CHIEF COMPLAINT: neck pain

PRESENT ILLNESS: Mr. [**Known lastname 10983**] is a 16 y/o male in previously good health until
[**2147-5-9**] when he was a belted backseat passenger durng rollover
MVA.  He was found outside of vehicle with ankle pain, left
flank abrasion, left axillary abrasion, and neck pain.  He is
amnestic to the event, and was placed in a cervical collar. Upon
arrival to outside hospital cervical spine CT was read as C4
burst fracture by radiologist.  Neurological exam was reported
to be nonfocal at the outside hospital. He was transferred to
[**Hospital1 18**] ED for higher level of care.

MEDICAL HISTORY: exercise induced asthma

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-19**] bilaterally  EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
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    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: none
Closed fracture of fourth cervical vertebra,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle
Fx c4 vertebra-closed,Loss control mv acc-psgr
Admission Date:  [**2147-5-10**]              Discharge Date:   [**2147-5-12**]

Date of Birth:  [**2130-12-3**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2724**]
Chief Complaint:
neck pain


Major Surgical or Invasive Procedure:
CORPECTOMY


History of Present Illness:
Mr. [**Known lastname 10983**] is a 16 y/o male in previously good health until
[**2147-5-9**] when he was a belted backseat passenger durng rollover
MVA.  He was found outside of vehicle with ankle pain, left
flank abrasion, left axillary abrasion, and neck pain.  He is
amnestic to the event, and was placed in a cervical collar. Upon
arrival to outside hospital cervical spine CT was read as C4
burst fracture by radiologist.  Neurological exam was reported
to be nonfocal at the outside hospital. He was transferred to
[**Hospital1 18**] ED for higher level of care.

Past Medical History:
exercise induced asthma


Social History:
none


Family History:
noncontributory


Physical Exam:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-19**] bilaterally  EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
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    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G

Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.

Propioception intact
Toes downgoing bilaterally
Rectal exam normal sphincter control


Pertinent Results:
[**2147-5-11**] 06:45AM BLOOD WBC-11.3* RBC-4.14* Hgb-12.1* Hct-34.0*
MCV-82 MCH-29.2 MCHC-35.6* RDW-12.4 Plt Ct-241
[**2147-5-9**] 10:00PM BLOOD PT-14.2* PTT-24.7 INR(PT)-1.2*
[**2147-5-10**] 05:42AM BLOOD Glucose-96 UreaN-8 Creat-0.6 Na-141 K-3.7
Cl-107 HCO3-24 AnGap-14

MR CERVICAL SPINE W/O CONTRAST  [**2147-5-10**] 8:40 AM

MR CERVICAL SPINE W/O CONTRAST

Reason: further elucidate extent of c-spine injury, eval for
ligamen

[**Hospital 93**] MEDICAL CONDITION:
16M restrained rear passenger in 110mph mvc, ejected. with C4
burst fx
REASON FOR THIS EXAMINATION:
further elucidate extent of c-spine injury, eval for ligamentous
injury
CONTRAINDICATIONS for IV CONTRAST: None.

HISTORY: 16-year-old involved in a motor vehicle collision.
Burst fracture of C4 to further elucidate extent of cervical
spinal injury and ligamentous integrity.

TECHNIQUE: Multiplanar and multisequence imaging of the cervical
spine was performed without gadolinium.

COMPARISON: There is no relevant prior imaging for comparison.

FINDINGS:

There is a fracture through the body of C4 with loss of height
of the anterior body of C4. There is a disc protrusion at C4-5
level which is causing mild spinal stenosis. There is fluid in
the facet joints without subluxation.
The posterior longitudinal ligament is torn and the anterior
longitudinal ligament is also probably torn. The ligament flavum
and the interspinous ligaments are intact.

There is increased signal in the thecal sac immediately below
C4, likely pulsation artifact. There are no abnormal signals
within the cord itself. The other vertebral levels are intact
and there is edema in the T3 and T4 vertebrae, suggestive of
marrow edema. The visualized spinal muscles and soft tissues
appear unremarkable.

CONCLUSION:

Fracture of the body of C4 with loss of height of anterior C4
along with associated ligamentous injuries as described above.


Brief Hospital Course:
The patient was seen by the trauma service and neurosurgery
service in the ER and admitted to the trauma ICU under the
general surgery service. An MRI was obtained which showed the
acute fracture. On HD#2 he was taken to the OR for the above
procedure.  He tolerated the procedure well and recovered in the
PACU.  He was then transferred to the floor and the neurosurgery
service. Post operatively he had no neurological deficits. On
POD#1 he was seen by PT who cleared him for home.  On POD#2 he
had some increased pain due to not taking his Percocet
overnight. His pain was controlled with low dose Valium and
liquid Percocet.  On POD#2 he was tolerating a regular diet,
voiding without difficulty and his pain was controlled.  He was
discharged home in stable condition and instructed to wear the
cervical collar at all times. He will follow up with Dr. [**Last Name (STitle) 548**].


Medications on Admission:
None

Discharge Medications:
1. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4H (every 4 hours) as needed for pain.
Disp:*14 ML(s)* Refills:*0*
2. Diazepam 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours)
as needed for pain, anxiety.
Disp:*5 Tablet(s)* Refills:*0*
3. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q4H (every
4 hours) as needed: do not take with percocet elixer.
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*30 Capsule(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
Nurses R Us, Inc.

Discharge Diagnosis:
C4 COMPRESSION FRACTURE S/P CORPECTOMY

Discharge Condition:
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:
PLEASE RETURN TO THE OFFICE IN 10 DAYS FOR REMOVAL OF YOUR
STAPLES/SUTURES

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 6 WEEKS.
YOU WILL NEED AP AND LATERAL CERVICAL XRAYS PRIOR TO YOUR
APPOINMENT
{'Closed fracture of fourth cervical vertebra,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle'}


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: neck pain

PRESENT ILLNESS: Mr. [**Known lastname 10983**] is a 16 y/o male in previously good health until
[**2147-5-9**] when he was a belted backseat passenger durng rollover
MVA.  He was found outside of vehicle with ankle pain, left
flank abrasion, left axillary abrasion, and neck pain.  He is
amnestic to the event, and was placed in a cervical collar. Upon
arrival to outside hospital cervical spine CT was read as C4
burst fracture by radiologist.  Neurological exam was reported
to be nonfocal at the outside hospital. He was transferred to
[**Hospital1 18**] ED for higher level of care.

MEDICAL HISTORY: exercise induced asthma

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: [**3-19**] bilaterally  EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
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    FE   FF    IP    Q     AT    [**Last Name (un) 938**]    G

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: none 

### Response:
{'Closed fracture of fourth cervical vertebra,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle'}
