CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 51 yo male reportedly under alcohol intoxication fell down a set
of 15
stairs.  Questionable LOC. Was taken to an area hospital where
he was A & Ox2 and agitated and was intubated for combativeness.
A CT scan of
head, neck and torso showed rib fractures, scalp hematoma, and
grade II liver laceration. He was also found to have an avulsion
of the scalp with loss of tissue. Patient was then transferred
to [**Hospital1 18**] for further care.

MEDICAL HISTORY: Hypertension

MEDICATION ON ADMISSION: Diovan

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
Vitals: 99.2 86 119/72 16 100%CMV/AS PEEP5
Intubated, Sedated
On ventilation
Right sided parieto-occipital scalp avulsion injury with
tissue loss. Defect 4x5 cm with no exposed bony cranium. Second
linear 4 cm laceration as well with no tissue loss.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH
Closed fracture of four ribs,Injury to liver with open wound into cavity, laceration, unspecified,Open wound of scalp, without mention of complication,Accidental fall on or from other stairs or steps,Accidents occurring in other specified places,Acute alcoholic intoxication in alcoholism, continuous,Closed fracture of clavicle, unspecified part
Fracture four ribs-close,Liver lacerat unspcf opn,Open wound of scalp,Fall on stair/step NEC,Accident in place NEC,Ac alcohol intox-contin,Fx clavicle NOS-closed
Admission Date:  [**2183-11-23**]              Discharge Date:   [**2183-11-28**]

Date of Birth:  [**2132-8-15**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
s/p Fall

Major Surgical or Invasive Procedure:
Scalp suturing
Epidural catheter placement

History of Present Illness:
51 yo male reportedly under alcohol intoxication fell down a set
of 15
stairs.  Questionable LOC. Was taken to an area hospital where
he was A & Ox2 and agitated and was intubated for combativeness.
A CT scan of
head, neck and torso showed rib fractures, scalp hematoma, and
grade II liver laceration. He was also found to have an avulsion
of the scalp with loss of tissue. Patient was then transferred
to [**Hospital1 18**] for further care.

Past Medical History:
Hypertension

Social History:
+EtOH

Family History:
Noncontributory

Physical Exam:
Upon admission:
Vitals: 99.2 86 119/72 16 100%CMV/AS PEEP5
Intubated, Sedated
On ventilation
Right sided parieto-occipital scalp avulsion injury with
tissue loss. Defect 4x5 cm with no exposed bony cranium. Second
linear 4 cm laceration as well with no tissue loss.


Pertinent Results:
[**2183-11-23**] 10:02AM   GLUCOSE-122* LACTATE-3.5* NA+-147 K+-4.4
CL--107 TCO2-17*
[**2183-11-23**] 09:50AM   ASA-NEG ETHANOL-140* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2183-11-23**] 09:50AM   WBC-23.8* RBC-4.78 HGB-15.5 HCT-45.1 MCV-94
MCH-32.4* MCHC-34.4 RDW-13.3
[**2183-11-23**] 09:50AM   PLT COUNT-273
[**2183-11-23**] 09:50AM   PT-11.5 PTT-20.6* INR(PT)-1.0
[**2183-11-23**] 09:50AM   FIBRINOGE-397

Chest XRAY [**2183-11-23**]
IMPRESSION:
1. ET tube in satisfactory position. NGT can be advanced to
ensure side-
hole is within the stomach.

2. Low lung volumes, bibasilar atelectasis, and mild pulmonary
vascular
congestion.

3. First left rib fracture and probable fractures of the right
fourth and
fifth lateral ribs.




Brief Hospital Course:
He was admitted to the Trauma service and transferred to the
trauma ICU for close monitoring. Serial abdominal exams and
hematocrits were followed because of his liver injury which was
nonoperative.

Plastic Surgery was consulted to manage the scalp avulsion which
was irrigated and sutured. The sutures were removed on day of
discharge.

The Pain service was consulted for epidural catheter for
management of his rib fractures. A thoracic epidural was placed
at bedside in the ICU on [**11-24**] without incident. He was also
started on PCA Dilaudid which was later changed to oral form.
The epidural was eventually removed as his pain control was much
improved.

Orthopedics was also consulted for his clavicle fracture; this
injury was non operative. It was recommended that he wear a
sling and to not bear any weight on the affected extremity.
follow up in [**Hospital 5498**] clinic in  [**12-24**] weeks.

