CHIEF COMPLAINT: Back pain fall out of window

PRESENT ILLNESS: 25 y/o female became worried that intruder was breaking into
her house so she tried to escape via a bathroom window and fell
2
stories on to back. She had immediate back pain.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: BCP

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: O: T: 96.7 BP:124 /65 HR:96 R 18 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: neck in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Right ankle swelling.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G

FAMILY HISTORY: 2 Brothers with brain tumors

SOCIAL HISTORY: Hx:works as a waitress, lives with boyfriend in
[**Name (NI) 23962**]. Non smoker, [**3-17**] drinks per week, no drugs
Closed fracture of lumbar spine with spinal cord injury,Laceration of lung without mention of open wound into thorax,Accidental puncture or laceration during a procedure, not elsewhere classified,Drug-induced psychotic disorder with hallucinations,Accidental fall from or out of building or other structure,Home accidents,Posttraumatic stress disorder,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Delusional disorder,Other sedatives and hypnotics causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use
Cl lumbar fx w cord inj,Lung laceration-closed,Accidental op laceration,Drug psy dis w hallucin,Fall from building,Accident in home,Posttraumatic stress dis,Acc cut/hem in surgery,Delusional disorder,Adv eff sedat/hypnot NEC,Adv eff opiates
Admission Date:  [**2192-10-25**]              Discharge Date:   [**2192-11-5**]

Date of Birth:  [**2167-6-12**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Back pain fall out of window

Major Surgical or Invasive Procedure:
T12-L1 Laminectomies
T11-L3 Fusion


History of Present Illness:
25 y/o female became worried that intruder was breaking into
her house so she tried to escape via a bathroom window and fell
2
stories on to back. She had immediate back pain.


Past Medical History:
None

Social History:
Hx:works as a waitress, lives with boyfriend in
[**Name (NI) 23962**]. Non smoker, [**3-17**] drinks per week, no drugs

Family History:
2 Brothers with brain tumors

Physical Exam:
O: T: 96.7 BP:124 /65 HR:96 R 18 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: neck in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Right ankle swelling.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G

Sensation: Intact to light touch, propioception,
Reflexes: B T Br Pa Ac
Right 2+---------
Left 2+---------

Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control per ER resident



Pertinent Results:
[**2192-11-5**] 11:05AM BLOOD WBC-10.0 RBC-2.92* Hgb-9.1* Hct-26.9*
MCV-92 MCH-31.2 MCHC-34.0 RDW-13.1 Plt Ct-633*
[**2192-11-5**] 11:05AM BLOOD Plt Ct-633*
[**2192-11-5**] 11:05AM BLOOD Glucose-104 UreaN-8 Creat-0.7 Na-137
K-4.0 Cl-98 HCO3-30 AnGap-13
[**2192-10-25**] 05:31AM BLOOD Amylase-90
[**2192-11-5**] 11:05AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1
[**2192-10-30**] 06:40AM BLOOD TSH-2.3
[**2192-10-25**] 05:31AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG

Brief Hospital Course:
Ms [**Known lastname 410**] was admitted to the Neurosurgery service into the
trauma ICU for close observation of her neurological
funcitioning specifically her motor strenght.  She underwent an
MRI which showed: Burst fracture of L1 with retropulsion and
25-50% narrowing of the spinal canal with mild extrinsic
indentation on the anterior aspect of the distal spinal cord. No
evidence of abnormal signal within the cord.  She also underwent
multiple trauma view X-Rays which were negative.  On [**10-25**] she
had emergent surgery for thoracic/lumbar decompression and
instrumented fusion with laminectomies at T12-L1 and pedicle
screw fusions at T11-T12, L2-L3. Post operatively she remained
full strenght with no deficits.  On POD#2 she was transferred to
the surgical floor and received a TLSO brace and began to work
with physcial therapy.  On 914 she had a spinal angiogram to
assess her spinal arteries for the second stage of her surgery.

While on the surgical floor the patient was noted to be tearful
and emotionally labile psychiatry was consulted and treated her
for PTSD which they recommended discussing her anxieties.  A CT
was also done as her brother and sister have both had brain
tumors.

On [**11-1**] she underwent a anterior fixation of T12 to L2.  Post
operatively she had a chest tube in place for approximately 24
hours.  Again she was noted to be full strenght throughout
without any parastesias.  She began working with PT and was
found safe to be discharged on [**11-5**].  She was tolerating a
regular diet and voiding without anything difficulty.  She was
cleared to wear brace only when out of bed.


Medications on Admission:
BCP

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*40 Capsule(s)* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain: use while on Percocet.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
L1 Burst Fx


Discharge Condition:
Neurologically stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR SPINE CASES

??????	Do not smoke
??????	Keep wound(s) clean and dry / No tub baths or pools for two
weeks from your date of surgery
??????	If you have steri-strips in place ?????? keep dry x 72 hours.  Do
not pull them off. They will fall off on their own or be taken
off in the office
??????	No pulling up, lifting> 10 lbs., excessive bending or
twisting
??????	Limit your use of stairs to 2-3 times per day
??????	Have a family member check your incision daily for signs of
infection
??????	If you are required to wear one, wear cervical collar or back
brace as instructed
??????	You may shower briefly without the collar / back brace unless
instructed otherwise
??????	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
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit

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:
Have staples out on [**2192-11-12**] between 0900-1200
Follow up with Dr [**Last Name (STitle) **] in 4 weeks with CT of lumbar spine



Completed by:[**2192-11-9**]
{'Closed fracture of lumbar spine with spinal cord injury,Laceration of lung without mention of open wound into thorax,Accidental puncture or laceration during a procedure, not elsewhere classified,Drug-induced psychotic disorder with hallucinations,Accidental fall from or out of building or other structure,Home accidents,Posttraumatic stress disorder,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Delusional disorder,Other sedatives and hypnotics causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use'}


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 fall out of window

PRESENT ILLNESS: 25 y/o female became worried that intruder was breaking into
her house so she tried to escape via a bathroom window and fell
2
stories on to back. She had immediate back pain.

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: BCP

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: O: T: 96.7 BP:124 /65 HR:96 R 18 O2Sats 98%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: EOMs
Neck: neck in collar
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Right ankle swelling.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T FE FF IP Q AT [**Last Name (un) 938**] G

FAMILY HISTORY: 2 Brothers with brain tumors

SOCIAL HISTORY: Hx:works as a waitress, lives with boyfriend in
[**Name (NI) 23962**]. Non smoker, [**3-17**] drinks per week, no drugs 

### Response:
{'Closed fracture of lumbar spine with spinal cord injury,Laceration of lung without mention of open wound into thorax,Accidental puncture or laceration during a procedure, not elsewhere classified,Drug-induced psychotic disorder with hallucinations,Accidental fall from or out of building or other structure,Home accidents,Posttraumatic stress disorder,Accidental cut, puncture, perforation or hemorrhage during surgical operation,Delusional disorder,Other sedatives and hypnotics causing adverse effects in therapeutic use,Other opiates and related narcotics causing adverse effects in therapeutic use'}
