CHIEF COMPLAINT: Back and leg pain

PRESENT ILLNESS: Ms. [**Known lastname 50359**] has a long history of back and leg pain due to her
scoliosis.  She now presents for surgical intervention.

MEDICAL HISTORY: DJD, anxiety, reactive airway dz, chronic HA; [**Doctor First Name **]: knee scopes,
cervical fusion c4-5

MEDICATION ON ADMISSION: Fentanyl patch 50, ativan .5 tid, ativan 2 qhs, zoloft 200 qd,
toprol XL 25 [**Last Name (LF) **], [**First Name3 (LF) **], baclofen, benadryl, colace, nexium,
zantac.

ALLERGIES: Penicillins

PHYSICAL EXAM: NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; hyperreflexic at biceps, triceps and
brachioradialis
BLE-  good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes deminished at quads and Achilles

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies
Scoliosis [and kyphoscoliosis], idiopathic,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Asthma, unspecified type, unspecified,Other iatrogenic hypotension,Delirium due to conditions classified elsewhere,Arthrodesis status
Idiopathic scoliosis,Ac posthemorrhag anemia,Urin tract infection NOS,Asthma NOS,Iatrogenc hypotnsion NEC,Delirium d/t other cond,Arthrodesis status
Admission Date:  [**2129-11-21**]              Discharge Date:   [**2129-11-28**]

Date of Birth:  [**2068-9-23**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
Penicillins

Attending:[**First Name3 (LF) 3190**]
Chief Complaint:
Back and leg pain

Major Surgical or Invasive Procedure:
Thoracolumbar fusion for sccoliosis

History of Present Illness:
Ms. [**Known lastname 50359**] has a long history of back and leg pain due to her
scoliosis.  She now presents for surgical intervention.

Past Medical History:
DJD, anxiety, reactive airway dz, chronic HA; [**Doctor First Name **]: knee scopes,
cervical fusion c4-5

Social History:
Denies

Family History:
N/C

Physical Exam:
NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; hyperreflexic at biceps, triceps and
brachioradialis
BLE-  good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes deminished at quads and Achilles

Pertinent Results:
[**2129-11-25**] 03:11AM BLOOD WBC-10.2 RBC-2.66* Hgb-8.4* Hct-24.3*
MCV-91 MCH-31.6 MCHC-34.6 RDW-13.6 Plt Ct-201
[**2129-11-24**] 03:20AM BLOOD WBC-10.4 RBC-2.92* Hgb-9.1* Hct-26.0*
MCV-89 MCH-31.1 MCHC-34.9 RDW-14.1 Plt Ct-147*
[**2129-11-23**] 10:25PM BLOOD WBC-10.1 RBC-2.98* Hgb-9.5* Hct-27.4*
MCV-92 MCH-31.8 MCHC-34.6 RDW-14.0 Plt Ct-164
[**2129-11-23**] 02:24AM BLOOD WBC-9.6 RBC-3.01* Hgb-9.5* Hct-27.4*
MCV-91 MCH-31.5 MCHC-34.6 RDW-14.2 Plt Ct-147*
[**2129-11-22**] 05:14PM BLOOD WBC-8.9 RBC-3.19* Hgb-9.9* Hct-29.4*
MCV-92 MCH-31.1 MCHC-33.7 RDW-14.2 Plt Ct-157

Brief Hospital Course:
Ms. [**Known lastname 50359**] was admitted to the service of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] for a
thoracolumbar fusion for her scoliosis.  She was informed and
consented for the procedure and elected to proceed.  Please see
Operative Note for procedure in detail.
Post-operatively she was administered antibiotics and pain
medication.  She was in the SICU for two days where her
hematocrit was closely followed.  Her catheter and drain were
removed POD 3 and 4 respectively and she was able to take PO's.
She was diagnosed with a UTI and was placed on Cipro for 10
days. Her pain was well controlled and she remained afebrile
throughout her hosptial course.  She will return to clinic in
ten days.  She was discharged in good condition.


Medications on Admission:
Fentanyl patch 50, ativan .5 tid, ativan 2 qhs, zoloft 200 qd,
toprol XL 25 [**Last Name (LF) **], [**First Name3 (LF) **], baclofen, benadryl, colace, nexium,
zantac.

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed.
2. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
3. Diphenhydramine HCl 25 mg Capsule Sig: Two (2) Capsule PO Q6H
(every 6 hours) as needed.
4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2)
Spray Nasal DAILY (Daily).
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed.
7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed.
8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q12H (every 12 hours) as needed.
9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12
hours).
10. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QAM (once a day
(in the morning)).
11. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO QPM (once a day
(in the evening)).
12. Baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY 1200 ().

13. Baclofen 10 mg Tablet Sig: One (1) Tablet PO DAILY 1600 ().

14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
15. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO
0800,1200,1600 ().
16. Lorazepam 1 mg Tablet Sig: Two (2) Tablet PO HS (at
bedtime).
17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 1 weeks.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at
[**Hospital6 1109**] - [**Location (un) 1110**]

Discharge Diagnosis:
Scoliosis
UTI
Post-op anemia


Discharge Condition:
Good


Discharge Instructions:
Please continue to take your pain medication with an over the
counter laxative.  Call the clinic if you notice any redness or
discharge from the incision site.  Call the clinic for any
additional concerns.

Physical Therapy:
Activity:  Activity as tolerated
TLSO for ambulation; may be out of bed to chair without.

Treatments Frequency:
Please continue to change the dressings daily with dry, sterile
gauze.

Followup Instructions:
Please follow up in the Spine Clinic during your previously
scheduled appointments.



Completed by:[**2129-11-28**]
{'Scoliosis [and kyphoscoliosis], idiopathic,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Asthma, unspecified type, unspecified,Other iatrogenic hypotension,Delirium due to conditions classified elsewhere,Arthrodesis status'}


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 and leg pain

PRESENT ILLNESS: Ms. [**Known lastname 50359**] has a long history of back and leg pain due to her
scoliosis.  She now presents for surgical intervention.

MEDICAL HISTORY: DJD, anxiety, reactive airway dz, chronic HA; [**Doctor First Name **]: knee scopes,
cervical fusion c4-5

MEDICATION ON ADMISSION: Fentanyl patch 50, ativan .5 tid, ativan 2 qhs, zoloft 200 qd,
toprol XL 25 [**Last Name (LF) **], [**First Name3 (LF) **], baclofen, benadryl, colace, nexium,
zantac.

ALLERGIES: Penicillins

PHYSICAL EXAM: NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at biceps, triceps, wrist extension and
flexion, finger extension and flexion and intrinsics; sensation
intact in all dermatomes; hyperreflexic at biceps, triceps and
brachioradialis
BLE-  good strength at hip flexion and
extension/abduction/adduction, knee flexion and extension, ankle
dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact
distally; reflexes deminished at quads and Achilles

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies 

### Response:
{'Scoliosis [and kyphoscoliosis], idiopathic,Acute posthemorrhagic anemia,Urinary tract infection, site not specified,Asthma, unspecified type, unspecified,Other iatrogenic hypotension,Delirium due to conditions classified elsewhere,Arthrodesis status'}
