CHIEF COMPLAINT: Back and leg pain

PRESENT ILLNESS: Dr. [**Known lastname 3761**] has a long history of back and leg pain.  He has
attemptede conservative therapy but has failed.  He now presents
for surgical intervention.

MEDICAL HISTORY: Dyslipidemia
Hypertension
Ischemic Heart Disease s/p MIx3, stent x3. Cardiac cath [**2-/2200**]
showed no flow limiting epicardial vessels, patent LAD, occluded
PDA.
hearing loss
severe GERD
renal insufficiency Cr 1.4-1.6 at baseline

MEDICATION ON ADMISSION: Acetaminophen
Aciphex
Atenolol
Atorvastatin
Diazepam
Ezetimibe
Fexofenadine
Furosemide
Gabapentin
Metoclopramide
Methocarbamol
Multivitamins
Nasacort AQ
Nitroglycerin SL
Omeprazole
Ondansetron
Prochlorperazine
Ranexa
Senna
Zolpidem Tartrate

ALLERGIES: Avodart / Niacin

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
+ axial back pain

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies
Scoliosis [and kyphoscoliosis], idiopathic,Acute posthemorrhagic anemia,Lumbosacral spondylosis without myelopathy,Degeneration of lumbar or lumbosacral intervertebral disc,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Esophageal reflux,Unspecified hearing loss,Other acute postoperative pain
Idiopathic scoliosis,Ac posthemorrhag anemia,Lumbosacral spondylosis,Lumb/lumbosac disc degen,Hyperlipidemia NEC/NOS,Hy kid NOS w cr kid I-IV,Chronic kidney dis NOS,Cor ath unsp vsl ntv/gft,Status-post ptca,Old myocardial infarct,Esophageal reflux,Hearing loss NOS,Acute postop pain NEC
Admission Date:  [**2200-11-10**]              Discharge Date:   [**2200-11-18**]

Date of Birth:  [**2132-8-11**]             Sex:   M

Service: ORTHOPAEDICS

Allergies:
Avodart / Niacin

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

Major Surgical or Invasive Procedure:
[**2200-11-10**] anterior fusion L3-S1 stage 1
Anterior fusion T10-L3 stage 2 on [**11-10**] via thoracotomy stage 2
T10-S1 posterior fusion [**11-11**] stage 3


History of Present Illness:
Dr. [**Known lastname 3761**] has a long history of back and leg pain.  He has
attemptede conservative therapy but has failed.  He now presents
for surgical intervention.

Past Medical History:
Dyslipidemia
Hypertension
Ischemic Heart Disease s/p MIx3, stent x3. Cardiac cath [**2-/2200**]
showed no flow limiting epicardial vessels, patent LAD, occluded
PDA.
hearing loss
severe GERD
renal insufficiency Cr 1.4-1.6 at baseline


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
+ axial back pain

Pertinent Results:
[**2200-11-15**] 05:15AM BLOOD WBC-6.2 RBC-3.79*# Hgb-12.2*# Hct-33.7*#
MCV-89 MCH-32.1* MCHC-36.1* RDW-15.7* Plt Ct-114*
[**2200-11-14**] 03:39AM BLOOD WBC-6.5 RBC-2.87* Hgb-9.3* Hct-25.5*
MCV-89 MCH-32.3* MCHC-36.4* RDW-16.1* Plt Ct-97*
[**2200-11-13**] 01:27AM BLOOD WBC-8.2 RBC-3.37* Hgb-10.6* Hct-30.2*
MCV-90 MCH-31.5 MCHC-35.1* RDW-17.0* Plt Ct-117*
[**2200-11-12**] 01:36AM BLOOD WBC-6.0 RBC-2.91* Hgb-9.5* Hct-26.6*
MCV-92 MCH-32.7* MCHC-35.7* RDW-15.6* Plt Ct-146*
[**2200-11-15**] 05:15AM BLOOD Glucose-114* UreaN-15 Creat-0.6 Na-129*
K-3.6 Cl-97 HCO3-25 AnGap-11
[**2200-11-13**] 01:27AM BLOOD Glucose-121* UreaN-17 Creat-0.7 Na-136
K-3.9 Cl-107 HCO3-24 AnGap-9
[**2200-11-11**] 08:17PM BLOOD Glucose-163* UreaN-17 Creat-1.0 Na-136
K-4.4 Cl-105 HCO3-25 AnGap-10
[**2200-11-11**] 04:10AM BLOOD Glucose-136* UreaN-14 Creat-1.0 Na-134
K-4.2 Cl-104 HCO3-25 AnGap-9
[**2200-11-15**] 05:15AM BLOOD Calcium-7.3* Phos-1.9* Mg-1.9
[**2200-11-13**] 01:27AM BLOOD Calcium-7.1* Phos-2.0* Mg-2.0
[**2200-11-11**] 08:17PM BLOOD Calcium-8.9 Phos-4.0 Mg-1.7

