CHIEF COMPLAINT: s/p MVA vs tree

PRESENT ILLNESS: HPI:19 yr old male unrestrained driver s/p car vs tree at
reported high rate of speed.  Per reports pt has not moved his
lower extremities.  Pt brought from scene to [**Hospital1 18**] for further
evaluation.  Pt was paralyzed, sedated and intubated in the
trauma bay upon arrival.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival
PHYSICAL EXAM:
T:  BP:122/72    HR:71    RR: 16       O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:         EOMs
Neck: Hard cervical collar on
Lungs: CTA bilaterally
Cardiac: NSR on monitor
Abd:
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated
Reportedly pt moving upper extremities spontaneously upon
arrival
w/ no movement of LE.  Per EMS report they also did not see any
movement of lower extremities.  Decreased rectal tone.  Pt
currently difficult to examine as he is paralyzed and sedated.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: noncontributory
Closed fracture of C5-C7 level with other specified spinal cord injury,Acute respiratory failure,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Open wound of ear, part unspecified, without mention of complication,Multiple and unspecified open wound of upper limb, without mention of complication,Closed fracture of nasal bones
C5-c7 fx-cl/cord inj NEC,Acute respiratry failure,Loss control mv acc-driv,Abn react-surg proc NEC,Open wound of ear NOS,Open wound arm mult/NOS,Nasal bone fx-closed
Admission Date:  [**2106-2-5**]              Discharge Date:   [**2106-2-16**]

Date of Birth:  [**2086-11-14**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
s/p MVA vs tree


Major Surgical or Invasive Procedure:
1. Anterior cervical discectomy with C6 C7 corpectomy with graft
2. IVCF
3. bronchospcopy
4. Tracheostomy placement
5. Percutaneous endoscopic gastrostomy tube placement


History of Present Illness:
HPI:19 yr old male unrestrained driver s/p car vs tree at
reported high rate of speed.  Per reports pt has not moved his
lower extremities.  Pt brought from scene to [**Hospital1 18**] for further
evaluation.  Pt was paralyzed, sedated and intubated in the
trauma bay upon arrival.


Past Medical History:
None

Social History:
noncontributory

Family History:
noncontributory

Physical Exam:
on arrival
PHYSICAL EXAM:
T:  BP:122/72    HR:71    RR: 16       O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:         EOMs
Neck: Hard cervical collar on
Lungs: CTA bilaterally
Cardiac: NSR on monitor
Abd:
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated
Reportedly pt moving upper extremities spontaneously upon
arrival
w/ no movement of LE.  Per EMS report they also did not see any
movement of lower extremities.  Decreased rectal tone.  Pt
currently difficult to examine as he is paralyzed and sedated.

Motor:
Moves upper extremities spontaneously; follows some simple
commands on upper extremities, no movement of lower extremities
spontaneosly or to painful stimuli

CURRENTLY
Afebrile, vital signs stable
Gen: WD/WN, comfortable, NAD.
HEENT: PERRLA, EOMI.
Neck: Tracheostomy site clean, intact.  ACDF incision clean,
dry, intact; staples removed.
Lungs: CTA bilaterally
Cardiac: NSR
Abd: Soft, NT, ND.
Extrem: Warm and well-perfused.
Neuro: Sensation to nipple level; none below.
Mental status: Alert & oriented x3, follows commands.
Motor:
   IP  Q  AT  G  [**Last Name (un) 938**]
R  0   0  0   0   0
L  0   0  0   0   0

   D   B  T   Grip
R  4+  5  3+  5
L  4+  5  4-  4+

Pertinent Results:
[**2106-2-14**] 04:01AM BLOOD WBC-9.2 RBC-2.96* Hgb-8.5* Hct-25.5*
MCV-86 MCH-28.8 MCHC-33.4 RDW-13.5 Plt Ct-327
[**2106-2-14**] 04:01AM BLOOD Glucose-105 UreaN-16 Creat-0.7 Na-143
K-3.9 Cl-106 HCO3-29 AnGap-12
[**2106-2-14**] 04:01AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.4*

Brief Hospital Course:
Pt was admitted through the emergency department to the ICU on
[**2106-2-5**].  He was brought to the operating room on [**2-5**] for
anterior cervical discectomy with corpectomies of C6 and 7 with
cage and plates placed.  A rigid cervical collar was re-applied
postoperatively.  He was returned to the ICU where his VS and
neurological exam were followed closely.

He was weaned and extubated on [**2-6**] and transferred to step down
neuro ICU.  Additional imaging of the spine to include MRI of T
and L spine were ordered.  An MRA of the Cervical spine was also
ordered to r/o vertebral artery dissection.  The pts diet was
advanced and he was tolerating PO intake without emesis or
difficulty.  His exam postoperatively was that he was paraplegic
to B/L LE's with patchy and inconsistent sensation to lower
thorax and legs.