Social work was consulted for coping and for alcohol screening
and counseling.

He was evaluated by Physical and Occupational therapy and was
eventually cleared for discharge to home. Recommendations for
outpatient Physical therapy were made and patient was given a
prescription for this.


Medications on Admission:
Diovan

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
3. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation.
4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime) as needed for constipation.
5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours).
Disp:*90 Capsule(s)* Refills:*1*
7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet
Sustained Release PO Q12H (every 12 hours).
Disp:*60 Tablet Sustained Release(s)* Refills:*0*
8. Morphine 15 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours)
as needed for breakthrough pain.
Disp:*60 Tablet(s)* Refills:*0*
9. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**11-21**]
Puffs Inhalation Q6H (every 6 hours) as needed for shortness of
breath or wheezing.
Disp:*1 * Refills:*1*
10. Outpatient Physical Therapy
Dx: s/p Motor vehicle crash, right clavicle fracture and
multiple rib fractures
Sig: Active and passive ROM exercises for strengthing and
conditioning 2-3x/week for 4-8 weeks


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Fall
Scalp laceration
Multiple rib fractures (right [**1-23**]; left 1st)
Right clavicle fracture
Grade II liver laceration

Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
adequately controlled.

Discharge Instructions:
If you become suddenly dizzy, feel lightheaded as if you are
going to pass out go to the nearest Emergency room immediately

DO NOT drink alcohol, take illicit drugs, drive and/or operate
heavy machinery while you are taking narcotics for pain.

DO NOT bear any weight on your right arm because of the
fracture.

Take the pain medication as prescribed. Also take a stool
softener and laxative while you are on the pain medication.

It is important that you take deep breaths, use the incentive
spirometer and cough every hour that you are awake in order to
prevent pneumonia which is a common complication associated with
rib fractures.

Return to the Emergency room if you develop any fevers, chills,
productive cough, shortness of breath, abdominal pain, nausea,
vomiting, diarrhea and/or any other symptoms that are concenring
to you.

Cleanse the area on your scalp with the wound cleanser and apply
a dry guauze daily. Return to the Emergency room if the wound
becomes red and/or if you notice thick drainage from the wound.


Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **], Trauma surgery, in clinic for
evaluation of your rib fractures and liver injury. Call
[**Telephone/Fax (1) 6429**] for an appointment. Inform the office that an AP
chest xray will be need on day of the appointment prior to
seeing Dr. [**Last Name (STitle) **].

Follow up in [**12-24**] weeks with Dr. [**Last Name (STitle) 1005**], Orthopedics. call
[**Telephone/Fax (1) 1228**] for an appointment.


Completed by:[**2183-12-30**]
{'Closed fracture of four ribs,Injury to liver with open wound into cavity, laceration, unspecified,Open wound of scalp, without mention of complication,Accidental fall on or from other stairs or steps,Accidents occurring in other specified places,Acute alcoholic intoxication in alcoholism, continuous,Closed fracture of clavicle, unspecified part'}


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: s/p Fall

PRESENT ILLNESS: 51 yo male reportedly under alcohol intoxication fell down a set
of 15
stairs.  Questionable LOC. Was taken to an area hospital where
he was A & Ox2 and agitated and was intubated for combativeness.
A CT scan of
head, neck and torso showed rib fractures, scalp hematoma, and
grade II liver laceration. He was also found to have an avulsion
of the scalp with loss of tissue. Patient was then transferred
to [**Hospital1 18**] for further care.

MEDICAL HISTORY: Hypertension

MEDICATION ON ADMISSION: Diovan

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admission:
Vitals: 99.2 86 119/72 16 100%CMV/AS PEEP5
Intubated, Sedated
On ventilation
Right sided parieto-occipital scalp avulsion injury with
tissue loss. Defect 4x5 cm with no exposed bony cranium. Second
linear 4 cm laceration as well with no tissue loss.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH 

### Response:
{'Closed fracture of four ribs,Injury to liver with open wound into cavity, laceration, unspecified,Open wound of scalp, without mention of complication,Accidental fall on or from other stairs or steps,Accidents occurring in other specified places,Acute alcoholic intoxication in alcoholism, continuous,Closed fracture of clavicle, unspecified part'}
