CHIEF COMPLAINT: Fall from wheelchair

PRESENT ILLNESS: 75 M on coumadin for AFib, wheelchair bound [**1-17**] cerebral palsy
fell from wheelchair onto face after accidentally driving off of
curb. C/O facial pain, No LOC, intubated for airway protection.
Pt was seen and stabilized at [**Hospital3 **] with vitK and 2
units FFP for elevated INR.

MEDICAL HISTORY: Cerebral palsy, Central Cervical Cord Contusion, BPH,
Nephrolithiasis, AFib.

MEDICATION ON ADMISSION: 1. Coumadin 2.5mg po qM-W-F-[**Doctor First Name **], 5mg po qTu-Th-Sa
2. Metoprolol XL 100mg po qd
3. Enablex daily
4. Proscar daily
5. Protonix daily
6. Tylenol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 100.0 99.6 99AF 114/55 26 100% PS50% 7/5 --> 410x24
NAD, trach in place
Card: Tachy, AFib
Resp: Coarse breath sounds bilaterally, CT sites clean/dry and
intact
Abd: Soft, NTND. GJ tube intact w/ G capped
Ext: Waffle boots in place.

FAMILY HISTORY: NC

SOCIAL HISTORY: Wheelchair bound, lives at home.
Closed fracture of malar and maxillary bones,Staphylococcal septicemia, unspecified,Severe sepsis,Acute respiratory failure,Peritoneal abscess,Acute kidney failure with lesion of tubular necrosis,Other postoperative infection,Congenital diplegia,Accidental fall from wheelchair,Other specified intestinal obstruction,Closed fracture of metacarpal bone(s), site unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Atrial fibrillation,Long-term (current) use of anticoagulants,Diaphragmatic hernia without mention of obstruction or gangrene,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Incomplete bladder emptying,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified
Fx malar/maxillary-close,Staphylcocc septicem NOS,Severe sepsis,Acute respiratry failure,Peritoneal abscess,Ac kidny fail, tubr necr,Other postop infection,Congenital diplegia,Fall from wheelchair,Intestinal obstruct NEC,Fx metacarpal NOS-closed,Abn react-surg proc NEC,Atrial fibrillation,Long-term use anticoagul,Diaphragmatic hernia,BPH w urinary obs/LUTS,Incmplet bldder emptying,Hy kid NOS w cr kid I-IV
Admission Date:  [**2158-5-14**]              Discharge Date:   [**2158-6-23**]

Date of Birth:  [**2083-7-4**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
Fall from wheelchair

Major Surgical or Invasive Procedure:
Abdominal drain placements
Chest drain placements
Chest tube placement bilaterally
Ureteral Stent Placement
Bilateral nasal bone stabilization
Exploratory Laparotomy

History of Present Illness:
75 M on coumadin for AFib, wheelchair bound [**1-17**] cerebral palsy
fell from wheelchair onto face after accidentally driving off of
curb. C/O facial pain, No LOC, intubated for airway protection.
Pt was seen and stabilized at [**Hospital3 **] with vitK and 2
units FFP for elevated INR.

Past Medical History:
Cerebral palsy, Central Cervical Cord Contusion, BPH,
Nephrolithiasis, AFib.

Social History:
Wheelchair bound, lives at home.

Family History:
NC

Physical Exam:
100.0 99.6 99AF 114/55 26 100% PS50% 7/5 --> 410x24
NAD, trach in place
Card: Tachy, AFib
Resp: Coarse breath sounds bilaterally, CT sites clean/dry and
intact
Abd: Soft, NTND. GJ tube intact w/ G capped
Ext: Waffle boots in place.

