CHIEF COMPLAINT: Neck pain

PRESENT ILLNESS: History of rollover motor vehicle accident with trauma to neck.
History of tingling in ulnar nerve distribution bilaterally.
past history of neck pain.

MEDICAL HISTORY: History of lumbar spine surgery done in the past.

MEDICATION ON ADMISSION: dilaudid, tylenol, valium.

ALLERGIES: Morphine

PHYSICAL EXAM: Neuro [**6-3**] in both upper and lower extremities.
SILT
Tenderness over neck.
Tenderness over left sided toes.

FAMILY HISTORY: 

SOCIAL HISTORY: Occasional smoker
Closed fracture of C5-C7 level with other specified spinal cord injury,Intraspinal abscess,Vascular myelopathies,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Other postoperative infection,Closed fracture of one or more phalanges of foot,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle,Acute osteomyelitis, other specified sites,Bacteremia,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Tobacco use disorder,Cervical spondylosis without myelopathy
C5-c7 fx-cl/cord inj NEC,Intraspinal abscess,Vascular myelopathies,React-oth int ortho dev,Other postop infection,Fx phalanx, foot-closed,Loss control mv acc-psgr,Ac osteomyelitis NEC,Bacteremia,MRSA elsewhere/NOS,Tobacco use disorder,Cervical spondylosis
Admission Date:  [**2138-9-27**]              Discharge Date:   [**2138-9-30**]

Date of Birth:  [**2087-4-10**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
Morphine

Attending:[**Doctor Last Name 1350**]
Chief Complaint:
Neck pain

Major Surgical or Invasive Procedure:
C6-c7 laminectomy, C5-6, c6-7 foraminotomies and c4-T1 posterior
instrumented spinal fusion.


History of Present Illness:
History of rollover motor vehicle accident with trauma to neck.
History of tingling in ulnar nerve distribution bilaterally.
past history of neck pain.

Past Medical History:
History of lumbar spine surgery done in the past.


Social History:
Occasional smoker

Physical Exam:
Neuro [**6-3**] in both upper and lower extremities.
SILT
Tenderness over neck.
Tenderness over left sided toes.

Pertinent Results:
[**2138-9-27**] 03:31AM   PH-7.41 COMMENTS-GREEN TOP
[**2138-9-27**] 03:31AM   HGB-13.0 calcHCT-39 O2 SAT-96 CARBOXYHB-3 MET
HGB-0.3
[**2138-9-27**] 03:31AM   GLUCOSE-98 LACTATE-2.1* NA+-138 K+-3.3*
CL--98* TCO2-24
[**2138-9-27**] 03:31AM   HGB-13.0 calcHCT-39 O2 SAT-96 CARBOXYHB-3 MET
HGB-0.3
[**2138-9-27**] 03:31AM   freeCa-1.10*
[**2138-9-27**] 03:30AM URINE  HOURS-RANDOM
[**2138-9-27**] 03:30AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2138-9-27**] 03:30AM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.002
[**2138-9-27**] 03:30AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2138-9-27**] 03:20AM   UREA N-10 CREAT-0.6
[**2138-9-27**] 03:20AM   estGFR-Using this
[**2138-9-27**] 03:20AM   LIPASE-28
[**2138-9-27**] 03:20AM   ASA-NEG ETHANOL-143* ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
[**2138-9-27**] 03:20AM   WBC-15.2* RBC-3.71* HGB-11.6* HCT-33.8*
MCV-91 MCH-31.4 MCHC-34.4 RDW-12.8
[**2138-9-27**] 03:20AM   PLT COUNT-358
[**2138-9-27**] 03:20AM   PT-13.2 PTT-25.5 INR(PT)-1.1
[**2138-9-27**] 03:20AM   FIBRINOGE-285

Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service and
taken to the Operating Room for the above procedure.  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
continued for 24hrs postop per standard protocol. Initial postop
pain was controlled with a PCA.  Diet was advanced as tolerated.
 The patient was transitioned to oral pain medication when
tolerating PO diet.  Foley was removed on POD#1.  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.

Discharge Medications:
1. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every four (4)
hours as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for itchy.
Disp:*20 Capsule(s)* Refills:*0*
5. Estrogens  Sig: One (1) Tablet  DAILY (Daily): home med.
6. Valium 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours
as needed for muscle spasms.
Disp:*40 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
C6 left side lamina and pedicle fracture with floating lateral
mass.
left 2nd toe proximal phalanx fracture.


