Na-139
K-4.7 Cl-106 HCO3-24 AnGap-14
[**2155-9-14**] 02:47AM BLOOD Calcium-8.0* Phos-3.0# Mg-1.6
[**2155-9-13**] 11:51AM BLOOD Calcium-8.2* Phos-5.1* Mg-1.6

Brief Hospital Course:
Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2155-9-13**] and taken to the Operating Room for an anterior
corpectomy of C5 with C4-6 anterior/posterior fusion with
instrumentation. The surgery was without complication and the
patient was transferred to the SICU for monitoring.
TEDs/pnemoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were given per standard protocol.
Initial postop pain was controlled with a PCA. On HD#2 (/[**2152**])
he returned to the operating room for a scheduled posterior
decompression and fusion C4-6 part of a staged 2-part procedure.
Please refer to the dictated operative note for further details.
The second surgery was also without complication and the patient
was transferred to the PACU in a stable condition.
Post-op he developed what appeared to be a bacterial infection
in his left eye.  He was placed on ophthalmic antibiotics.
Postoperative HCT was stable. He was kept NPO until bowel
function returned then diet was advanced as tolerated. The
patient was transitioned to oral pain medication when tolerating
PO diet. Foley was removed on POD#2 from the second procedure,
however, needed to be replaced due to urinary retention.  Please
discontinue when able.  He was fitted with a cervical collar for
ambulation. Physical therapy was consulted for mobilization OOB
to ambulate. Hospital course was otherwise unremarkable.  He was
given a chest x-ray which showed atelectasis and he was started
on Cipro by Dr. [**Last Name (STitle) 363**] to prevent a pneumonia. On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.

Medications on Admission:
None

Discharge Medications:


1. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 5 mg [**1-13**] tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID Duration: 7
Days
RX *erythromycin 5 mg/gram (0.5 %) One application four times a
day Disp #*28 Tube Refills:*0
3. OxycoDONE (Immediate Release)  5-10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg [**1-13**] tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
4. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
C5 burst fracture
Central cord syndrome
Post-op atelectasis


Discharge Condition:
Good


Discharge Instructions:
Dear Mr. [**Known lastname **],

It was a pleasure taking care of you at [**Hospital1 18**].  You have
undergone the following operation: ANTERIOR/POSTERIOR Lumbar
Decompression With Fusion



Immediately after the operation:



-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.



-Rehabilitation/ Physical Therapy:

o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.


oLimit any kind of lifting.



-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.



-Collar: You have been given a collar. This is to be worn for
when you are walking. You may take it off when sitting in a
chair or while lying in bed.



-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.



-You should resume taking your normal home medications. No
NSAIDs.



-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.



Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.


Physical Therapy:
Activity:  Out of bed to chair qd
  Cervical collar:   when OOB

Treatments Frequency:
Please change the dressing daily.

Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days



Completed by:[**2155-9-17**]
{'Closed fracture of C5-C7 level with central cord syndrome,Other respiratory complications,Pulmonary collapse,Purulent endophthalmitis, unspecified,Accident from diving or jumping into water [swimming pool],Open wound of forehead, without mention of complication,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution,Retention of urine, unspecified'}


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 and Decreased Extremity Movement

PRESENT ILLNESS: 24M with no significant PMH presents after cocaine use and
diving head-first off a dock into a [**Doctor Last Name **] with 2ft water.
Immediate decreased movement of upper and lower ext. No LOC, GCS
15, transferred from [**Hospital 46**] Hosp after receiving decadron.
Imaging revealed a C5 burst fracture.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: AVSS
Gen: WD/WN young male strapped to spine board
HEENT: laceration over right anterior scalp
Neck: TTP over C6-C7
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:
      D    B     T    WE   WF    IP    Q  H     AT    [**Last Name (un) 938**]    G
R     4    5     0    0    3     0     3  3     3     3      3

FAMILY HISTORY: N/C

SOCIAL HISTORY: + cocaine 

### Response:
{'Closed fracture of C5-C7 level with central cord syndrome,Other respiratory complications,Pulmonary collapse,Purulent endophthalmitis, unspecified,Accident from diving or jumping into water [swimming pool],Open wound of forehead, without mention of complication,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation,Accidents occurring in residential institution,Retention of urine, unspecified'}
