CHIEF COMPLAINT: fall with T9,10,11 fractures and lower extremity paralysis

PRESENT ILLNESS: 57 yo obese man with HTN who sustained 3 ft fall from boat.
No deficits initially.  Went home initially and had back pain.
Presented to OSH ED walking in.  While there, developed
parasthesias in the bilateral LE.  Then developed weakness which
was eventually fulminant.  On transfer, had sensory level to all
modalities at level of umbilicus (T10) and complete LE
paralysis.

MEDICAL HISTORY: mild HTN.  He thinks he may have DM but has never been
told.

MEDICATION ON ADMISSION: Paxil 200 daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: AF  BP: 230/120     HR: 85    R: 85       O2Sats 97RA
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: C-collar.
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    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5     5    0     0      0     0     0
L     5    5     5    5     5    0     0      0     0     0

FAMILY HISTORY: not available

SOCIAL HISTORY: metal worker. Daughter is a hospitalist at Bay state.
Closed fracture of T7-T12 level with other specified spinal cord injury,Acute respiratory failure,Hyperpotassemia,Unspecified pleural effusion,Other fall from one level to another in water transport injuring occupant of small boat, powered,Unspecified essential hypertension
T7-t12 fx-cl/crd inj NEC,Acute respiratry failure,Hyperpotassemia,Pleural effusion NOS,W/craft fall NEC-power,Hypertension NOS
Admission Date:  [**2130-4-24**]              Discharge Date:   [**2130-5-3**]

Date of Birth:  [**2072-1-1**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
 fall with T9,10,11 fractures and lower extremity paralysis


Major Surgical or Invasive Procedure:
decompressive laminectomy of T8, T9 and T10 and
partially T7, evacuation of the
epidural hematoma and fusion

History of Present Illness:
57 yo obese man with HTN who sustained 3 ft fall from boat.
No deficits initially.  Went home initially and had back pain.
Presented to OSH ED walking in.  While there, developed
parasthesias in the bilateral LE.  Then developed weakness which
was eventually fulminant.  On transfer, had sensory level to all
modalities at level of umbilicus (T10) and complete LE
paralysis.


Past Medical History:
mild HTN.  He thinks he may have DM but has never been
told.


Social History:
metal worker. Daughter is a hospitalist at Bay state.


Family History:
not available

Physical Exam:
T: AF  BP: 230/120     HR: 85    R: 85       O2Sats 97RA
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: C-collar.
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    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5     5    0     0      0     0     0
L     5    5     5    5     5    0     0      0     0     0

Sensation: Complete sensory level around T10.  ntact to light
touch, propioception, pinprick and
vibration bilaterally.

Reflexes: B T Br Pa Ac
Right
Left

Propioception intact
Toes downgoing bilaterally
Rectal exam poor sphincter control

CT/MRI: CT from OSH shows Clam shell fracture T9/10.  No
Malignment.  No MRI available.


Pertinent Results:
[**2130-4-30**] 12:53AM BLOOD WBC-5.7 RBC-3.88* Hgb-11.5* Hct-34.2*
MCV-88 MCH-29.6 MCHC-33.6 RDW-14.8 Plt Ct-107*
[**2130-4-28**] 04:07AM BLOOD Neuts-93.0* Lymphs-3.4* Monos-3.2 Eos-0.2
Baso-0.2
[**2130-4-30**] 12:53AM BLOOD Glucose-108* UreaN-32* Creat-1.1 Na-147*
K-3.9 Cl-109* HCO3-34* AnGap-8
[**2130-4-30**] 12:53AM BLOOD Calcium-8.0* Phos-3.1 Mg-2.3
[**2130-4-30**] 01:39AM BLOOD Type-ART Temp-38.3 pO2-120* pCO2-64*
pH-7.37 calTCO2-38* Base XS-9

Thoracic MR [**4-24**]: T9 fracture with rupture of the anterior
longitudinal ligament and anterior epidural hematoma

CT Chest [**4-25**]: Atelectasis and/or consolidation along the medial
aspect of the left lung. This appearance may reflect pulmonary
contusion secondary to recent trauma. Small pleural effusions.
Fracture of a lower thoracic vertebral body. The endotracheal
tube is low.

CT C spine [**4-25**]: Horizontal fracture of the vertebral body of T9
with sparing of the posterior elements. Widened intervertebral
space at T8-9 reflective of disruption of the anterior
longitudinal ligament, but no spondylolisthesis. Mild
enlargement of epidural collection at this level compared to the
MR from the previous day.

Doppler US [**4-30**]: Grayscale and color Doppler son[**Name (NI) 867**] was
performed of the right and left common femoral, superficial
femoral, and popliteal veins. Normal compressibility, waveforms,
augmentation, and flow are demonstrated. No intraluminal
thrombus is identified.