Pertinent Results:
Microbiology:
[**5-15**] Sputum: oropharnygeal flora
[**5-15**] MRSA: neg
[**5-25**]: Sputum ecoli pan [**Last Name (un) 36**] (R ampicillin)
[**5-25**] Bcx [**12-17**]: coag +staph, pan [**Last Name (un) 36**].
[**5-26**] Ucx: neg
[**5-29**] Bcx: NGTD x2
[**5-31**] Bcx: NGTD x2
[**5-31**] Ucx: NGTD
[**5-31**] Sputum: NGTD
[**6-1**] Cdiff: Neg
[**6-2**] Ucx:NG
[**6-2**] pl Fluid:NGTD
[**6-5**] Bl Cx: neg
[**6-5**] Ucx: NG
[**6-6**] Stool clx - C. diff negative
[**6-7**] BClx - neg
[**6-7**] UClx - NG
[**6-7**] sputum cx - NGTD
[**6-8**] BAL - NGTD
[**6-8**] Bcx - NGTD
[**6-9**] Cath tip neg
[**6-9**] Abd fluid - 3+ PMNs, NGTD
[**6-9**] Abd LUQ fluid - 1+ PMNS, NGTD
[**6-10**] Pleural fluid - NGTD
[**6-10**] Ucx - neg
[**6-12**] sputum - contaminated
[**6-12**] Bclx x2 - NG
[**6-12**] Uclx - NG
[**6-13**] wound clx swab - Staph coag neg rare, 1+ PMNs
[**6-14**] pleural fluid x1 - NG
[**6-14**] pleural fluid x2 - NG
[**6-14**] pleural fluid x3 - NG
[**6-18**] sputum cx GNR
[**6-18**] Blcx - (aerobic/anaerobic) GPC in pairs/clusters, Coag neg
Staph
[**6-19**] C. diff - negative
[**6-21**] C. diff - negative
[**6-21**] BCx - P
[**6-21**] UCx - P
[**6-21**] Sputum Cx - P

Imaging:
[**5-14**] CT Cspine: severe central canal stenosis [**1-17**] severe djd
from c3-c7. fusion of c6 and c7. no acute fracture. djd can
predispose to cord injury in setting of trauma.
[**5-15**] CT torso: RLL opacification. Small left pleural effusion.
Large hiatal hernia.
[**5-25**] CT torso: Right mod-severe hydro/pyoureteronephrosis with
heterogeneous enhancement of the r kidney compatible with
pyelonephritis. Multiple obstructing distal ureteral calculi
measuring up to 7mm. Free air and contrast in the peritneal
cavity. PEG tube is not in the stomach. small contrast in the
rectum likely from video swallow from [**2158-5-17**]. While bowel
perforation can not be entirely excluded on the basis of this
study findings most likely represent injection of contrast and
air into the peritoneum through the PEG that is extraluminal.
Bowel and a drenal enhancement pattern is compatible with shock.
Small free abd.pelvic fluid. Small pericardial effusion.
cardiomegaly. dilated esophagus. Small bilat pleural eff (L>R)
and rll atx or pna. Possible left shoulder osteochondromatosis.
scoliosis. l renal small hypodensities likely cyst.
[**5-26**] CXR: Pulmonary and mediastinal vasculature are now engorged
but there is no edema. Atelectasis persists at the right lung
base. The stomach is now distended with fluid.
[**5-29**] CXR: Increased bilateral moderate pleural effusion
[**5-30**] CXR: RLL opacity is consistent with almost complete
collapse of the right lower lobe and a large hiatal hernia
[**5-31**] RUQ US: no biliary dilatation,edematous gall bladder
[**6-1**] CT head: no ICH. Increased mucosal thikcening of the
sphenoid sinuses, with persistent fluid within the ethmoid and
maxillary sinuses.
[**6-1**] CT torso w/I: no abscess.
[**6-2**]: pleural catheter right hemithorax with resolution pl eff.
Left enlargement of a moderate-to-large left pleural effusion
[**6-3**]:Large left and small right pleural effusions are similar in
size, but there has been apparent development of a small
component of loculation of the left effusion at the level of the
second left anterior rib. A confluent area of atelectasis in
this region could potentially mimic loculated pleural
fluid,however.
[**6-4**] BLE US: No DVT
[**6-5**] CXR: Moderate R pl eff and RLL collapse, and l pl eff and
LLL atelectasis all more severe
[**2158-6-11**] CXR: small to moderate pleural effusions b/l stable,
area of linear consolidation within LUL, stable
[**6-12**] CT Chest - bilateral pleural effusions.
[**6-13**] CT chest - Interval decrease in the loculated areas of
ascites. Interval decrease in R pleural effusion most likely [**1-17**]

