CHIEF COMPLAINT: 

PRESENT ILLNESS: 

MEDICAL HISTORY: Significant for a left ankle fracture,
appendectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Liver cancer.

SOCIAL HISTORY: A college student, no tobacco, drugs or
alcohol.
Sacral spinal cord injury without evidence of spinal bone injury,Retention of urine, unspecified,Nontraffic accident involving motor-driven snow vehicle injuring driver of motor vehicle other than motorcycle
Sacral spinal cord injur,Retention urine NOS,Snow veh acc-driver
Admission Date:  [**2135-1-3**]       Discharge Date:  [**2135-1-11**]

Date of Birth:   [**2105-5-7**]       Sex:  M

Service:  Trauma

ADMITTING DIAGNOSES:  Back pain, left lower extremity
weakness, and urine and stool incontinence.

SECONDARY DIAGNOSES:
1.  History of appendectomy.
2.  History of right ankle fracture.

ADMITTING HISTORY AND PHYSICAL:  A 29-year-old male without
significant past medical history presents complaining of
severe mid back pain, left lower extremity tingling and
weakness and heaviness as well as multiple episodes of urine
and stool incontinence today status post snowmobile accident
at 9 p.m. last night. The patient reports that his snowmobile
rolled over. He does not recall the details of the accident,
but he stated the vehicle rolled over him; no loss of
consciousness. He felt disoriented after the accident, able
to ambulate, incontinent of stool and urine at the time of
the accident, seen at an outside hospital. X-rays were taken,
discharged home, report of no injury. Today noticed
increasing back pain and heaviness of the left lower
extremity and tingling of the left lower extremity. There is
no abnormal sensation in the groin and rectal regions per his
report. The patient also complains of severe right upper
quadrant pain since yesterday, no nausea and vomiting, no
headache, no hematuria, no bright red blood per rectum.

PAST MEDICAL HISTORY:  Significant for a left ankle fracture,
appendectomy.

FAMILY HISTORY:  Liver cancer.

SOCIAL HISTORY:  A college student, no tobacco, drugs or
alcohol.

ADMISSION PHYSICAL EXAMINATION:  Temperature 97.8, pulse 121,
blood pressure 111/69, respirations 16, saturation 98%.
General: A well-developed, well-nourished, young male in no
apparent distress. Normocephalic, atraumatic. Mucous
membranes moist. Neck is nontender, in C-collar. Regular rate
and rhythm. Clear to auscultation bilaterally. Abdomen is
soft, tender to palpation in the right lower quadrant, no
guarding, no rebound. No skin abrasions or injuries. Back is
tender to palpation in the mid to lower back. Rectal has
slightly decreased tone, guaiac negative. Cranial nerves
II-XII intact, [**5-24**] upper extremity strength bilaterally,
normal sensation; in the abdomen and saddle region, slight
anesthesia below the umbilicus. Left lower extremity shows
anesthesia anteriorly. The right lower lobe shows anesthesia
anteriorly as well, not as extensive as on the left. The left
lower extremity shows decreased strength in all muscle
groups, approximately [**1-25**]. The right lower extremity shows
5/5 strength, normal sensation. There are no deformities in
either lower extremity.

ADMISSION LABORATORIES:  White count 10.3, hematocrit 42.8,
platelets 277,000. Chemistries as follows: 143, 4.2, 103, 29,
8, 0.9, 122, 9.6, 4.2, 1.8. Coags: 21.6, 1.0.

IMAGING:  Chest x-ray and pelvic x-ray negative. T- and
L-spine x-rays negative. CT of the abdomen and pelvic is
negative. MRI of the T-, L- and C-spine is negative.

Toxicology positive for benzodiazepines.

BRIEF HOSPITAL COURSE:  The patient was admitted to the ICU
setting for pain control and neurologic, neurosurgical
consultation obtained. Neurosurgical evaluation included
review of the MRI, which they agreed there were no findings.
They found decreased strength in the left lower extremity and
slight anesthesia of the upper right extremity and left lower
extremity to pinprick.

The patient remained in the intensive care unit setting for
approximately two days. The patient's lab exams were normal
while he was in there, with slightly magnesium, which was
repleted. The patient had a Foley in place. There was no
gross evidence of bowel incontinence observed by the nurses
while the patient was in the hospital.

The patient was eventually transferred to the floor. During
his stay, his pain was controlled with Dilaudid, PCA
initially and then switched to Dilaudid p.o. He was
maintained on Pepcid and heparin for prophylaxis. The patient
was initially n.p.o. with IV fluid but then was advanced to a
normal diet without event.

The patient did not tolerate removing the Foley as he was
unable to urinate without the Foley. He did have an episode
of hematuria, which was attributed to Foley trauma, possibly
due to the patient pulling at his own Foley.

A neurology consultation was obtained, and they suggested
cord contusion was the most likely explanation for his left
lower extremity weakness. As the patient presented outside
the 24-hour window for steroids, steroids were not used while
he was in the hospital.

The patient, additionally, had x-rays of his sacrum to rule
out fracture, which were negative, and he had a CT of his
pelvis, which was negative for fracture, ruling out any kind
of sacral fracture causing neurologic signs.

Physical therapy was consulted, and they were able to get him
out of bed and determined him safe for home and suggested
outpatient physical therapy be continued. However, as the
patient did not have appropriate insurance for VNA, he would
be unable to obtain this. However, it was determined that he
would be able to get up and get around at home without
difficulty.

The patient was eventually agreeable to discharge on [**1-10**] as he was tolerating a regular diet and his pain was well
controlled with Dilaudid.

A GU consultation was also obtained while he was in the
hospital for the slight hematuria and urinary retention. They
suggested the patient be discharged home with a leg bag and
follow up with neurology as previously scheduled to have his
Foley removed and have a voiding trial.

DISCHARGE INSTRUCTIONS:  The patient was discharged to home.
His instructions were to call the neurology or trauma doctors
if [**Name5 (PTitle) **] developed increasing weakness or concerning change in
sensation. His followup appointments were with the neurology
clinic in four to eight weeks for reevaluation and with
neurology clinic in seven days for removal of the Foley
catheter, with which he was discharged. He also had an AFO
placed for his left foot drop, which he was to wear at all
times.

DISCHARGE MEDICATIONS:  Bisacodyl suppository, Colace,
hydromorphone 2 mg tablets one to three tablets q.3-4h (50
were dispensed), and Ambien as needed for sleep.


                            [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D.  [**MD Number(1) 11889**]

Dictated By:[**Last Name (NamePattern1) **]
MEDQUIST36

D:  [**2135-1-12**]  14:18
T:  [**2135-1-12**]  15:30
JOB#:  [**Job Number 54280**]
{'Sacral spinal cord injury without evidence of spinal bone injury,Retention of urine, unspecified,Nontraffic accident involving motor-driven snow vehicle injuring driver of motor vehicle other than motorcycle'}


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: 

PRESENT ILLNESS: 

MEDICAL HISTORY: Significant for a left ankle fracture,
appendectomy.

MEDICATION ON ADMISSION: 

ALLERGIES: 

PHYSICAL EXAM: 

FAMILY HISTORY: Liver cancer.

SOCIAL HISTORY: A college student, no tobacco, drugs or
alcohol. 

### Response:
{'Sacral spinal cord injury without evidence of spinal bone injury,Retention of urine, unspecified,Nontraffic accident involving motor-driven snow vehicle injuring driver of motor vehicle other than motorcycle'}