Discharge Condition:
Stable.


Discharge Instructions:
You have undergone the following operation: Posterior Cervical
Decompression and 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 in a car
or chair for more than ~45 minutes without getting up and
walking around.

weightbearing as tolerated left foot with post-op shoe and buddy
tape for 2nd toe fracture.

-	Rehabilitation/ Physical Therapy:
o	2-3 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.
o	Isometric Extension Exercise in the collar: 2x/day x 10 times
perform extension exercises as instructed.

-	Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks.  You may remove the collar to take a shower.  Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.

-	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. Call the office at that
time. If you have an incision on your hip please follow the same
instructions in terms of wound care.

-	You should resume taking your normal home medications.

-	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 narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy.  In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.

-	Follow up:	
o	Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o	At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o	We will then see you at 6 weeks from the day of the operation.
At that time we will most likely obtain Flexion/Extension X-rays
and often able to place you in a soft collar which you will wean
out of over 1 week.

Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.


Followup Instructions:
follow up with Dr [**Last Name (STitle) 1007**] in 2 weeks following discharge. Please
call [**Telephone/Fax (1) 9769**] to make an appointment.
follow up in ortho trauma clinic in [**3-4**] weeks for left 2nd toe
fracture. call [**Telephone/Fax (1) 1228**] for appt.



Completed by:[**2138-9-30**]

Admission Date:  [**2138-10-5**]              Discharge Date:   [**2138-11-6**]

Date of Birth:  [**2087-4-10**]             Sex:   F

Service: ORTHOPAEDICS

Allergies:
Morphine

Attending:[**First Name3 (LF) 3645**]
Chief Complaint:
fever and drainage from posterior c-spine incision

Major Surgical or Invasive Procedure:
[**2138-10-6**]: I&D of posterior c-spine wound infection with retention
of bone graft and hardware by Dr. [**Last Name (STitle) 1007**].
[**2138-10-17**]: repeat I&D of posterior c-spine wound infection with
removal of bone graft, retention of hardware, and placement of
wound VAC by Dr. [**Last Name (STitle) 1007**].
[**2138-10-20**]: repeat I&D of posterior c-spine wound infection with
retention of hardware and placement of wound VAC by Dr. [**Last Name (STitle) 1352**].
[**2138-10-23**]: repeat I&D of posterior c-spine wound infection with
retention of hardware and placement of incisional VAC by Dr.
[**Last Name (STitle) 1007**].
[**2138-10-31**]: repeat I&D of posterior c-spine wound infection with
removal of bilateral T1 screws and revision fusion with ICBG and
extension of posterior instrumented fusion from C3-T2 by Dr.
[**Last Name (STitle) 1352**].


History of Present Illness:
51yo F s/p C4-T1 PSF with ICBG on [**2138-9-28**] by dr. [**Last Name (STitle) **] for frx
disloc, C6 floating lateral mass from MVC. Fevers/chills x 1
day, serosang drainage from incision. c/o some "numbness" in
hands bilaterally but had this before. Neuro exam intact,
including sensation. Not systemically septic. transferred from
[**Hospital **] hosp ER. T100.2 in ER. WCC 23.5 w/L shift.

Past Medical History:
as above
History of lumbar spine surgery done in the past.


Social History:
Occasional smoker


Physical Exam:
on admission.
well-appearing female. mod distress.
BUE: good strength/sensation, still some loss of distal fine
motor skills.
BLE: good strength/sensation.
posterior c-spine incision with breakdown of inferior incision,
erythema and purulent drainage.

Pertinent Results:
[**2138-10-5**] 04:50PM   GLUCOSE-98 UREA N-7 CREAT-0.6 SODIUM-130*
POTASSIUM-3.7 CHLORIDE-89* TOTAL CO2-28 ANION GAP-17
[**2138-10-5**] 04:50PM   CRP-164.6*
[**2138-10-5**] 04:50PM   WBC-23.5*# RBC-3.50* HGB-10.7* HCT-32.8*
MCV-94 MCH-30.6 MCHC-32.7 RDW-12.9
[**2138-10-5**] 04:50PM   NEUTS-92.3* LYMPHS-5.0* MONOS-1.6* EOS-0.9
BASOS-0.2
[**2138-10-5**] 04:50PM   PLT COUNT-472*#
[**2138-10-5**] 04:50PM   SED RATE-59*