draining. Slight interval increase in the L pleural effusion.
Still present areas of loculated fluid within the abdomen as
well as at
the hiatal junction
[**6-14**] CXR - decrease of the left pleural effusion. no evidence of
ptx, There is also new R chest tube,additional decrease R
pleural effusion
[**6-14**] post WS CXR
[**6-15**] CXR - no interval change
[**6-18**] am CXR - right pigtail catheter has been removed. Right
chest tube is seen at the base with some loculated pneumothorax
in the subpulmonic region. On the left, the chest tube has also

been pulled back somewhat and there is new subpulmonic and
medial lower lung pneumothorax on this side as well. Right IJ
catheter has been removed. Tracheostomy tube remains in place.
[**6-18**] pm CXR - post d/c of LEFT chest tube, small PTx remains.
[**6-19**] CXR - In comparison with the study of [**6-18**], there is
progressive decrease in the left pneumothorax with only a
minimal possible subpulmonic collection. Right chest tube
remains in place and persistent opacification is seen at the
right base.
[**6-19**] CT Torso - Multiple foci of loculated intraperitoneal fluid,
the largest in the left upper quadrant with 2 cm thickness, none
of which appear large enough to warrant drainage placement.
Bilateral small pneumothoraces. Resolution of right
hydronephrosis with persistent urolithiasis with stones seen in
the right collecting system and urinary bladder. One of the
stones appears to be located at the right UVJ, but none in the
distal ureter. Bilateral small pleural effusions with near right
lower lobe collapse and atelectasis in the left lower lobe.
[**6-19**] CT sinus - Redemonstration of extensive facial fractures,
thoroughly characterized on [**2158-5-14**] CT. There is pansinus
mucosal disease, though decreased compared to [**2158-6-1**].
There is hyperdense fluid seen layering in the left maxillary
and right sphenoid sinus, compatible with inspissated
secretions. No aerosolized secretions are identified. There is
fluid
opacification of the bilateral mastoid air cells. There are no
osseous changes associated with these processes. Clinical
correlation is advised to exclude acute mastoiditis. Stable
ventriculomegaly. No extra-axial fluid collections in the
visualized cranium


