CHIEF COMPLAINT: C5 Fracture

PRESENT ILLNESS: Mr. [**Known lastname 85633**] is a 20 yo RH man with no significant PMH. He
states that he was drinking with friends [**2139-4-17**] ([**12-24**] drinks)
and "did something stupid" jumping into the shallow end of a
[**Doctor Last Name **]. He immediately felt that "there was something wrong" and
struggled to get to the surface. He had severe pain and tingling
in his arms and was transferred in C collar. He currently feels
severe painful paresthesias in his arms and hands. They also
feel
weak as does his L leg. He denies neck pain.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
Vitals: T: 97.2 P: 87 R: 16 BP: 96/38 SaO2: 100% on RA
General: Awake, cooperative, appears in pain, grimacing
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: C collar in place
Pulmonary: CTAB
Cardiac: nl S1 S2
Abdomen: soft, NT/ND
Extremities: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: -in culinary school, mother is a physician
[**Name Initial (NameIs) 85634**]:  occasional (not on a daily basis)
-tobacco:  occasional
-drugs:  occasional MJ
Closed fracture of C5-C7 level with central cord syndrome,Accident from diving or jumping into water [swimming pool],Retention of urine, unspecified,Orthostatic hypotension,Other left bundle branch block
C5-c7 fx-cl/cen cord syn,Diving accident,Retention urine NOS,Orthostatic hypotension,Left bb block NEC
Admission Date:  [**2139-4-18**]              Discharge Date:   [**2139-4-27**]

Date of Birth:  [**2116-4-11**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1271**]
Chief Complaint:
C5 Fracture

Major Surgical or Invasive Procedure:
None


History of Present Illness:
Mr. [**Known lastname 85633**] is a 20 yo RH man with no significant PMH. He
states that he was drinking with friends [**2139-4-17**] ([**12-24**] drinks)
and "did something stupid" jumping into the shallow end of a
[**Doctor Last Name **]. He immediately felt that "there was something wrong" and
struggled to get to the surface. He had severe pain and tingling
in his arms and was transferred in C collar. He currently feels
severe painful paresthesias in his arms and hands. They also
feel
weak as does his L leg. He denies neck pain.


Past Medical History:
Denies

Social History:
-in culinary school, mother is a physician
[**Name Initial (NameIs) 85634**]:  occasional (not on a daily basis)
-tobacco:  occasional
-drugs:  occasional MJ


Family History:
NC

Physical Exam:
Physical Exam:
Vitals: T: 97.2 P: 87 R: 16 BP: 96/38 SaO2: 100% on RA
General: Awake, cooperative, appears in pain, grimacing
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: C collar in place
Pulmonary: CTAB
Cardiac: nl S1 S2
Abdomen: soft, NT/ND
Extremities: no edema

Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent.

CN
I: not tested
II,III: pupils  OD 3.5->2.5 OS [**1-20**], fundi normal
III,IV,VI: EOMI, no ptosis. 3 beats endgaze nystagmus to R
V: sensation intact V1-V3 to LT
VII: Facial strength intact/symmetrical, symm forehead wrinkling


VIII: hears finger rub bilaterally
IX,X: palate elevates symmetrically, uvula midline
[**Doctor First Name 81**]: SCM/trapezeii [**3-25**] bilaterally
XII: tongue protrudes midline, no dysarthria

Motor: Normal bulk and tone;
*Motor exam limited by severe pain with all movements in UE
  Delt [**Hospital1 **] Tri WE FE Grip
  C5   C6 C7  C6 C7 C8/T1
L 1    0  0   0  1  1
R 1    0  0   0  1  1

   IP Quad Hamst DF [**Last Name (un) 938**] PF
   L2 L3  L4-S1  L4 L5  S1/S2
L  1  2   2      2  2   2
R  5-----------------

Reflex: No clonus
  [**Hospital1 **] Tri Bra Pat An Plantar
  C5 C7  C6  L4  S1 CST
L 1  0   0   3   0  Mute
R 1  0   0   3   0  Mute

-Sensory: severe dysesthesia to light touch in UE bilaterally,
symmetric pinprick throughout. Nl proprioception throughout.

-Coordination: deferred

-Gait: UA

Rectal tone- nl, sensation nl

Upon discharge his neuro exam was as follows:
hyperesthesia;no clonus
Bil [**Doctor First Name **]/biceps [**3-25**], R tri 4+, L tri 4-, r grasp [**2-23**], l grasp
[**1-23**]. interossei [**12-26**] R, wrist flex R [**12-26**] Lower extremities [**3-25**].
Hyperesthesia in hands. No clonus


Pertinent Results:
[**2139-4-18**] CT Torso:
IMPRESSION:
No evidence of acute intra-abdominal, pelvic or thoracic trauma.


[**2139-4-18**] CT Cspine:
IMPRESSION:
1. Burst fracture of C5 vertebral body with mild, 3 mm
retropulsion and mild vertebral body height loss; there is no
associated signficant epidural hematoma, spinal canal stenosis
or mass effect on the thecal sac.
2. Right C5 lamina and articular process fracture, without
subluxation, and left C5 lamina/spinous process fracture with no
extension into the foramina transversaria.
3. No other fracture, with otherwise overall normal aligment.