Brief Hospital Course:
Neurological:

Patient arrived with complete paraplegia with sensory level
around T11.  Was emergenly scanned by MR and had findings of
epidural hematoma as reported above. He arrived on the steroid
protocol and this was continued for a 24 hour course.  Was taken
to the OR emergently for decompressive laminectomy.  Patient
tolerated procedure well.  TLSO has been prescribed
postoperatively.
Post-operatively, patient tolerated extubation.  Initially his
examination was unchanged with complete paraplegia and continued
T11 sensory level.  Over the next 48 hours he recooperated
partial sensation throughout the legs and lower abdomen.
However, at time of discharge on [**4-30**], patient was still unable
to exhibit any purposeful movement (continues to show some
reflexive tripple flexor response).  On discharge, the wound
looked clean, intact and without any sign of infection.
Prophylaxing the patient against DVT has been discussed and will
take place after transfer as an IVC filter is the recommendation
of Dr [**Last Name (STitle) 26803**].

Cards:

Patient did not have major cardiac events this admission.
Received large ammount of fluids on admission as part of
rescuscitation.  Was then having some respiratory compromise and
peripheral edema and was in process of diuresis on transfer.
Currently on a Lasix drip and diuresing well with negative 2
liters on [**4-29**] and negative 800CC [**Last Name (un) 834**] 0000 to 0800 [**4-30**].  At
this time, patient having CTA of the chest to work up his
apparent mismatch based on repeated ABGs.  Although pulmonary
embolism is on the differential, this would be a chronic rather
than acute pathophysiology as his aberrant ABGs are not new and
his oxygenation/hemodynamics have not decompensated.  CTA of the
chest pending at this time, and [**First Name8 (NamePattern2) **] [**Last Name (un) 6550**] to be followed up after
transfer.  Have also discussed doing an echocardiogram which is
not emergent but should be completed in near future.  This will
be done after transfer.

Resp:
patient repeatedly retaining high ammounts of CO2.  Was tried on
various settings of CPAP.  Had trials both of night time and
also round the clock, which he initially tolerated.  However, on
[**4-29**] he developed some respiratory distress and had to be
reintubated.  On intubation, there was copius ammounts of sputum
which were likely contributing to his poor respiratory status.
Other contributing factors of fluid over load, brace, habitus
and pain likely exacerbated this.  Patient currently intubated
on transfer.  Fluid overload as discussed above currently being
treated with Lasix Gtt and patient diuresing nicely.  CXR from
[**4-29**]: 1. Slight increase in perihilar edema. 2. Bibasilar
atelectasis and effusions.  3. Diffuse mediastinal widening due
to increased mediastinal fat deposition. and CXR from [**4-30**]
Accounting for positional differences probably no change with
pleural effusions, right greater than left. Lines and tubes as
described above.

GI: NG was placed [**4-29**] and patient was started on tube feeds.
Patient was treated prophylactically with protonix.

Renal: Patient had some mild renal insufficiency in the first 48
hours after admission.  Creatinine increased from 1.0 to 1.7,
but corrected without treatment to level of 1.1 on transfer.  Pt
was started on a lasix drip on [**4-29**] and adequate diuresis
achieved around 1L neg daily.

ID: initially no infectious issues.  Has been having fevers
including in the last 24 hours before transfer.  Is currently on
Piperacillin-Tazobactam 4.5 gm IV Q8hours (started [**4-29**] at
1600), Vancomycin 1000mg IV Q12 hours (started [**4-29**] at 1600).
Has negative/pending blood cultures [**Last Name (un) 834**] [**4-27**] and [**4-29**].  Sputum
culture from [**4-27**] contaminated by oral flora and sputum
Gram-stain from [**4-29**] showing oropharyngeal flora.  Culture [**Last Name (un) 834**]
[**4-29**] was NGTD at discharge.

Endo: Patient reported that he suspected he may have DM but had
never been medically tested.  Was maintained on a tight insuling
sliding scale throughout the admission.  Patient should have
HBA1c or some glucose tolerance testing in the near future.