Brief Hospital Course:
Pt was stabilized at an OSH ([**Hospital3 2005**]) and transferred to
[**Hospital1 18**] for definitive management. He was seen and evaluated in
the Trauma Bay and found to have a LeFort I fx, for which he had
been intubated for airway protection. His other imaging was
negative for acute injury, although his CSpine was relevant for
severe central canal stenosiss from degenerative disc disease
from C3-C7. On admission to the ICU, the patient was noted to
have labile pressures, but was flluid responsive. He was started
on Unasyn with plastic surgery's recommendations for
nonoperative management of LeFort I Fracture. He was noted to be
in AFib and this was managemd with lopressor and diltiazem for
the duration of his admission, although his coumadin was held
for concern of bleeding. His left metacarpal fracture was seen
by Orthopedics and stabilized with a splint. On [**5-16**] he was
succesfully extubated and his nasal packings were removed
without evidence of rebleeding. At this time he was alert and
oriented and able to sit up in bed. On [**5-18**] the patient was
transferred to the floor. Because of his facial fractures, he
was unable to tolerate POs, and Dobhoff/NG tube placement was
contraindicated, so the patient was planned for a GTube. In the
interim the patient was nutrionally maintained on TPN. On [**5-24**]
the patient had a percutaneous gastric tube placed in the
operating room with concurrant nasal fracture reduction. At the
end of the procedure, the tube was endoscopically examined and
determined to be properly placed and secured into place with
nonabsorbable suture. His Gtube was placed to gravity prior to
initiation of tube feedings. On [**5-25**] the patient was noted to be
in rapid afib and respiratory distress for which he required
intubation. The patient was transferred to the ICU and
resuscitatied with crystalloid and maintained on neosynephrine
for unstable pressures. Cardiac enzymes were cycled and the
patient underwent both bronchoscopy and CT Torso to evaluate for
potential causes of his septic picture. His minimum pressure
prior to resuscitation was 50/30, and recovvered appropritately
with pressures and IVF resuscitation. His CT torso was reviewed
and demonstrated that PO contrast instilled through the G tube
was free within the peritoneum along with free air, and
herniation of the stomach through the hiatus of the diaphragm.
Additionally a right sided hydronephrosis [**1-17**] ureteral calculus
was identified. Urology was consulted for hydronephrosis and a
ureteral stent was placed along with a percutaneous nephrostomy
tube. Additionally the patient was noted to be in acute renal
failure for which the nephrology service was consulted and the
patient started on CRRT as tolerated by his labile blood
pressures. On [**5-26**] the patient was taken to the OR for ex-lap
and resiting of his PEG with reduction of his hiatal hernia. He
was maintained on levofloxacin, cefepime and flagyl initially
and his antibiotics tailored to known cultures for the remainder
of his admission with the help of the Infectious Disease
service. Blood cultures were positive from prior to OR. He
continued to require levophed and vasopressin for maintainance
of perfusing pressures postoperatively. On weaning sedation the
patient was noted to have significant decrease in mental status,
but was responsive to stimulus. On [**5-30**] the patient was
restarted on tube feedings without any worsening peritoneal
signs or evidence of worsening sepsis. By [**6-2**] the patient was
succesfully weaned from his pressors, but remained intubated [**1-17**]
mental status changes, and CT head and Torso obtained on [**6-1**]
indicated no intracranial hemorrhage and no abscesses
intrabdominally, but did demonstrate large bilateral pleural
effusions, for which IR was consulted and placed a R pigtail
catheter.  He failed a trial extubation on [**6-4**]. On [**6-6**] he
underwent tracheostomy placement for his prolonged intubation
and this was performed without difficulty, although the patient
did have difficulty tolerating tube feeds at this time, and his
G tube was changed to a G-J by IR on [**6-7**]. He continued to have
persistent fevers and on [**6-8**] CT Torso demonstrated multiple
abdominal fluid collections for which an IR pigtails x3 were
placed with serous output. His thoracic pigtail output was noted
to be decreased oon [**6-13**] and he continued to have persistent
pleural effusions were noted, so bilateral chest tubes were
placed without difficulty. Additionally, he was noted to have a
large purulent fluid collection underlying his wound and this
was opened and packed with wet to dry dressings initially, then
converted to a wound vac.  His tube feeds were advanced to goal
and his chest tubes and abdominal pig tails were allowed to
drain until they were observed to have decreased output, then
removed. His GTube was capped and the Jejunal portion remained
functional without increased residuals. Repeat imaging showed
stable fluid collections the largest of which was 2cm. On HD 40
the patient was afebrile and maintained on Vancomycin and Zosyn,
at which time he was screened and transferred to a Long Term
Acute Care facility for further management.

Medications on Admission:
1. Coumadin 2.5mg po qM-W-F-[**Doctor First Name **], 5mg po qTu-Th-Sa
2. Metoprolol XL 100mg po qd
3. Enablex daily
4. Proscar daily
5. Protonix daily
6. Tylenol prn


Discharge Medications:
1. Acetaminophen 640 mg/20 mL Suspension [**Doctor First Name **]: One (1)  PO Q6H
(every 6 hours) as needed for fever, pain.
Disp:*1000 mL* Refills:*0*
2. Glucagon (Human Recombinant) 1 mg Recon Soln [**Doctor First Name **]: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. Bisacodyl 10 mg Suppository [**Doctor First Name **]: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
4. White Petrolatum-Mineral Oil 56.8-42.5 % Ointment [**Doctor First Name **]: One
(1) Appl Ophthalmic QID (4 times a day) as needed for dry eyes.

