CHIEF COMPLAINT: Back pain due top scoliosis

PRESENT ILLNESS: Ms. [**Known lastname **] returns for her posterior thoracolumbar fusion.

MEDICAL HISTORY: Gout

MEDICATION ON ADMISSION: See previous list.

ALLERGIES: Prochlorperazine / Decongestant Sinus

PHYSICAL EXAM: A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives with husband.
Other kyphoscoliosis and scoliosis,Acute posthemorrhagic anemia,Accidental puncture or laceration of dura during a procedure,Hemorrhage complicating a procedure,Unspecified otitis media,Gout, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Other acute postoperative pain,Arthrodesis status,Other acquired deformity of back or spine,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Scoliosis NEC,Ac posthemorrhag anemia,Accid punc/op lac dura,Hemorrhage complic proc,Otitis media NOS,Gout NOS,Spin sten,lumbr wo claud,Acute postop pain NEC,Arthrodesis status,Other acq back deformity,Abn react-artif implant
Admission Date:  [**2186-3-27**]              Discharge Date:   [**2186-4-13**]

Date of Birth:  [**2137-5-24**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
Prochlorperazine / Decongestant Sinus

Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back pain due top scoliosis

Major Surgical or Invasive Procedure:
Removal previous [**Location (un) 931**] Rod Instrumentation
Total laminectomy of L5, L4, L3 and L2
Fusion T3-S1
Instrumentation L4-S1


History of Present Illness:
Ms. [**Known lastname **] returns for her posterior thoracolumbar fusion.

Past Medical History:
Gout

Social History:
Lives with husband.


Family History:
Non-contributory

Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles


Pertinent Results:
[**2186-4-12**] 09:47AM BLOOD WBC-7.5 RBC-4.11* Hgb-11.5* Hct-35.1*
MCV-85 MCH-28.0 MCHC-32.8 RDW-14.3 Plt Ct-653*
[**2186-4-9**] 02:14PM BLOOD WBC-6.1# RBC-3.92* Hgb-11.7* Hct-34.2*
MCV-87 MCH-29.7 MCHC-34.1 RDW-14.7 Plt Ct-439#
[**2186-4-7**] 07:06AM BLOOD WBC-14.0* RBC-3.29* Hgb-9.6* Hct-27.5*
MCV-83 MCH-29.1 MCHC-34.9 RDW-15.2 Plt Ct-260
[**2186-4-6**] 02:07AM BLOOD WBC-10.4# RBC-3.11* Hgb-8.9* Hct-26.5*
MCV-85 MCH-28.7 MCHC-33.6 RDW-14.9 Plt Ct-419
[**2186-4-4**] 08:55AM BLOOD WBC-4.3 RBC-3.72* Hgb-10.5* Hct-31.7*
MCV-85 MCH-28.1 MCHC-33.0 RDW-14.9 Plt Ct-400#
[**2186-4-9**] 02:14PM BLOOD Glucose-105* UreaN-4* Creat-0.4 Na-140
K-3.4 Cl-101 HCO3-31 AnGap-11
[**2186-4-6**] 02:07AM BLOOD Glucose-146* UreaN-9 Creat-0.5 Na-138
K-4.4 Cl-103 HCO3-29 AnGap-10
[**2186-4-4**] 08:55AM BLOOD Glucose-102* UreaN-15 Creat-0.4 Na-139
K-3.7 Cl-102 HCO3-28 AnGap-13
[**2186-3-29**] 01:04AM BLOOD Glucose-121* UreaN-11 Creat-0.5 Na-139
K-3.8 Cl-106 HCO3-26 AnGap-11

Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**3-27**] and taken to the Operating Room for a posterior
thoracolumbar fusion for scoliosis. Please refer to the dictated
operative note for further details. The patient was transferred
to the PACU in a stable condition. A lumbar drain was placed
intraoperatively due to a dural tear and was left in place for
one week.  TEDs/pnemoboots were used for postoperative DVT
prophylaxis. Intravenous antibiotics were given per standard
protocol. Initial postop pain was controlled with a PCA.
Postoperative HCT was low and she was transfused PRBCs.  She
remained flat for 48 hours and the head of her bed was slowly
elevated. She was kept NPO until bowel function returned then
diet was advanced as tolerated. The patient was transitioned to
oral pain medication when tolerating PO diet.  She was fitted
with a TLSO to be worn when ambulating or sitting in a chair.
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.

Medications on Admission:
See previous list.

Discharge Medications:
1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1)
Tablet, Chewable PO QID (4 times a day) as needed for heartburn.

2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Estroven Maximum Strength 400 mcg Tablet Sig: One (1) Tablet
PO Daily ().
5. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4
hours) as needed for pain.
6. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1)  PO
DAILY (Daily) as needed for constipation.
7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
constipation.
8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itching.
10. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
11. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three
(3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours).
12. Ciprofloxacin 500 mg Tablet Sig: 1.5 Tablets PO Q12H (every
12 hours) for 5 days.
13. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as
needed for spasm.


Discharge Disposition:
Extended Care

Facility:
apple rehab

Discharge Diagnosis:
Scoliosis
Post-op acute blood loss anemia
Dural tear


Discharge Condition:
Good


Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Thoracolumbar Decompression With 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 or stand
more than ~45 minutes without getting up and walking around.



-Rehabilitation/ Physical Therapy:

o2-3 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.


oLimit any kind of lifting.



-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.



-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.



-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. Cover it with a sterile dressing. Call the
office.



-You should resume taking your normal home medications. No
NSAIDs.



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



Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.


Physical Therapy:
Activity:  Activity as tolerated
 Thoracic lumbar spine:   when OOB
TLSO when OOB- Apply brace when sitting at bedside

Treatments Frequency:
Please change the dressing daily.

Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 2 weeks



Completed by:[**2186-4-13**]
{'Other kyphoscoliosis and scoliosis,Acute posthemorrhagic anemia,Accidental puncture or laceration of dura during a procedure,Hemorrhage complicating a procedure,Unspecified otitis media,Gout, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Other acute postoperative pain,Arthrodesis status,Other acquired deformity of back or spine,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}


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: Back pain due top scoliosis

PRESENT ILLNESS: Ms. [**Known lastname **] returns for her posterior thoracolumbar fusion.

MEDICAL HISTORY: Gout

MEDICATION ON ADMISSION: See previous list.

ALLERGIES: Prochlorperazine / Decongestant Sinus

PHYSICAL EXAM: A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles

FAMILY HISTORY: Non-contributory

SOCIAL HISTORY: Lives with husband. 

### Response:
{'Other kyphoscoliosis and scoliosis,Acute posthemorrhagic anemia,Accidental puncture or laceration of dura during a procedure,Hemorrhage complicating a procedure,Unspecified otitis media,Gout, unspecified,Spinal stenosis, lumbar region, without neurogenic claudication,Other acute postoperative pain,Arthrodesis status,Other acquired deformity of back or spine,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