Brief Hospital Course:
Dr. [**Last Name (STitle) 83277**] was admitted to the [**Hospital1 18**] Spine Surgery Service on
[**2200-11-10**] and taken to the Operating Room for L3-S1 interbody
fusion through an anterior approach.  In addition, he underwent
a fusion T11 to L3 through a thoracotomy.  Chest tube placement
was performed in the OR. 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#2
he returned to the operating room for a scheduled T10-S1
decompression with PSIF as part of a staged 3-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 low and he was transfused multiple units PRBCs. He was
transfered to the SICU for hemodynamic monitoring.  A
bupivicaine epidural pain catheter placed at the time of the
posterior surgery remained in place until postop day one when it
was removed. He 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#3 from the second procedure. He was fitted with a TLSO
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:
Acetaminophen
Aciphex
Atenolol
Atorvastatin
Diazepam
Ezetimibe
Fexofenadine
Furosemide
Gabapentin
Metoclopramide
Methocarbamol
Multivitamins
Nasacort AQ
Nitroglycerin SL
Omeprazole
Ondansetron
Prochlorperazine
Ranexa
Senna
Zolpidem Tartrate


Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H
(every 6 hours) as needed for rash.
3. multivitamin     Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
5. atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

8. ranolazine 500 mg Tablet Sustained Release 12 hr Sig: One (1)
Tablet Sustained Release 12 hr PO BID (2 times a day).
9. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for angina.
10. metoclopramide 10 mg Tablet Sig: 1.5 Tablets PO TID (3 times
a day).
11. methocarbamol 500 mg Tablet Sig: 1-2 Tablets PO BID (2 times
a day) as needed for spasm.
12. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
13. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
14. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime)
as needed for insomnia.
15. fentanyl 50 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
18. oxycodone 5 mg Tablet Sig: 1-3 Tablets PO Q3H (every 3
hours) as needed for pain.
19. Atrovent  Nasal
20. amitriptyline 10 mg Tablet Sig: Three (3) Tablet PO HS (at
bedtime).


Discharge Disposition:
Extended Care

Facility:
[**Hospital 11292**] Health Care

Discharge Diagnosis:
Scoliosis, spondylosis and spinal stenosis
Acute post-op blood loss anemia


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
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:  Out of bed w/ assist
 Thoracic lumbar spine brace:   when OOB

Treatments Frequency:
Please continue to inspect the incisions daily

Followup Instructions:
With Dr. [**Last Name (STitle) 363**] in 10 days



Completed by:[**2200-11-18**]
{'Scoliosis [and kyphoscoliosis], idiopathic,Acute posthemorrhagic anemia,Lumbosacral spondylosis without myelopathy,Degeneration of lumbar or lumbosacral intervertebral disc,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Esophageal reflux,Unspecified hearing loss,Other acute postoperative pain'}


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: Dr. [**Known lastname 3761**] has a long history of back and leg pain.  He has
attemptede conservative therapy but has failed.  He now presents
for surgical intervention.

MEDICAL HISTORY: Dyslipidemia
Hypertension
Ischemic Heart Disease s/p MIx3, stent x3. Cardiac cath [**2-/2200**]
showed no flow limiting epicardial vessels, patent LAD, occluded
PDA.
hearing loss
severe GERD
renal insufficiency Cr 1.4-1.6 at baseline

MEDICATION ON ADMISSION: Acetaminophen
Aciphex
Atenolol
Atorvastatin
Diazepam
Ezetimibe
Fexofenadine
Furosemide
Gabapentin
Metoclopramide
Methocarbamol
Multivitamins
Nasacort AQ
Nitroglycerin SL
Omeprazole
Ondansetron
Prochlorperazine
Ranexa
Senna
Zolpidem Tartrate

ALLERGIES: Avodart / Niacin

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
+ axial back pain

FAMILY HISTORY: N/C

SOCIAL HISTORY: Denies 

### Response:
{'Scoliosis [and kyphoscoliosis], idiopathic,Acute posthemorrhagic anemia,Lumbosacral spondylosis without myelopathy,Degeneration of lumbar or lumbosacral intervertebral disc,Other and unspecified hyperlipidemia,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified,Chronic kidney disease, unspecified,Coronary atherosclerosis of unspecified type of vessel, native or graft,Percutaneous transluminal coronary angioplasty status,Old myocardial infarction,Esophageal reflux,Unspecified hearing loss,Other acute postoperative pain'}