5. Heparin (Porcine) 5,000 unit/mL Solution [**Doctor First Name **]: One (1)
Injection TID (3 times a day).
6. Ipratropium Bromide 0.02 % Solution [**Doctor First Name **]: One (1)  Inhalation
Q6H (every 6 hours) as needed for wheeze.
7. Docusate Sodium 50 mg/5 mL Liquid [**Doctor First Name **]: One (1)  PO BID (2
times a day) as needed for constipation.
8. Senna 8.6 mg Tablet [**Doctor First Name **]: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
9. Insulin Regular Human 100 unit/mL Solution [**Doctor First Name **]: One (1)
Injection ASDIR (AS DIRECTED) as needed for hyperglycemia.
10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1)
Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily).
11. Lorazepam 0.5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q4H (every 4
hours) as needed for anxiety.
12. Diltiazem HCl 30 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO twice a day.
13. Dextrose 50% in Water (D50W)     Syringe [**Last Name (STitle) **]: One (1)
Intravenous PRN (as needed) as needed for hypoglycemia protocol.

14. Sodium Chloride 0.9%  Flush 3 mL IV Q8H:PRN line flush
Peripheral line: Flush with 3 mL Normal Saline every 8 hours and
PRN.
15. Piperacillin-Tazobactam-Dextrs 4.5 gram/100 mL Piggyback
[**Last Name (STitle) **]: One (1)  Intravenous Q8H (every 8 hours) as needed for
pneumonia for 7 days.
Disp:*21 * Refills:*0*
16. Vancomycin 500 mg Recon Soln [**Last Name (STitle) **]: One (1) Recon Soln
Intravenous Q 12H (Every 12 Hours) for 7 days.
Disp:*14 Recon Soln(s)* Refills:*0*
17. Heparin, Porcine (PF) 10 unit/mL Syringe [**Last Name (STitle) **]: Two (2) ML
Intravenous PRN (as needed) as needed for line flush.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 **] Center- MACU

Discharge Diagnosis:
Sepsis
PEG placement, Dislodged PEG
Trach placement
Pulmonary Effusion
Abdominal Abscesses
LeFort I facial fracture
Left 1st metacarpal fracture

Discharge Condition:
Mental Status - Responds to stimulus

Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.

Discharge Instructions:
In addition to the below standardized instructions, the patient
will require:
  IV antibiotics as ordered until [**6-28**]
  Tracheostomy care/Respiratory Care - Currently maintained on
pressure support with a peep of 5 and pressure support of 5 at
50%
  Wound care (Wound Vac)


General Discharge Instructions:
You have had an abdominal operation. This sheet goes over some
questions and concerns you or your family may have. If you have
additional questions, or [**Male First Name (un) **]??????t understand something about your
operation, please call your [**Male First Name (un) 5059**].

ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside. But avoid traveling long distances until you
see your [**Male First Name (un) 5059**] at your next visit.
[**Male First Name (un) **]??????t lift more than 20-25 pounds for 6 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
You may resume sexual activity unless your doctor has told you
otherwise.

HOW YOU [**Month (only) **] FEEL:
You may feel weak or ??????washed out?????? for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All these feelings and reactions are normal and should go away
in a short time. If they do not, tell your [**Month (only) 5059**].

YOUR INCISION:
Your incision may be slightly red around the stitches or
staples. This is normal.
You may gently wash away dried material around your incision.
Do not remove steri-strips for 2 weeks. (These are the thin
paper strips that might be on your incision.) But if they fall
off before that, it??????s OK.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your [**Month (only) 5059**].
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Over the next 6-12 months, your incision will fade and become
less prominent.
YOUR BOWELS:

Constipation is a common side effect of medicine such as
Percocet or codeine. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as Milk
of Magnesia, 1 tablespoon) twice a day. You can get both of
these medicines without a prescription.

If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your [**Month (only) 5059**].

After some operations, diarrhea can occur. If you get diarrhea,
[**Male First Name (un) **]??????t take anti-diarrhea medicines. Drink plenty of fluids and
see if it goes away. If it does not go away, or is severe and
you feel ill, please call your [**Male First Name (un) 5059**]

PAIN MANAGEMENT:

