CHIEF COMPLAINT: back and leg pain

PRESENT ILLNESS: A 62-year-old woman who suffered from neurogenic claudication
and lumbar stenosis. Conservative therapy had been unsuccessful
in ameliorating his symptoms.

MEDICAL HISTORY: fibromyalgia, arthritis, HL, glaucoma, lyme disease

MEDICATION ON ADMISSION: wellbutrin
eye drops

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: per medical record

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: nonsmoker , [**4-22**] EtOH per week
Lumbosacral spondylosis without myelopathy,Major depressive affective disorder, single episode, unspecified,Accidental puncture or laceration of dura during a procedure,Other specified retention of urine,Esophageal reflux,Pure hypercholesterolemia,Myalgia and myositis, unspecified,Acquired spondylolisthesis,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation
Lumbosacral spondylosis,Depress psychosis-unspec,Accid punc/op lac dura,Oth spcf retention urine,Esophageal reflux,Pure hypercholesterolem,Myalgia and myositis NOS,Acq spondylolisthesis,Abn react-artif implant
Admission Date:  [**2171-10-3**]              Discharge Date:   [**2171-10-7**]

Date of Birth:  [**2109-6-7**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
back and leg pain

Major Surgical or Invasive Procedure:
[**2171-10-3**]: L3-5 Laminectomy, facetectomy and fusion


History of Present Illness:
A 62-year-old woman who suffered from neurogenic claudication
and lumbar stenosis. Conservative therapy had been unsuccessful
in ameliorating his symptoms.


Past Medical History:
fibromyalgia, arthritis, HL, glaucoma, lyme disease

Social History:
nonsmoker , [**4-22**] EtOH per week

Family History:
non-contributory

Physical Exam:
per medical record

Exam upon discharge:
motor full
incision cdi with staples
foley in place


Brief Hospital Course:
Pt electively presented for lumbar decompression and fusion.
Surgery was without complication and the patient tolerated it
well. She was admitted for close monitoring and pain control to
the ICU post op.  She was kept flat until the morning for
intra-op dural leak and repair.
On POD#1 she required pain medication titration. On POD#2
ambulation was encouraged and PT was consulted for assistance
with discharge planning. Her incision was clean dry and intact
with staples.  Her foley was removed but she required multiple
straight catheterization and foley was replaced.  her pain was
managed and she was ambulating with walker.  She was seen by PT
and recommedned home with services. She received instructions
for leg bag and will get VNA at home for support.

Medications on Admission:
wellbutrin
eye drops

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
2. Risperidone 0.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6
hours) as needed for pain.
4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
5. Methocarbamol 500 mg Tablet Sig: One (1) Tablet PO TID (3
times a day).
Disp:*90 Tablet(s)* Refills:*2*
6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
7. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as
needed for insomnia.
8. Butalbital-Acetaminophen-Caff 50-325-40 mg Tablet Sig: [**1-19**]
Tablets PO Q8H (every 8 hours) as needed for headache.
Disp:*30 Tablet(s)* Refills:*0*
9. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **]
(2 times a day).
10. Cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic daily ().
11. Bupropion HCl 100 mg Tablet Sustained Release Sig: Two (2)
Tablet Sustained Release PO BID (2 times a day).
12. Simvastatin 10 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).


Discharge Disposition:
Home With Service

Facility:
Community Nurse [**First Name (Titles) **] [**Last Name (Titles) **] Care,Inc

Discharge Diagnosis:
lumbar stenosis
urinary retention

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:
DISCHARGE INSTRUCTIONS FOR SPINE CASES

??????        Do not smoke
??????        Keep wound clean / No tub baths or pools until seen in
follow up/ begin daily showers [**2171-10-7**]
??????        No pulling up, lifting> 10 lbs., excessive bending or
twisting for two weeks.
??????        Limit your use of stairs to 2-3 times per day
??????        Have a family member check your incision daily for
signs of infection
??????        Take pain medication as instructed; you may find it
best if taken in the a.m. when you wake if you experience muscle
stiffness and before bed for sleeping discomfort
??????        Do not take any anti-inflammatory medications such as
Motrin, Advil, aspirin, Ibuprofen etc. for 3 months to promote
bone fusion.
??????        Increase your intake of fluids and fiber as pain
medicine (narcotics) can cause constipation

Followup Instructions:
PLEASE RETURN TO THE OFFICE IN [**10-31**] DAYS FOR REMOVAL OF YOUR
STAPLES

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS. You will need xrays prior to your
appointment.

You will need to follow up with urologist for removal of your
catheter in approximately 1 week - call PCP to get local
urologist or call [**Hospital 18**] [**Hospital 159**] clinic : [**Telephone/Fax (1) 101341**]


Completed by:[**2171-10-7**]
{'Lumbosacral spondylosis without myelopathy,Major depressive affective disorder, single episode, unspecified,Accidental puncture or laceration of dura during a procedure,Other specified retention of urine,Esophageal reflux,Pure hypercholesterolemia,Myalgia and myositis, unspecified,Acquired spondylolisthesis,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 and leg pain

PRESENT ILLNESS: A 62-year-old woman who suffered from neurogenic claudication
and lumbar stenosis. Conservative therapy had been unsuccessful
in ameliorating his symptoms.

MEDICAL HISTORY: fibromyalgia, arthritis, HL, glaucoma, lyme disease

MEDICATION ON ADMISSION: wellbutrin
eye drops

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: per medical record

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: nonsmoker , [**4-22**] EtOH per week 

### Response:
{'Lumbosacral spondylosis without myelopathy,Major depressive affective disorder, single episode, unspecified,Accidental puncture or laceration of dura during a procedure,Other specified retention of urine,Esophageal reflux,Pure hypercholesterolemia,Myalgia and myositis, unspecified,Acquired spondylolisthesis,Surgical operation with implant of artificial internal device causing abnormal patient reaction, or later complication,without mention of misadventure at time of operation'}
