CHIEF COMPLAINT: s/p fall

PRESENT ILLNESS: 74 y/o F presents from OSH s/p fall down 13 stairs. Patient
states that she had to use the bathroom and because of the
recent storm had no electricity in her home and fell down her
stairs. She does not recall if she lost consciousness, but
reports bilateral numbness and tingling. She states that the
numbness and
tingling start in her fingers, mostly in the thumbs, and
radiates towards her neck L arm and to the elbow in her R arm.
She denies any pain in her neck or bowel/bladder incontinence.
CT chest reveals spinous process fractures at C7 and T1 that are
minimally displaced.

MEDICAL HISTORY: osteoporosis

MEDICATION ON ADMISSION: MVI, caltrate, aspirin QOD

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Pupils: PERRL        EOMs: tracking
Neck: In hard cervical collar, neck tender to palpation

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives and takes care of husband, denies ETOH or tobacco
use.
Closed fracture of C1-C4 level with unspecified spinal cord injury,Accidental fall on or from other stairs or steps,Home accidents,Contusion of face, scalp, and neck except eye(s),Osteoporosis, unspecified,Other alteration of consciousness
C1-c4 fx-cl/cord inj NOS,Fall on stair/step NEC,Accident in home,Contusion face/scalp/nck,Osteoporosis NOS,Other alter consciousnes
Admission Date:  [**2109-9-2**]              Discharge Date:   [**2109-9-4**]

Date of Birth:  [**2035-6-12**]             Sex:   F

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
s/p fall

Major Surgical or Invasive Procedure:
none


History of Present Illness:
74 y/o F presents from OSH s/p fall down 13 stairs. Patient
states that she had to use the bathroom and because of the
recent storm had no electricity in her home and fell down her
stairs. She does not recall if she lost consciousness, but
reports bilateral numbness and tingling. She states that the
numbness and
tingling start in her fingers, mostly in the thumbs, and
radiates towards her neck L arm and to the elbow in her R arm.
She denies any pain in her neck or bowel/bladder incontinence.
CT chest reveals spinous process fractures at C7 and T1 that are
minimally displaced.


Past Medical History:
osteoporosis


Social History:
Lives and takes care of husband, denies ETOH or tobacco
use.


Family History:
non-contributory

Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Pupils: PERRL        EOMs: tracking
Neck: In hard cervical collar, neck tender to palpation

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
      D    B     T    IP    Q  H     AT    [**Last Name (un) 938**]    G
R     4    4+    4+   5-    5- 5-    5-     5-    5-
L     4-   4-    4+   5     5   5    5      5     5

Sensation: decreased sensation in the L forearm

On Discharge:
Motor:
      D    B     T    IP    Q  H     AT    [**Last Name (un) 938**]    G
R     4    4+    4+   5-    5- 5-    5-     5-    5-
L     3    4-    5-   5     5  5     5      5     5

Hard c-collar in place


Pertinent Results:
CT TORSO: [**2109-9-2**]- IMPRESSION:
1. Minimally displaced fractures of C7 and T1. No other
fractures, or
traumatic injury is present.
2. Fibroid uterus.

MRI C-Spine [**2109-9-2**]- IMPRESSION
1. Multiple fractures of the spinous process of C4, C7 and T1,
not as well
visualized on this study as CT.
2. Large prevertebral or retropharyngeal hematoma, 2.3 cm in
AP-width,
extends from skull base to C4 causing partial effacement of the
airway
3. Central canal stenosis at levels C5, C6 and C7.
4. Increased STIR signal in the interspinous ligaments of C2-C3
and C4-C5
suggestive of ligamentous injury.


Brief Hospital Course:
Pt was admitted to the ICU on the neurosurgery service for close
neurological observation and to monitor airway status secondary
to her retropharyngeal hematoma. An MRI of the C-spine was
completed and revealed cervical fractures, ligamentous injury
and the retropharyngeal hematoma. She was started on high dose
PO steroids.
The patient remained neurologically stable overnight and was
cleared for transfer to the stepdown unit on [**9-3**]. Decadron was
weaned and SBP was allowed to auto-regulate. On [**9-4**], she was
transferred to the floor and PT recommended rehab. She was
discharged to rehab on [**9-4**] after eating and voiding
appropriately.

Medications on Admission:
MVI, caltrate, aspirin QOD


Discharge Medications:
1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
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 BID (2 times a
day).
4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
5. insulin regular human 100 unit/mL Solution Sig: One (1)
Injection ASDIR (AS DIRECTED).
6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
7. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO q8 () for 1
days.
8. dexamethasone 1.5 mg Tablet Sig: Two (2) Tablet PO q8 () for
1 days.
9. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO q8 () for 1
days.
10. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO q8 () for
1 days.
11. dexamethasone 0.5 mg Tablet Sig: Two (2) Tablet PO q12 ()
for 1 days.
12. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**]

Discharge Diagnosis:
Cervical Spine Fractures
Spinal Cord Injury
Retropharyngeal hematoma


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
??????	Do not smoke.
??????	No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
??????	You are required to wear your cervical collar at all times
??????	Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
??????	Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
??????	Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit.


Followup Instructions:
Follow Up Instructions/Appointments

??????Please return to the office in [**7-14**] days (from date of surgery)
for removal of your staples/sutures and/or a wound check. This
appointment can be made with the Nurse Practitioner.  Please
make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite
a distance from our office, please make arrangements for the
same, with your PCP.
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**Last Name (STitle) **] to be seen in 4 weeks.
??????You will need an MRI c-spine w/ and w/o contrast



Completed by:[**2109-9-4**]
{'Closed fracture of C1-C4 level with unspecified spinal cord injury,Accidental fall on or from other stairs or steps,Home accidents,Contusion of face, scalp, and neck except eye(s),Osteoporosis, unspecified,Other alteration of consciousness'}


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 fall

PRESENT ILLNESS: 74 y/o F presents from OSH s/p fall down 13 stairs. Patient
states that she had to use the bathroom and because of the
recent storm had no electricity in her home and fell down her
stairs. She does not recall if she lost consciousness, but
reports bilateral numbness and tingling. She states that the
numbness and
tingling start in her fingers, mostly in the thumbs, and
radiates towards her neck L arm and to the elbow in her R arm.
She denies any pain in her neck or bowel/bladder incontinence.
CT chest reveals spinous process fractures at C7 and T1 that are
minimally displaced.

MEDICAL HISTORY: osteoporosis

MEDICATION ON ADMISSION: MVI, caltrate, aspirin QOD

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic
Pupils: PERRL        EOMs: tracking
Neck: In hard cervical collar, neck tender to palpation

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Lives and takes care of husband, denies ETOH or tobacco
use. 

### Response:
{'Closed fracture of C1-C4 level with unspecified spinal cord injury,Accidental fall on or from other stairs or steps,Home accidents,Contusion of face, scalp, and neck except eye(s),Osteoporosis, unspecified,Other alteration of consciousness'}
