CHIEF COMPLAINT: Pain in neck following fall from horse.

PRESENT ILLNESS: History of fall from horse back with trauma to head and neck

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: tenderness over neck.
Bilateral upper extremity [**6-17**]
Bilateral lower extremities [**6-17**]

FAMILY HISTORY: 

SOCIAL HISTORY: 
Closed fracture of C5-C7 level with anterior cord syndrome,Accident involving animal being ridden injuring rider of animal,C5-C7 level with anterior cord syndrome,Closed dislocation, multiple cervical vertebrae,Stiffness of joint, not elsewhere classified, other specified sites,Disturbance of skin sensation,Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication,Morbid obesity
C5-c7 fx-cl/ant cord syn,Ridden animal acc-rider,Anterior cord synd/c5-c7,Disloc mult cerv vert-cl,Jt stiffness NEC-oth jt,Skin sensation disturb,Broken tooth-uncomplic,Morbid obesity
Admission Date:  [**2104-11-9**]              Discharge Date:   [**2104-11-13**]

Date of Birth:  [**2061-5-15**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Pain in neck following fall from horse.

Major Surgical or Invasive Procedure:
C4-C7 laminectomy with C3-T1 posterior instrumented spinal
fusion.


History of Present Illness:
History of fall from horse back with trauma to head and neck


Physical Exam:
tenderness over neck.
Bilateral upper extremity [**6-17**]
Bilateral lower extremities [**6-17**]

Pertinent Results:
[**2104-11-9**] 09:28PM   LACTATE-1.9
[**2104-11-9**] 09:28PM   LACTATE-1.9
[**2104-11-9**] 09:15PM   GLUCOSE-143* UREA N-14 CREAT-1.1 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
[**2104-11-9**] 09:15PM   estGFR-Using this
[**2104-11-9**] 09:15PM   estGFR-Using this
[**2104-11-9**] 09:15PM   WBC-15.7* RBC-4.72 HGB-14.7 HCT-41.6 MCV-88
MCH-31.2 MCHC-35.4* RDW-13.9

Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure.  Refer to
the dictated operative note for further details.  The surgery
was without complication and the patient was transferred to the
PACU in a stable condition.  TEDs/pnemoboots were used for
postoperative DVT prophylaxis.  Intravenous antibiotics were
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA.  Diet was advanced as tolerated.
 The patient was transitioned to oral pain medication when
tolerating PO diet.  Foley was removed on POD#3.  Physical
therapy was consulted for mobilization OOB to ambulate.
Hospital course was otherwise unremarkable.  On the day of
discharge the patient was afebrile with stable vital signs,
comfortable on oral pain control and tolerating a regular diet.

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*120 Tablet(s)* Refills:*0*
4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every six
(6) hours.
Disp:*120 Tablet(s)* Refills:*2*
5. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours): One
tablet BD for 7 days
One tablet OD for 7 days.
Disp:*21 Tablet Sustained Release 12 hr(s)* Refills:*0*
6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
Disp:*90 Capsule(s)* Refills:*2*


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**]

Discharge Diagnosis:
C6-C7 fracture dislocation.


Discharge Condition:
Stbale


Discharge Instructions:
You have undergone the following operation: Posterior Cervical
Decompression and 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 in a car
or chair for more than ~45 minutes without getting up and
walking around.

-	Rehabilitation/ Physical Therapy:
o	2-3 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.
o	Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.

-	Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks.  You may remove the collar to take a shower.  Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.

-	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. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.

-	You should resume taking your normal home medications.

-	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 narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy.  In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.

-	Follow up:	
o	Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o	At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o	We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.

Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.


Followup Instructions:
Follow up with Dr [**Last Name (STitle) 1007**] in 2 weeks following surgery.



Completed by:[**2104-11-13**]
{'Closed fracture of C5-C7 level with anterior cord syndrome,Accident involving animal being ridden injuring rider of animal,C5-C7 level with anterior cord syndrome,Closed dislocation, multiple cervical vertebrae,Stiffness of joint, not elsewhere classified, other specified sites,Disturbance of skin sensation,Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication,Morbid obesity'}


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: Pain in neck following fall from horse.

PRESENT ILLNESS: History of fall from horse back with trauma to head and neck

MEDICAL HISTORY: 

MEDICATION ON ADMISSION: 

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: tenderness over neck.
Bilateral upper extremity [**6-17**]
Bilateral lower extremities [**6-17**]

FAMILY HISTORY: 

SOCIAL HISTORY:  

### Response:
{'Closed fracture of C5-C7 level with anterior cord syndrome,Accident involving animal being ridden injuring rider of animal,C5-C7 level with anterior cord syndrome,Closed dislocation, multiple cervical vertebrae,Stiffness of joint, not elsewhere classified, other specified sites,Disturbance of skin sensation,Open wound of tooth (broken) (fractured) (due to trauma), without mention of complication,Morbid obesity'}
