CHIEF COMPLAINT: C5 Fx

PRESENT ILLNESS: Mr. [**Known lastname **] was the unrestrained driver in
high speed mvc where he lost control of his car and spun into a
tree with the passengers side taking the impact. Pt. is amnestic

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: Gavapentin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: : T: BP: 126 / 67 HR: 77 R: 16 O2Sats: 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 to mm B EOMs: intact
Neck: [**Location (un) 2848**] J- collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T IP Q AT [**Last Name (un) 938**] G
R 3 5 5 5 5 5 5 5
L 3+ 5 5 5 5 5 5 5

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Tobacco x 7 yrs, 1ppk/day, with intermit ant periods of
abstinence
ETOH [**2-1**] glasses of wine/ week
Recreational Marijuana
Closed fracture of fifth cervical vertebra,Contusion of lung without mention of open wound into thorax,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Closed fracture of scapula, other
Fx c5 vertebra-closed,Lung contusion-closed,Loss control mv acc-driv,Fx scapula NEC-closed
Admission Date:  [**2142-1-14**]              Discharge Date:   [**2142-1-18**]

Date of Birth:  [**2113-5-5**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
C5 Fx

Major Surgical or Invasive Procedure:
C 5 Corpectomy


History of Present Illness:
Mr. [**Known lastname **] was the unrestrained driver in
high speed mvc where he lost control of his car and spun into a
tree with the passengers side taking the impact. Pt. is amnestic

to events after he lost control of his car. He was later found
ambulating away from the car by a friend, he was taken to an
outside hospital and flown here to [**Hospital1 18**].


Past Medical History:
None

Social History:
Tobacco x 7 yrs, 1ppk/day, with intermit ant periods of
abstinence
ETOH [**2-1**] glasses of wine/ week
Recreational Marijuana


Family History:
Non contributory

Physical Exam:
: T: BP: 126 / 67 HR: 77 R: 16 O2Sats: 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 to mm B EOMs: intact
Neck: [**Location (un) 2848**] J- collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T IP Q AT [**Last Name (un) 938**] G
R 3 5 5 5 5 5 5 5
L 3+ 5 5 5 5 5 5 5

Deltoid exam limited secondary to pain/ existing scapular
fracture

Sensation: Intact to light touch

Toes downgoing bilaterally

No Clonus


Pertinent Results:
[**2142-1-16**] 05:33AM BLOOD WBC-19.0*# RBC-4.32* Hgb-12.9* Hct-36.7*
MCV-85 MCH-29.7 MCHC-35.0 RDW-12.9 Plt Ct-176
[**2142-1-16**] 05:33AM BLOOD Plt Ct-176
[**2142-1-16**] 05:33AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-136
K-4.2 Cl-98 HCO3-28 AnGap-14
[**2142-1-16**] 05:33AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.4*

Brief Hospital Course:
28-year-old gentleman was involved in a motor vehicle accident.
A trauma exam found a pulmonary contusion and scapular fx.intact
and suffered a C5 burst fracture. He was taken to the operating
room for reconstruction without complications. Post operatively
he had a CXR to follow up on his pulmonary contusion which was
improved. He remained neurologically completely intact. He was
seen by PT who felt he was safe to go home. [**Hospital **] hospital
stay was slightly prolonged b/c he was having some difficulty
swallowing solid food and pills.  He was evaluated by speech
therapy via a video swallow.  He has been put on a puree diet
with thin liquids and directed as to what foods would be safe
and comfortable for him to eat. He has been given specific
directions to call for an appointment and a repeat video swall
eval in [**4-4**] weeks.


Medications on Admission:
Gavapentin

Discharge Medications:
1. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): may resume when you are able to take whole pills.

2. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take while using Percocet.
Disp:*60 Capsule(s)* Refills:*0*
3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: Five (5)
ML PO Q4-6H () as needed for severe pain.
Disp:*60 ML(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
C5 Body Fx
L scapular fracture
dysphagia


Discharge Condition:
Neurologically stable


Discharge Instructions:
??????	Do not smoke.
??????	Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
??????	You have steri-strips in place, do not pull them off. They
will fall off on their own or be taken off in the office.  You
may trim the edges if they begin to curl.
??????	No pulling up, lifting more than 10 lbs., or excessive bending
or twisting.
??????	Limit your use of stairs to 2-3 times per day.
??????	Have a friend or family member check your incision daily for
signs of infection.
??????	If you are required to wear one, wear your cervical collar or
back brace as instructed.
??????	You may shower briefly without the collar or back brace;
unless you have been instructed otherwise.
??????	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.

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, and drainage.
??????	Fever greater than or equal to 101?????? F.
??????	Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
.  Since you were having difficulty swallowing solid foods you
were
seen by speech therapy and had a video swallow evaluation, they
recommend that you keep your food consistance to puree (finely
ground foods until they it is smooth) and you can also have thin
liquids ( consistancy of  water).

Followup Instructions:
Follow up in 6 weeks with Dr [**Last Name (STitle) 548**] you will need XRays prior to
your appointment, call [**Doctor First Name **] for an appointment [**Telephone/Fax (1) 2992**].

You will need to have a repeat Swallow evaluation via a Video
swallow again iin 3-4 weeks, please call [**Telephone/Fax (1) 3731**] to make an
appointment.


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

Completed by:[**2142-1-18**]
{'Closed fracture of fifth cervical vertebra,Contusion of lung without mention of open wound into thorax,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Closed fracture of scapula, other'}


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: C5 Fx

PRESENT ILLNESS: Mr. [**Known lastname **] was the unrestrained driver in
high speed mvc where he lost control of his car and spun into a
tree with the passengers side taking the impact. Pt. is amnestic

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: Gavapentin

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: : T: BP: 126 / 67 HR: 77 R: 16 O2Sats: 97%
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 4 to mm B EOMs: intact
Neck: [**Location (un) 2848**] J- collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T IP Q AT [**Last Name (un) 938**] G
R 3 5 5 5 5 5 5 5
L 3+ 5 5 5 5 5 5 5

FAMILY HISTORY: Non contributory

SOCIAL HISTORY: Tobacco x 7 yrs, 1ppk/day, with intermit ant periods of
abstinence
ETOH [**2-1**] glasses of wine/ week
Recreational Marijuana 

### Response:
{'Closed fracture of fifth cervical vertebra,Contusion of lung without mention of open wound into thorax,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring driver of motor vehicle other than motorcycle,Closed fracture of scapula, other'}
