CHIEF COMPLAINT: Back and leg pain

PRESENT ILLNESS: Ms. [**Known lastname **] has a long history of back and leg pain.  She has
attempted conservative therapy including physical therapy and
has failed.  She now presents for surgical intervention.

MEDICAL HISTORY: RA, depression, anxiety, HLD, GERD, ST depressions intraop on
nitro gtt, bronchitis, arthritis, HA, GERD +tobacco, ETOH 5/day,
spinal stenosis cervical/lumbar, insomnia

MEDICATION ON ADMISSION: premarin, diclofenac, prozac, gabapentin, hydrochlorothiazide,
prilosec, imitrex, tramadol, zolpidem

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles; + sciatica

FAMILY HISTORY: N/C

SOCIAL HISTORY: denies
Lumbosacral spondylosis without myelopathy,Alcohol withdrawal delirium,Degeneration of lumbar or lumbosacral intervertebral disc,Nonspecific abnormal electrocardiogram [ECG] [EKG],Tobacco use disorder,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Pure hypercholesterolemia,Esophageal reflux
Lumbosacral spondylosis,Delirium tremens,Lumb/lumbosac disc degen,Abnorm electrocardiogram,Tobacco use disorder,Depressive disorder NEC,Migrne unsp wo ntrc mgrn,Pure hypercholesterolem,Esophageal reflux
Admission Date:  [**2160-5-6**]              Discharge Date:   [**2160-5-14**]

Date of Birth:  [**2099-8-26**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
Patient recorded as having No Known Allergies to Drugs

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

Major Surgical or Invasive Procedure:
Anterior/posterior lumbar fusion with instrumentation


History of Present Illness:
Ms. [**Known lastname **] has a long history of back and leg pain.  She has
attempted conservative therapy including physical therapy and
has failed.  She now presents for surgical intervention.


Past Medical History:
RA, depression, anxiety, HLD, GERD, ST depressions intraop on
nitro gtt, bronchitis, arthritis, HA, GERD +tobacco, ETOH 5/day,
spinal stenosis cervical/lumbar, insomnia

Social History:
denies

Family History:
N/C

Physical Exam:
A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles; + sciatica


Pertinent Results:
[**2160-5-14**] 10:55AM BLOOD Hct-27.5*
[**2160-5-13**] 06:45AM BLOOD WBC-7.7 RBC-2.45* Hgb-7.8* Hct-23.1*
MCV-94 MCH-31.9 MCHC-33.9 RDW-14.0 Plt Ct-443*
[**2160-5-12**] 03:13AM BLOOD WBC-9.8 RBC-2.36* Hgb-7.5* Hct-22.3*
MCV-95 MCH-31.7 MCHC-33.6 RDW-13.8 Plt Ct-354
[**2160-5-11**] 05:55AM BLOOD WBC-10.7 RBC-2.63* Hgb-8.4* Hct-25.1*
MCV-96 MCH-32.1* MCHC-33.6 RDW-13.7 Plt Ct-361
[**2160-5-10**] 06:15AM BLOOD WBC-9.3 RBC-2.66* Hgb-8.7* Hct-25.6*
MCV-96 MCH-32.8* MCHC-34.1 RDW-13.5 Plt Ct-307
[**2160-5-9**] 10:52AM BLOOD WBC-10.9 RBC-2.98* Hgb-9.5* Hct-28.3*
MCV-95 MCH-32.0 MCHC-33.6 RDW-13.6 Plt Ct-276
[**2160-5-6**] 05:30PM BLOOD WBC-9.6 RBC-3.62* Hgb-11.5* Hct-34.2*
MCV-95 MCH-31.7 MCHC-33.5 RDW-14.2 Plt Ct-301
[**2160-5-12**] 03:13AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-133
K-2.7* Cl-94* HCO3-32 AnGap-10
[**2160-5-11**] 05:55AM BLOOD Glucose-113* UreaN-5* Creat-0.6 Na-135
K-2.6* Cl-93* HCO3-28 AnGap-17
[**2160-5-9**] 10:52AM BLOOD Glucose-126* UreaN-7 Creat-0.7 Na-136
K-3.3 Cl-97 HCO3-28 AnGap-14