Approx 12 MN on [**2-7**] into [**2-8**] the pts mother, who was at the
bedside felt that her son was not doing as well.  Pt was seen
and evaluated.  He was febrile now to 101.8 with slight inc in
resp's. His oxygen saturation was 96-98%.  Approx one hour later
he was re-evaluated and found to be more dysnpneic with
tachypnea to the low 40's.  ABG/CXR/ and cultures were obtained
as his temp had risen to 103.8 axillary.  He was transferred
back to the TICU within the hour.  He was monitored closely and
supportive care was given.

His resp status declined and the pt ultimately required
re-intubation at approx 3am on [**2-9**].  Repeat CXR was concerning
for hemothorax and also showed partial collapse of left lung. CT
chest showed no evidence of PNA and was suggestive of mucoid
impaction.  He had a bronchscopy at the bedside which yeilded a
large mucus plug.  He self extubated later that day and was
supported with suplimental O2.  MRI of the T-spine was obtained,
demonstrating s/p C5-T1 fusion for spinal injury with cord
transection at C6 levels, a small amount of subarachnoid
hemorrhage in the lumbosacral canal, and L5-S1 central disc
protrusion, with known nerve root impingement.

[**2-10**] CXR: Interval near complete drainage of left-sided pleural
effusion.
No pneumothorax identified on this upright radiograph.

[**2-11**] IVC placed and positioning confirmed via CXR. Tracheostomy
and PEG also placed.

[**2-12**] CTA C-spine: No vertebral artery dissection.

[**2-13**]: arterial line discontinued and tip sent for culture (no
growth).  C-collar removed while patient in bed.

[**2-14**]: Patient mobilization begun (out of bed with assist).

[**2-15**]: C-spine and T-spine films obtained.  Patient prepared for
discharge to extended care facility in [**Location (un) 9012**].  Patient was
stable at time of discharge summary completion, with no active
acute care issues.


Medications on Admission:
unknown

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H
(every 4 to 6 hours) as needed.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Neb
Inhalation Q6H (every 6 hours) as needed.
5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL
Injection TID (3 times a day).
6. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain for 7 days.
7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed.
9. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb
Inhalation Q6H (every 6 hours) as needed.
10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed.
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
12. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon
Soln Intravenous Q8H (every 8 hours) for 3 days.


Discharge Disposition:
Extended Care

Facility:
[**Last Name (un) 3952**]  Center

Discharge Diagnosis:
1. s/p C6 spinal cord injury
2. respiratory failure


Discharge Condition:
Stable

Discharge Instructions:
??????	Do not smoke
??????	Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
??????	No pulling up, lifting> 10 lbs., excessive bending or
twisting
??????	Have a your incision checked daily for signs of infection
??????	If you are required to wear one, wear cervical collar or back
brace as instructed
??????	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

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



Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH
DR.[**Last Name (STitle) **] UPON RETURN TO THE GREATER [**Location (un) **] AREA.
PLEASE OBTAIN AP & LATERAL X-RAYS OF YOUR C-SPINE AND T-SPINE IN
6 WEEKS.  PLEASE FAX A COPY OF THE REPORT TO DR.[**Doctor Last Name **] OFFICE.



Completed by:[**2106-2-15**]
{'Closed fracture of C5-C7 level with other specified spinal cord injury,Acute respiratory failure,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Open wound of ear, part unspecified, without mention of complication,Multiple and unspecified open wound of upper limb, without mention of complication,Closed fracture of nasal bones'}


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: s/p MVA vs tree

PRESENT ILLNESS: HPI:19 yr old male unrestrained driver s/p car vs tree at
reported high rate of speed.  Per reports pt has not moved his
lower extremities.  Pt brought from scene to [**Hospital1 18**] for further
evaluation.  Pt was paralyzed, sedated and intubated in the
trauma bay upon arrival.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: on arrival
PHYSICAL EXAM:
T:  BP:122/72    HR:71    RR: 16       O2Sats:100%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils:         EOMs
Neck: Hard cervical collar on
Lungs: CTA bilaterally
Cardiac: NSR on monitor
Abd:
Extrem: Warm and well-perfused.
Neuro:
Mental status: Intubated and sedated
Reportedly pt moving upper extremities spontaneously upon
arrival
w/ no movement of LE.  Per EMS report they also did not see any
movement of lower extremities.  Decreased rectal tone.  Pt
currently difficult to examine as he is paralyzed and sedated.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: noncontributory 

### Response:
{'Closed fracture of C5-C7 level with other specified spinal cord injury,Acute respiratory failure,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Open wound of ear, part unspecified, without mention of complication,Multiple and unspecified open wound of upper limb, without mention of complication,Closed fracture of nasal bones'}