[**2139-4-18**] Head CT:
IMPRESSION: No acute intracranial abnormality

[**2139-4-18**]: MRI Cspine:
IMPRESSION:
1. Extensive bone marrow edema involving much of the C5
vertebral body,
corresponding to the known burst fracture, with anterior
compression and no more than 3 mm retropulsion of, particularly,
its inferior endplate, as on the CT.
2. No definite associated epidural hematoma.
3. Extensive edema throughout the C3 through C6 supraspinous
ligaments,
reflecting acute injury with marked bowing of the stretched
posterior
longitudinal ligament, which appears intact. There is no
evidence of
asssociated interspinous ligamentous or facet articular capsular
injury.
4. Equivocal faint T2- and STIR-hyperintense focus within the
left paramedian central cord substance, which may reflect acute
edema, related to the acute flexion-sprain injury; however,
there is no evidence of the presence of deoxyhemoglobin to
suggest hemorrhagic cord contusion.
5. Otherwise, normal cervical spinal cord caliber and intrinsic
signal
intensity.


Brief Hospital Course:
Mr [**Known lastname 85633**] is a 23 yo gentleman who sustained a C5 fx and
spinal cord contusion after diving into shallow water. He was
admitted to the ICU for close monitoring. A hard cervical collar
was placed- to remain on at all times. A MAP of 85 was
maintained for 24hrs. A foley was placed for urinary retention
as his bladder scan showed > 900 mL. Chronic pain mgmt was
consulted and a Dilaudid PCA was recommended. Pain was managed
with a combination of Gabapentin, Tylenol, and Dilaudid. On
[**2139-4-20**] he was transferred to the floor. He was weaned from his
dilaudid PCA and converted to PO pain medication. Bladder
training was initiated and PT/OT were consulted. During
ambulation it was noted he did have orthostatic hypotension but
remained asymptomatic.
On [**4-21**] patient remained neurologically stable with some
improvement in his UE's strengths. He continued to work with
PT/OT and bladder training. He is tolerating a PO diet.
On [**4-22**] it was noted that the patients blood pressure was
decreasing when foley was unclamped, then raised upon
reclamping. Pt remained asymptomatic. This subsided overnight.
On [**5-11**] The patient had less difficulty with hypotension and
dizziness after receiving Midrocine. He was minimal drop in BP
upon ambulation did not meet orthostatic criteria. He was
successfully voiding without residual on post void residuals. He
was slowly regaining some strength in his left arm.The patient
continued to work with PT and OT who determined he could be
discharged to home (hotel) the patient will stay in the [**Location (un) 86**]
area for the next 3-4 days. Out patient PT and OT have been set
up here at our medical center.


Medications on Admission:
None

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
3. Gabapentin 300 mg Capsule Sig: Three (3) Capsule PO TID (3
times a day).
Disp:*270 Capsule(s)* Refills:*2*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
Disp:*60 Tablet(s)* Refills:*2*
6. Midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a
day).
Disp:*90 Tablet(s)* Refills:*0*
7. Bisacodyl 10 mg Suppository Sig: One (1)  Rectal once a day.
Disp:*30 suppositories* Refills:*2*
8. Outpatient Occupational Therapy
Central cord syndrome with tricep and hand weakness, evaluate
and treat
9. Outpatient Physical Therapy
Central cord syndrome with tricep and hand weakness please
evaluate and treat


Discharge Disposition:
Home

Discharge Diagnosis:
C5 Fracture
Central Cord Syndrome


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Upper extremity weakness left weakness greater than right


Discharge Instructions:
??????	Do not smoke.
??????	You must wear a cervical collar at all times, including
showering. Nursing will give you an extra collar on discharge
??????	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.
????????????	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.
Use the suppository on a daily basis.


Followup Instructions:
-Outpatient OT has been set up for 1:30pm [**4-28**] in [**Hospital Ward Name 23**] 2 [**Hospital Ward Name **]
-Outpatient PT has been set up for 2:30pm [**4-28**] in [**Hospital Ward Name 23**] 2 [**Hospital Ward Name **]

- Please follow-up with up with a neurosurgeon once you arrive
back in [**State 4565**]. Please make outpatient PT/OT therapy
appointments as soon as you arrive back. We would recommend
seeing a psyzhiatrist.


                             [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**]

Completed by:[**2139-4-27**]
{'Closed fracture of C5-C7 level with central cord syndrome,Accident from diving or jumping into water [swimming pool],Retention of urine, unspecified,Orthostatic hypotension,Other left bundle branch block'}


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 Fracture

PRESENT ILLNESS: Mr. [**Known lastname 85633**] is a 20 yo RH man with no significant PMH. He
states that he was drinking with friends [**2139-4-17**] ([**12-24**] drinks)
and "did something stupid" jumping into the shallow end of a
[**Doctor Last Name **]. He immediately felt that "there was something wrong" and
struggled to get to the surface. He had severe pain and tingling
in his arms and was transferred in C collar. He currently feels
severe painful paresthesias in his arms and hands. They also
feel
weak as does his L leg. He denies neck pain.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Physical Exam:
Vitals: T: 97.2 P: 87 R: 16 BP: 96/38 SaO2: 100% on RA
General: Awake, cooperative, appears in pain, grimacing
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: C collar in place
Pulmonary: CTAB
Cardiac: nl S1 S2
Abdomen: soft, NT/ND
Extremities: no edema

FAMILY HISTORY: NC

SOCIAL HISTORY: -in culinary school, mother is a physician
[**Name Initial (NameIs) 85634**]:  occasional (not on a daily basis)
-tobacco:  occasional
-drugs:  occasional MJ 

### Response:
{'Closed fracture of C5-C7 level with central cord syndrome,Accident from diving or jumping into water [swimming pool],Retention of urine, unspecified,Orthostatic hypotension,Other left bundle branch block'}