Brief Hospital Course:
Patient was admitted to the [**Hospital1 18**] Spine Surgery Service from the
ER on [**2138-10-5**] she was taken to the Operating Room on the above
dates by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**].  Refer to the
dictated operative notes for further details.  The surgeries
were without complication and the patient was transferred to the
PACU in a stable condition, except as noted below.
TEDs/pnemoboots were used for postoperative DVT prophylaxis and
subcutaneous heparin was added following her last surgery.
Initial postop pain was controlled with a PCA.  Diet was
advanced as tolerated.  The patient was transitioned to oral
pain medication when tolerating PO diet.  Foley was removed.
Physical/occupational therapy was consulted for mobilization OOB
to ambulate.

preop and post-op blood cultures showed MRSA. OR tissue cultures
also showed MRSA. she was continued on vanco and ID was
consulted. she was intermittently febrile. blood cultures were
positive until [**10-8**] and then negative until [**10-12**] when a single
set showed enterobacter. ceftriaxone started for this and
switched to PO cipro on [**10-14**]. TTE on [**10-7**] and TEE on [**10-9**] showed
no endocarditis. vanco doses were frequently titrated due to
variability from trough goals. HV drains and incisional VAC were
removed on [**10-10**]. PICC placed on [**10-15**] after no growth for 48hrs
from blood cultures. ESR, CRP and WBC improving.

[**10-7**], [**10-8**] and [**10-9**] blood cx's with MRSA (treated with vanco).
[**10-11**] blood cx with enterobacter (started ceftaz, later switched
to cipro on [**10-14**]). [**10-13**] CXR neg for PNA. UA/urine cx neg. got
PICC [**10-15**] once blood cx's were negative for 48h.

wound drainage restarted [**10-14**]. taken to OR on [**10-17**]: significant
seropurulent fluid above and below fasica. all bone graft was
removed. hardware retained. [**10-17**] cx's: MRSA, enterobacter, e.
coli. added ceftaz 2gm q8h to cipro on [**10-18**]. [**10-20**] cx's: MRSA
from deep tissue. [**10-23**] cx's: gram positive bacteria. [**10-24**] ceftaz
stopped, plan to continue PO cipro for several weeks along with
vanco. further testing of cultures on [**10-29**] showed staph to be
insensitive to vancomycin, so this was stopped and daptomycin
was started on [**10-29**]. rifampin was started on [**11-3**]. plan to
continue these antibiotics and cipro for at least 6-8 weeks. she
may require long-term oral suppressive therapy due to presence
of hardware. the [**Hospital1 18**] ID service will follow her as an
outpatient and make these decisions. she will have weekly labs
followed by them.

patient returned to the OR on [**10-31**] for revision/extension of
posterior c-spine fusion. she tolerated the surgery well, but
upon exam in the PACU, was noted to have increased bilateral
upper extremity weakness and frank left lower extremity
paralysis. stat c-spine MRI demonstrated some increased cord
contusion/edema at C5-C7. she was transferred to the TSICU for
monitoring. c-spine CT scan showed hardware to be in good
alignment. c-spine MRI with contrast on [**11-2**], again showed cord
signal change at C5-C7. patient was transferred to the floor on
[**11-2**].

patient continued to work with PT/OT and appropriate splints for
bilateral wrists and left foot/ankle were provided. she is
regaining proximal strength in BUE (about [**5-4**] with EF/EE/WE),
but still with weak finger abduction and flexion (left weaker
than right). she continues to have some decreased sensation in
both hands and had fine motor problems dating back to her
original injury. her left leg has also improved. she has min HF,
trace great toe extension/flexion and no ADF, but [**5-4**] hip
adduction/knee extension/ankle plantar flexion. RLE has good
strength throughout. her neck incision is healing well with
sutures in place. her left posterior hip incision is also
healing. her right posterior hip incision has healed.

given these strength/functional limitations, she is an
appropriate candidate for acute/[**Hospital **] rehab before being
transitioned home.

On the day of discharge the patient was afebrile with stable
vital signs, posterior c-spine incision is intact and dry,
comfortable on oral pain control and tolerating a regular diet.

Medications on Admission:
dilaudid, tylenol, valium.