It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as ??????soreness.??????
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your [**Name2 (NI) 5059**].
You will receive a prescription from your [**Name2 (NI) 5059**] for pain
medicine to take by mouth. It is important you take this
medicine as directed. Do not take it more frequently than
prescribed. Do not take more medicine at one time than
prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your [**Name2 (NI) 5059**] about how long you will need to take
prescription pain medicine. Please [**Male First Name (un) **]??????t take any other pain
medicine, including non-prescription pain medicine, unless your
[**Male First Name (un) 5059**] has said it is OK.
If you are experiencing no pain, it is OK to skip a dose of pain
medicine.
To reduce pain, remember to exhale with any exertion or when you
change positions.
Remember to use your ??????cough pillow?????? for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
[**Name2 (NI) 5059**]:
sharp pain or any severe pain that lasts several hours
pain that is getting worse over time
pain accompanied by fever of more than 101
a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
In some cases, you will have a prescription for antibiotics or
other medication.
If you have any questions about what medicine to take or not to
take, please call your [**Name2 (NI) 5059**].

DANGER SIGNS:
Please call your [**Name2 (NI) 5059**] if you develop:
Worsening abdominal pain
Sharp or severe pain that lasts several hours				
Temperature of 101 degrees or higher
&#[**Numeric Identifier 96557**]; My doctor:
Name:___________________________
Phone number:                                     _
Severe diarrhea
Vomiting
Redness around the incision that is spreading				
Increased swelling around the incision
Excessive bruising around the incision
Cloudy fluid coming from the wound
Bright red blood or foul smelling discharge coming from the
wound
An increase in drainage from the wound


Followup Instructions:
Please follow up in the [**Hospital 2536**] clinic in [**1-18**] weeks. Call Acute Care
Surgery [**Telephone/Fax (1) 600**] to make an appointment
{'Closed fracture of malar and maxillary bones,Staphylococcal septicemia, unspecified,Severe sepsis,Acute respiratory failure,Peritoneal abscess,Acute kidney failure with lesion of tubular necrosis,Other postoperative infection,Congenital diplegia,Accidental fall from wheelchair,Other specified intestinal obstruction,Closed fracture of metacarpal bone(s), site unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Atrial fibrillation,Long-term (current) use of anticoagulants,Diaphragmatic hernia without mention of obstruction or gangrene,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Incomplete bladder emptying,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}


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: Fall from wheelchair

PRESENT ILLNESS: 75 M on coumadin for AFib, wheelchair bound [**1-17**] cerebral palsy
fell from wheelchair onto face after accidentally driving off of
curb. C/O facial pain, No LOC, intubated for airway protection.
Pt was seen and stabilized at [**Hospital3 **] with vitK and 2
units FFP for elevated INR.

MEDICAL HISTORY: Cerebral palsy, Central Cervical Cord Contusion, BPH,
Nephrolithiasis, AFib.

MEDICATION ON ADMISSION: 1. Coumadin 2.5mg po qM-W-F-[**Doctor First Name **], 5mg po qTu-Th-Sa
2. Metoprolol XL 100mg po qd
3. Enablex daily
4. Proscar daily
5. Protonix daily
6. Tylenol prn

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 100.0 99.6 99AF 114/55 26 100% PS50% 7/5 --> 410x24
NAD, trach in place
Card: Tachy, AFib
Resp: Coarse breath sounds bilaterally, CT sites clean/dry and
intact
Abd: Soft, NTND. GJ tube intact w/ G capped
Ext: Waffle boots in place.

FAMILY HISTORY: NC

SOCIAL HISTORY: Wheelchair bound, lives at home. 

### Response:
{'Closed fracture of malar and maxillary bones,Staphylococcal septicemia, unspecified,Severe sepsis,Acute respiratory failure,Peritoneal abscess,Acute kidney failure with lesion of tubular necrosis,Other postoperative infection,Congenital diplegia,Accidental fall from wheelchair,Other specified intestinal obstruction,Closed fracture of metacarpal bone(s), site unspecified,Other specified surgical operations and procedures causing abnormal patient reaction, or later complication, without mention of misadventure at time of operation,Atrial fibrillation,Long-term (current) use of anticoagulants,Diaphragmatic hernia without mention of obstruction or gangrene,Hypertrophy (benign) of prostate with urinary obstruction and other lower urinary tract symptoms (LUTS),Incomplete bladder emptying,Hypertensive chronic kidney disease, unspecified, with chronic kidney disease stage I through stage IV, or unspecified'}
