CHIEF COMPLAINT: ICH, SAH, depressed skull fracture s/p trauma

PRESENT ILLNESS: Pt is a 61 yo with unknown PMH who is admitted after being
hit by a [**Doctor Last Name **] while riding a bike without a helmet.  He was
reportedly conscious, but confused at the scene.  He went to an
OSH where he was following commands intermittently and answering
questions inappropriately.  He was agitated and disoriented.  He
was eventually intubated and transferred here after CT scans
showed multiple facial and skull fractures, a left frontal
depressed skull fracture, multiple IPHs and diffuse SAH, and
multiple spinal fractures.  He was given triple antibiotics,
pepcid, and started on propofol.  He also got morphine and
ativan.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: unknown

ALLERGIES: Penicillins

PHYSICAL EXAM: Exam upon admission:
Mental Status:Intubated and agitated, but opens eyes to command
off propofol.
HEENT:Depressed skull over left frontal lobe. No laceration
here.
No CSF leak seen currently.  Left eye swollen shut and
proptotic.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: non-contributory
Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed dislocation, first cervical vertebra,Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed fracture of seventh cervical vertebra,Hyperosmolality and/or hypernatremia,Closed fracture of orbital floor (blow-out),Other motor vehicle traffic accident involving collision with motor vehicle injuring pedal cyclist
Cl skull vlt fx w/o coma,Disloc 1st cerv vert-cl,Cl skul base fx w/o coma,Fx c7 vertebra-closed,Hyperosmolality,Fx orbital floor-closed,Mv coll NOS-ped cycl
Admission Date:  [**2181-6-30**]              Discharge Date:   [**2181-7-26**]

Date of Birth:  [**2120-4-1**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
ICH, SAH, depressed skull fracture s/p trauma

Major Surgical or Invasive Procedure:
1. 1.5 craniotomy for repair.
2. Elevation of displaced depressed skull fracture.
3. Reconstruction of displaced orbital rim.
4. Reconstruction of orbital roof and posterior wall.
5. Exenteration of frontal sinus with obliteration, packing and
sealing.
6. Ethmoidal sinus repair with packing and sealing.
7. Duraplasty.
8. Plastic cranioplasty.


History of Present Illness:
Pt is a 61 yo with unknown PMH who is admitted after being
hit by a [**Doctor Last Name **] while riding a bike without a helmet.  He was
reportedly conscious, but confused at the scene.  He went to an
OSH where he was following commands intermittently and answering
questions inappropriately.  He was agitated and disoriented.  He
was eventually intubated and transferred here after CT scans
showed multiple facial and skull fractures, a left frontal
depressed skull fracture, multiple IPHs and diffuse SAH, and
multiple spinal fractures.  He was given triple antibiotics,
pepcid, and started on propofol.  He also got morphine and
ativan.

Here, he was initially paralyzed, but when this wore off, he was
agitated and moving all extremities.  He was also following
midline commands.


Past Medical History:
unknown

Social History:
non-contributory

Family History:
non-contributory

Physical Exam:
Exam upon admission:
Mental Status:Intubated and agitated, but opens eyes to command
off propofol.
HEENT:Depressed skull over left frontal lobe. No laceration
here.
No CSF leak seen currently.  Left eye swollen shut and
proptotic.

CN:
Pupils: On right 3 to 2.5. Left swollen shut.
Nasal Tickle:
Gag/Cough:Present on tube.
Corneal Reflex:Present on right. None on left.
OCRs:Unable due to collar.

Motor:Moves all exts equally and strongly.

Toes:Mute bilaterally

Respiration:Pt is overbreathing ventilator.


Pertinent Results:
CT C spine [**6-29**]:
1. Right occipital condyle fracture and one-half vertebral body
posterior subluxation of the condyle on the C1 vertebral body.
2. Mild anterior widening of the C3/4 and C4/5 disc interspaces.
Ligamentous injury is suspected.
3. ? Fracture through the anterior inferior C7 vertebral body.

CTA [**6-29**]:
No evidence of carotid injury identified on CT angiography. No
evidence of dissection. No evidence of occlusion. Extensive
fractures and intracranial changes as on the previous CT head.

CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST  [**6-29**]:
1. Depressed left frontal and parietal bone fractures with 14 mm
depression of the fracture fragments and extension through the
left frontal sinus, ethmoid air cells and sphenoid sinus on the
right. The fracture line extends through the right cavernous
carotid canal and CTA should be performed for further
evaluation.
2. Comminuted nasal bone fracture.
3. Right maxillary sinus fracture.
4. Right occipital condyle fracture. Please see CT C-spine
report for full characterization as well as description of
posterior subluxation of the occipital condyles on C1.
5. Extensive intraparenchymal, extraaxial and subarachnoid
hemorrhage is best described on CT head scan performed on the
same day.