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
Disp:*60 Capsule(s)* Refills:*2*
2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
Disp:*60 Tablet(s)* Refills:*2*
3. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Three
(3) ML Intravenous Q8H (every 8 hours) as needed for line flush.
Disp:*50 flushes* Refills:*2*
4. Outpatient Lab Work
weekly labs to be drawn while on IV abx.
labs: cbc with diff, chem 8, LFTs, CPK. ESR, CRP.
results faxed to [**Hospital 18**] [**Hospital **] clinic at [**Telephone/Fax (1) 432**].
5. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
7. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): plan for 6-8weeks of treatment.
8. Diazepam 5 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours)
as needed for anxiety.
9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
10. Est Estrogens-Methyltest 0.625-1.25 mg Tablet Sig: One (1)
Tablet PO daily ().
11. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day): for DVT prophylaxis until
ambulating independently, regularly.
13. Rifampin 300 mg Capsule Sig: One (1) Capsule PO Q12H (every
12 hours): plan for 6-8wks of treatment.
14. Daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 **]y Five
(325) mg Intravenous Q24H (every 24 hours) as needed for
propylaxis: plan for 6-8wks of treatment.


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
postoperative wound infection of posterior c-spine fusion.
cervical spinal cord injury.
left 2nd toe proximal phalanx fracture.


Discharge Condition:
stable


Discharge Instructions:
You have undergone the following operation: Posterior Cervical
Decompression and Fusion and irrigation/debridement for
infection.

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 in a car
or chair for more than ~45 minutes without getting up and
walking around.

-	Rehabilitation/ Physical Therapy:
o	2-3 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.

-	Cervical Collar / Neck Brace: You need to wear the brace at
all times until your follow-up appointment which should be in 2
weeks.  You may remove the collar to take a shower.  Limit your
motion of your neck while the collar is off. Place the collar
back on your neck immediately after the shower.

-	Wound Care: 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 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. Call the office at that time. If you have
an incision on your hip please follow the same instructions in
terms of wound care.

-	You should resume taking your normal home medications.

-	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 narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy.  In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.

-	Follow up:	
o	Please Call the office and make an appointment for 2 weeks
after the day of your operation if this has not been done
already.
o	At the 2-week visit we will check your incision, take baseline
x rays and answer any questions.
o	We will then see you at 6 weeks from the day of the operation.


Please call the office if you have a fever>101.5 degrees
Fahrenheit, drainage from your wound, or have any questions.

Physical Therapy:
WBAT BLE. no heavy lifting with BUE. c-collar can be off for
hygiene. continue WBAT left foot with postop shoe/buddy tape as
needed for comfort for 2nd toe fracture (it is essentially
healed). use left multipodus boot when in bed. use wrist splints
when sleeping/not doing therapy.

Treatments Frequency:
daily DSD changes until fully healed.

Followup Instructions:
call [**Telephone/Fax (1) 3736**] to schedule follow up appt with dr. [**First Name8 (NamePattern2) **]
[**Last Name (NamePattern1) **] in about 2 weeks.

follow up appt with [**Hospital **] clinic: Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD
Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2138-11-19**] 10:50.

you need to have weekly labs drawn and faxed to [**Hospital 18**] [**Hospital **] clinic
at [**Telephone/Fax (1) 432**].



Completed by:[**2138-11-6**]
{'Closed fracture of C5-C7 level with other specified spinal cord injury,Intraspinal abscess,Vascular myelopathies,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Other postoperative infection,Closed fracture of one or more phalanges of foot,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle,Acute osteomyelitis, other specified sites,Bacteremia,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Tobacco use disorder,Cervical spondylosis without myelopathy'}


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: History of rollover motor vehicle accident with trauma to neck.
History of tingling in ulnar nerve distribution bilaterally.
past history of neck pain.

MEDICAL HISTORY: History of lumbar spine surgery done in the past.

MEDICATION ON ADMISSION: dilaudid, tylenol, valium.

ALLERGIES: Morphine

PHYSICAL EXAM: Neuro [**6-3**] in both upper and lower extremities.
SILT
Tenderness over neck.
Tenderness over left sided toes.

FAMILY HISTORY: 

SOCIAL HISTORY: Occasional smoker 

### Response:
{'Closed fracture of C5-C7 level with other specified spinal cord injury,Intraspinal abscess,Vascular myelopathies,Infection and inflammatory reaction due to other internal orthopedic device, implant, and graft,Other postoperative infection,Closed fracture of one or more phalanges of foot,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring passenger in motor vehicle other than motorcycle,Acute osteomyelitis, other specified sites,Bacteremia,Methicillin resistant Staphylococcus aureus in conditions classified elsewhere and of unspecified site,Tobacco use disorder,Cervical spondylosis without myelopathy'}