Brief Hospital Course:
Ms. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2160-5-6**] and taken to the Operating Room for L4-S1 interbody
fusion through an anterior approach. Please refer to the
dictated operative note for further details. The surgery was
without complication and the patient was transferred to the PACU
in a stable condition. TEDs/pnemoboots were used for
postoperative DVT prophylaxis. Intravenous antibiotics were
given per standard protocol. Initial postop pain was controlled
with a PCA. On HD#4 ([**2160-5-9**]) she returned to the operating
room for a scheduled L2-S1 decompression with PSIF at L4-S1 as
part of a staged 2-part procedure. Please refer to the dictated
operative note for further details. The second surgery was also
without complication and the patient was transferred to the PACU
in a stable condition. Postoperative HCT was 22 and she was
trasfused PRBCs with good effect. A bupivicaine epidural pain
catheter placed at the time of the posterior surgery remained in
place until postop check when it was removed POD1 from the
second procedure.
She began experiencing symptoms of alcohol withdrawl and was
transfered to the SICU for monitoring and the CIWA protocol was
administered for her symptoms.  She was stable throughout her
SICU stay and was subsequently transfered to the floor for
further mangaement.
She was kept NPO until bowel function returned then diet was
advanced as tolerated. The patient was transitioned to oral pain
medication when tolerating PO diet. Foley was removed on POD#2
from the second procedure. She was fitted with a lumbar
warm-n-form brace for comfort. Physical therapy was consulted
for mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.

Medications on Admission:
premarin, diclofenac, prozac, gabapentin, hydrochlorothiazide,
prilosec, imitrex, tramadol, zolpidem

Discharge Medications:
1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Conjugated Estrogens 0.3 mg Tablet Sig: One (1) Tablet PO
DAILY (Daily).
3. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
6. Sumatriptan Succinate 25 mg Tablet Sig: One (1) Tablet PO
Q3-4HOURS;PRN () as needed for migraine.
7. Zolpidem 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as
needed for insomnia.
Disp:*60 Tablet(s)* Refills:*0*
8. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for spasms.
Disp:*100 Tablet(s)* Refills:*0*
9. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release 12 hr(s)* Refills:*20*
10. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
11. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4H (every 4 hours) as needed for pain.
Disp:*100 Tablet(s)* Refills:*0*
13. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day) as needed for agitation.
Disp:*60 Tablet(s)* Refills:*0*


Discharge Disposition:
Home With Service

Facility:
[**Hospital 119**] Homecare

Discharge Diagnosis:
Lumbar disc degeneration and stenosis
Acute post op blood loss anemia
Alcohol withdrawl


Discharge Condition:
Good


Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion



Immediately after the operation:



-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.



-Rehabilitation/ Physical Therapy:

o2-3 times a day you should go for a walk for 15-30 minutes as
part of your recovery. You can walk as much as you can tolerate.


oLimit any kind of lifting.



-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.



-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.



-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually 2-3 days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.



-You should resume taking your normal home medications. No
NSAIDs.



-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
[**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.



Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.


Physical Therapy:
Activity:  Activity as tolerated
Advance from walker as tolerated.
LSO for ambulation; may be out of bed to chair without.

Treatments Frequency:
Please inspect the incisions for signs of infection.

Followup Instructions:
Please follow up in the Orthopaedic Spine clinic during your
previously scheduled appointments.  Call [**Telephone/Fax (1) 11061**] to confirm
your post-operative appointments.



Completed by:[**2160-6-4**]
{'Lumbosacral spondylosis without myelopathy,Alcohol withdrawal delirium,Degeneration of lumbar or lumbosacral intervertebral disc,Nonspecific abnormal electrocardiogram [ECG] [EKG],Tobacco use disorder,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Pure hypercholesterolemia,Esophageal reflux'}


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 **] has a long history of back and leg pain.  She has
attempted conservative therapy including physical therapy and
has failed.  She now presents for surgical intervention.

MEDICAL HISTORY: RA, depression, anxiety, HLD, GERD, ST depressions intraop on
nitro gtt, bronchitis, arthritis, HA, GERD +tobacco, ETOH 5/day,
spinal stenosis cervical/lumbar, insomnia

MEDICATION ON ADMISSION: premarin, diclofenac, prozac, gabapentin, hydrochlorothiazide,
prilosec, imitrex, tramadol, zolpidem

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: A&O X 3; NAD
RRR
CTA B
Abd soft NT/ND
BUE- good strength at deltoid, biceps, triceps, wrist
flexion/extension, finger flexion/extension and intrinics;
sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes
symmetric at biceps, triceps and brachioradialis
BLE- good strength at hip flexion/extension, knee
flexion/extension, ankle dorsiflexion and plantar flexion,
[**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes
symmetric at quads and Achilles; + sciatica

FAMILY HISTORY: N/C

SOCIAL HISTORY: denies 

### Response:
{'Lumbosacral spondylosis without myelopathy,Alcohol withdrawal delirium,Degeneration of lumbar or lumbosacral intervertebral disc,Nonspecific abnormal electrocardiogram [ECG] [EKG],Tobacco use disorder,Depressive disorder, not elsewhere classified,Migraine, unspecified, without mention of intractable migraine without mention of status migrainosus,Pure hypercholesterolemia,Esophageal reflux'}