[**6-29**] Head CT
1. Diffuse subarachnoid hemorrhage.
2. Left frontal, parietal and temporal subdural hematoma.
Subdural hematoma layers over the tentorium.
3. Left frontal extra-axial hemorrhage and intraparenchymal
hemorrhage and hemorrhagic contusions.
4. Right subfalcine herniation.
5. Depressed left frontal skull fracture with 14-mm depression
of the fracture fragments. Fracture line extends through the
right cavernous carotid canal. CTA is recommended to exclude
carotid injury. Other fractures are best described on CT
sinus/maxillofacial scan performed on the same day.


Brief Hospital Course:
Mr. [**Name13 (STitle) 42915**] was transferred from an OSH to [**Hospital1 18**] ER for
evaluation and treatment for a L depressed skull fracture, SAH,
and C1 occiput subluxation.  The pt arrived in the ED intubated
and unresponsive. Neurosurgery as well as plastic surgery, ENT
and trauma were consulted for further care.  An ICP monitor
(bolt) was placed in the ICU on admission, and ICPs were
monitored.  He was started on vancomycin, gentamicin, and flagyl
for empirical coverage; he was also loaded and continued on
Dilantin for seizure prophylaxis.  The patient was monitored
with serial CTs and neurological examinations.  The patient was
kept in a hard collar; though no vessel dissection was noted,
and there was no acute surgical issue concerning the neck, it
was determined that further assessment would be made once acute
concerns had been resolved.  The patient was taken to the trauma
ICU from the ER.  The patient was prepared for surgical repair,
to go to the operating room on the 6th.  On the fourth of
[**Month (only) 216**], the CT showed no change in SAH as well as the left
frontal contusion.  There was an interval decrease of the acute
left frontal and parietal SDH, as well as significant decrease
of the subfalcine herniation. The patient went to the operating
room on the sixth for a craniotomy, elevation of dispaced
depressed skull fracture, reconstrution of a displaced orbital
rim, orbital roof and posterior wall, and exenteration of the
frontal sinus with obliteration, packing and sealing, ethmoidal
sinus repair with packing and sealing, duraplasty, and plastic
cranioplasty. The post operative CT was improved.
.
The patient was evaluated by physical and occupational therapy
as well as speech and swallow post-operatively.
.
Starting [**7-3**], the dexamethasone was weaned, the patient was in
stable condition.  On [**7-5**], the patient was extubated, and doing
well post-extubation.  The patient continued to require a sitter
for disorientation and inappropriate behavior.  As the patient
had very poor oral intake, a Dobhoff tube was placed on [**7-7**],
which was pulled out twice by the patient.  There was a question
of a pneumomediastinum (read as present, but immediately
resolved by one radiologist, and as never having been present by
another) following Dobhoff tube placement, though the patient
remained stable with no complaints.  Repeat chest x-rays were
read as normal.  Speech and swallow were later consulted for
evaluation recommending a regular diet of thin liquids and
regular solids.  The patient was encouraged to eat, and his PO
intake increased.  Endocrinology had also been consulted for
evaluation of hypernatremia, who felt that both the adrenal and
thyroid axis were intact, and that diabetes insipidus was not
the etiology; the patient's sodium was closely monitored, and it
normalized slowly not warranting further intervention.
.
    On [**7-10**], the patient was transitioned to Keppra for seizure
prophylaxis, and his diet was changed to a regular one.  The
patient was closely monitored, and received a chest x-ray to
evaluate for possible pneumomediastinum with the change in diet,
and questionable history of a pneumomediastinum.  The patient
remained stable, though with waxing and [**Doctor Last Name 688**] orientation, and
no sign of pneumomediastinum.
.
The 14th and [**7-11**], the patient was possibly leaking
CSF [**Last Name (un) 834**] his nares.  Nasal drippings were sent for laboratory
examination, confirming a CSF leak.  The patient then went to
the operating room on [**7-12**] for lumbar drain placement for the
CSF leak; the patient was started on vancomycin for prophylaxis,
and tolerated the procedure well.  The drain was removed on
[**7-15**], w/o renewed nasal CSF leakage.
Opthalmology was consulted for evaluation of the patient's
visual fields post-operatively.
.
   The patient's family was also in discussion with the
neurosurgical team, social work, and case management regarding
disposition, as the patient had not been covered by insurance
for further rehabilitation as an out patient.
.
Multiple attempts were made over the coarse of [**7-11**] to
have the patient placed for rehabilitation, with an emphasis on
cognition. However, the patient required sitters to prevent him
from taking off the collar. With redirection or distraction he
was generally easily kept in line, and he probably does not need
full time one-on-one supervision once he is in a more active and
social environment such as rehab.  He did frequently remove
collar despite all attempts to keep in place.
.
Throughout his stay on the floor, other than the cognitive
issues (impulsivity, no encoding in short term memory,
recalcitrant behavior probaly secondary to desinhibition,
disorientation in time), his general neurological exam was
stable, with PERRL, full eye movements (perhaps limited
mechanical restriction of the L eye), symmetric facial motor and
sensory systems, straight tongue protrusion, no motor deficits
nor pronator drift, intact sensory systems to touch, symmetric
reflexes with downgoing toes.
.
Psychiatry evaluated pt and felt significance of injuries
prevented pt from holding information and placed him at risk for
potentially self-neglectful and harmful behavior.
DIAGNOSES:
Neuro:
I - BRAIN: Diffuse subarachnoid hemorrhage. Left frontal,
parietal and temporal subdural hematoma. Subdural hematoma
layers over the tentorium. Left frontal extra-axial hemorrhage
and intraparenchymal hemorrhagic contusions.
II - SKULL/FACE : Depressed left frontal skull fracture with
14-mm depression, s/p repair. Comminuted nasal bone fracture.
Right maxillary sinus fracture
III - SPINE:  Right occipital condyle fracture and one-half
vertebral body posterior subluxation of the condyle on the C1
vertebral body. Mild anterior widening of the C3/4 and C4/5 disc
interspaces. Questionable fracture through the anterior inferior