Medications on Admission:
Paxil 200 daily


Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2)  PO BID (2
times a day).
4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
7. Sertraline 50 mg Tablet Sig: Four (4) Tablet PO DAILY
(Daily).
8. Insulin Regular Human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED): Q6H
Regular
Glucose Insulin Dose
0-60   mg/dL 4 oz. Juice
and 15 gm crackers
61-120   mg/dL 0   Units
121-140   mg/dL 2   Units
141-160   mg/dL 5   Units
161-180   mg/dL 8   Units
181-200   mg/dL 11   Units
201-220   mg/dL 14   Units
221-240   mg/dL 17   Units
241-260   mg/dL 20   Units
261-280   mg/dL 23   Units
281-300   mg/dL 26   Units
301-320   mg/dL 29   Units
> 320   mg/dL Notify M.D.
.
9. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q3-4H (Every 3 to 4 Hours) as needed.
10. Propofol 10 mg/mL Emulsion Sig: [**1-3**]  Intravenous TITRATE TO
(titrate to desired clinical effect (please specify)).
11. Ipratropium Bromide 0.02 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours).
12. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2)
Puff Inhalation Q4-6H (every 4 to 6 hours) as needed for
wheezing.
13. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation
Q6H (every 6 hours) as needed for wheezing.
14. Ranitidine HCl 15 mg/mL Syrup Sig: [**1-3**]  PO BID (2 times a
day).
15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
16. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
17. Sodium Chloride 0.9%  Flush 3 ml IV DAILY:PRN
Peripheral IV - Inspect site every shift
18. HYDROmorphone (Dilaudid) 0.5-2 mg IV Q4H:PRN pain
19. Heparin Flush CVL  (100 units/ml) 1 ml IV DAILY:PRN
10ml NS followed by 1ml of 100 units/ml heparin (100 units
heparin) each lumen QD and PRN.  Inspect site every shift
20. Potassium Chloride 40 mEq / 100 ml SW IV PRN K<4.0


Discharge Disposition:
Extended Care

Discharge Diagnosis:
Paraplegia with cord contusion T8-T9 and spinal epidural
hematoma from T7-T9 with instability T8-T9 with anterior
longitudinal ligament disruption s/p T7-T11 laminectomy
decompression and epidural hematoma evacuation.


Discharge Condition:
Stable.


Discharge Instructions:
Dr. [**Last Name (STitle) 739**] recommends pt have an IVC filter placed when
medically feasible at [**Hospital6 16029**].

Followup Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES

??????	Do not smoke
??????	Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
??????	If you have steri-strips in place ?????? keep dry x 72 hours.  Do
not pull them off. They will fall off on their own or be taken
off in the office
??????	No pulling up, lifting> 10 lbs., excessive bending or
twisting
??????	Limit your use of stairs to 2-3 times per day
??????	Have a family member check your incision daily for signs of
infection
??????	If you are required to wear one, wear cervical collar or back
brace as instructed
??????	You may shower briefly without the collar / back brace unless
instructed otherwise
??????	Take pain medication as instructed; you may find it best if
taken in the a.m. when you wake for morning stiffness and before
bed for sleeping discomfort
??????	Do not take any anti-inflammatory medications such as Motrin,
Advil, aspirin, Ibuprofen etc. unless directed by your doctor
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit

CALL YOUR SURGEON 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 signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????	Fever greater than or equal to 101?????? F
??????	Any change in your bowel or bladder habits
Please follow up with Dr. [**Last Name (STitle) 739**] [**Telephone/Fax (1) **] on [**2130-5-30**]
with CT scan of the thoracic spine.


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

Completed by:[**2130-5-3**]
{'Closed fracture of T7-T12 level with other specified spinal cord injury,Acute respiratory failure,Hyperpotassemia,Unspecified pleural effusion,Other fall from one level to another in water transport injuring occupant of small boat, powered,Unspecified essential hypertension'}


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 with T9,10,11 fractures and lower extremity paralysis

PRESENT ILLNESS: 57 yo obese man with HTN who sustained 3 ft fall from boat.
No deficits initially.  Went home initially and had back pain.
Presented to OSH ED walking in.  While there, developed
parasthesias in the bilateral LE.  Then developed weakness which
was eventually fulminant.  On transfer, had sensory level to all
modalities at level of umbilicus (T10) and complete LE
paralysis.

MEDICAL HISTORY: mild HTN.  He thinks he may have DM but has never been
told.

MEDICATION ON ADMISSION: Paxil 200 daily

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: T: AF  BP: 230/120     HR: 85    R: 85       O2Sats 97RA
Gen: WD/WN, comfortable, NAD.
HEENT: NCAT
Neck: C-collar.
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    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G
R     5    5     5    5     5    0     0      0     0     0
L     5    5     5    5     5    0     0      0     0     0

FAMILY HISTORY: not available

SOCIAL HISTORY: metal worker. Daughter is a hospitalist at Bay state. 

### Response:
{'Closed fracture of T7-T12 level with other specified spinal cord injury,Acute respiratory failure,Hyperpotassemia,Unspecified pleural effusion,Other fall from one level to another in water transport injuring occupant of small boat, powered,Unspecified essential hypertension'}