C7 vertebral body.
IV - Post-traumatic cognitive dysfunction, as outlined above

Endocrine:
Transient hypernatremia directly post-traumatic, likely related
to high doses of mannitol.

GI:
Questionable transient pneumomediastinum, unable to objectify,
no clinical consequences with negative F/U studies.

Medications on Admission:
unknown

Discharge Medications:
1. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2
times a day).
Disp:*120 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
1. Comminuted displaced depressed frontal skull fracture with
orbital blow out
2. Frontal sinus fracture
3. Ethmoid sinus fracture
4. Frontal lobe contusions
5. c1 SUBLUXATION
6. C7 fracture
5. Left sided dural tear


Discharge Condition:
Stable


Discharge Instructions:
DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY

YOU MUST WEAR CERVICAL COLLAR AT ALL TIMES.
??????	Take your pain medicine as prescribed
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????	You have been prescribed an anti-seizure medicine, take it as
prescribed and follow up with laboratory blood drawing as
ordered
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit

CALL YOUR SURGEON IF YOU EXPERIENCE ANY OF THE FOLLOWING:

??????	New onset of tremors or seizures
??????	Any confusion or change in mental status
??????	Any numbness, tingling, weakness in your extremities
??????	Pain or headache that is continually increasing or not
relieved by pain medication
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????	Fever greater than or equal to 101?????? F


Followup Instructions:
PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN [**5-4**] WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN and c-spine WITHOUT
CONTRAST

You will need to follow up at the endocrinology clinic (please
call ([**Telephone/Fax (1) 33582**] to make an appointment) in [**Month (only) **].



Completed by:[**2181-7-26**]
{'Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed dislocation, first cervical vertebra,Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed fracture of seventh cervical vertebra,Hyperosmolality and/or hypernatremia,Closed fracture of orbital floor (blow-out),Other motor vehicle traffic accident involving collision with motor vehicle injuring pedal cyclist'}


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: ICH, SAH, depressed skull fracture s/p trauma

PRESENT ILLNESS: Pt is a 61 yo with unknown PMH who is admitted after being
hit by a [**Doctor Last Name **] while riding a bike without a helmet.  He was
reportedly conscious, but confused at the scene.  He went to an
OSH where he was following commands intermittently and answering
questions inappropriately.  He was agitated and disoriented.  He
was eventually intubated and transferred here after CT scans
showed multiple facial and skull fractures, a left frontal
depressed skull fracture, multiple IPHs and diffuse SAH, and
multiple spinal fractures.  He was given triple antibiotics,
pepcid, and started on propofol.  He also got morphine and
ativan.

MEDICAL HISTORY: unknown

MEDICATION ON ADMISSION: unknown

ALLERGIES: Penicillins

PHYSICAL EXAM: Exam upon admission:
Mental Status:Intubated and agitated, but opens eyes to command
off propofol.
HEENT:Depressed skull over left frontal lobe. No laceration
here.
No CSF leak seen currently.  Left eye swollen shut and
proptotic.

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: non-contributory 

### Response:
{'Closed fracture of vault of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed dislocation, first cervical vertebra,Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Closed fracture of seventh cervical vertebra,Hyperosmolality and/or hypernatremia,Closed fracture of orbital floor (blow-out),Other motor vehicle traffic accident involving collision with motor vehicle injuring pedal cyclist'}
