CHIEF COMPLAINT: fall

PRESENT ILLNESS: 40M fell while intoxicated w/ alcohol from the [**Location (un) **] and
broke his leg, open tib-fib.

MEDICAL HISTORY: noncontributory

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 119 181/108 100% on O2 bag
Combative, subsequently intubated.
RRR
CTA bilaterally anteriorly
abd soft nd
pelvis stable
rectal tone: nl; guaiac neg
Neck/back: no stepoffs, no deformity
extr: palp distal pulses; RLE 1cm lac c/w bone, not puncture
wound; RLE externally rotated.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: +etoh
denies illicits
denies tob
Unspecified fracture of ankle, open,Alcohol abuse, unspecified,Accidental fall from or out of building or other structure
Fx ankle NOS-open,Alcohol abuse-unspec,Fall from building
Admission Date:  [**2114-4-29**]              Discharge Date:   [**2114-5-5**]

Date of Birth:  [**2062-5-30**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
fall

Major Surgical or Invasive Procedure:
Open reduction internal fixation of the tibia.


History of Present Illness:
40M fell while intoxicated w/ alcohol from the [**Location (un) **] and
broke his leg, open tib-fib.

Past Medical History:
noncontributory

Social History:
+etoh
denies illicits
denies tob

Family History:
noncontributory

Physical Exam:
119 181/108 100% on O2 bag
Combative, subsequently intubated.
RRR
CTA bilaterally anteriorly
abd soft nd
pelvis stable
rectal tone: nl; guaiac neg
Neck/back: no stepoffs, no deformity
extr: palp distal pulses; RLE 1cm lac c/w bone, not puncture
wound; RLE externally rotated.

Pertinent Results:
[**2114-4-29**] 05:01PM   TYPE-ART TEMP-36.9 RATES-14/ TIDAL VOL-500
PEEP-5 O2-50 PO2-227* PCO2-45 PH-7.38 TOTAL CO2-28 BASE XS-1
INTUBATED-INTUBATED VENT-CONTROLLED
[**2114-4-29**] 12:49PM   GLUCOSE-96 UREA N-8 CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17
[**2114-4-29**] 12:49PM   CALCIUM-8.5 PHOSPHATE-2.1* MAGNESIUM-1.7
[**2114-4-29**] 12:49PM   WBC-8.8 RBC-4.06* HGB-11.4* HCT-34.3* MCV-84
MCH-28.1 MCHC-33.3 RDW-14.4
[**2114-4-29**] 12:49PM   PLT COUNT-175
[**2114-4-29**] 12:49PM   PT-10.6 PTT-17.5* INR(PT)-0.9
[**2114-4-29**] 04:10AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
[**2114-4-29**] 04:10AM URINE  COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009
[**2114-4-29**] 04:10AM URINE  BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
[**2114-4-29**] 03:30AM   AMYLASE-109*
[**2114-4-29**] 03:30AM   ASA-NEG ETHANOL-250* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2114-4-29**] 03:30AM   WBC-8.8 RBC-5.01 HGB-14.0 HCT-42.0 MCV-84
MCH-28.0 MCHC-33.4 RDW-14.3
.
LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST RIGHT  [**2114-4-29**] 11:39
AM
TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT
Reason: ORIF OPEN TIB FIB FX
FLUOROSCOPIC STUDY, LEFT TIBIA/FIBULA, [**2114-4-29**]
COMPARISON: Left tibia and fibula radiographs of earlier the
same date.
INDICATION: ORIF.
Fluoroscopic guidance was provided for open reduction and
internal fixation of comminuted fracture of the tibia. No
radiologists were involved in the procedure.
A series of spot fluoroscopic images demonstrate open reduction
and internal fixation of the tibial fracture which is maintained
in alignment with an intramedullary rod and interlocking screws.
Fracture of the fibula is again noted.
.
TIB/FIB (AP & LAT) RIGHT  [**2114-4-29**] 11:39 AM
TIB/FIB (AP & LAT) RIGHT; LOWER EXTREMITY FLUORO WITHOUT
Reason: ORIF OPEN TIB FIB FX
FLUOROSCOPIC STUDY, LEFT TIBIA/FIBULA, [**2114-4-29**]
COMPARISON: Left tibia and fibula radiographs of earlier the
same date.
INDICATION: ORIF.
Fluoroscopic guidance was provided for open reduction and
internal fixation of comminuted fracture of the tibia. No
radiologists were involved in the procedure.
A series of spot fluoroscopic images demonstrate open reduction
and internal fixation of the tibial fracture which is maintained
in alignment with an intramedullary rod and interlocking screws.
Fracture of the fibula is again noted.
.
ANKLE (2 VIEWS) RIGHT  [**2114-4-29**] 4:59 AM

TIB/FIB (AP & LAT) SOFT TISSUE; FOOT AP,LAT & OBL RIGHT

Reason: frac

[**Hospital 93**] MEDICAL CONDITION:
54 year old man with [**Location (un) **] fall
REASON FOR THIS EXAMINATION:
frac
INDICATION: 54-year-old male with fall.
TECHNIQUE: Seven views of right tibia and fibula.
No comparison.
FINDINGS: Note is made of comminuted fracture, medial angulation
at the fracture site with multiple oblique fracture lines in
distal tibia. The fracture line does not seem to extend to the
articular surface of the ankle, however, the evaluation is
somewhat limited due to overlying cast. There is oblique
fracture of the proximal fibula as well. The evaluation of ankle
joint and foot are somewhat limited due to overlying materials.
No gross fracture of the foot is seen.
IMPRESSION: Comminuted fracture of the distal tibia with
angulation with multiple oblique fracture lines. Oblique
fracture of the proximal fibula.
The information has been communicated to the ED dashboard.
.
PELVIS (AP ONLY)  [**2114-4-29**] 4:58 AM
PELVIS (AP ONLY)
Reason: ? [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
54 year old man with [**Location (un) **] fall
REASON FOR THIS EXAMINATION:
? inj
INDICATION: 54-year-old man status post fall.
TECHNIQUE: Frontal view of the pelvis.
COMPARISON: CT torso study performed on the same day.
FINDINGS: Note is made of small bone fragment at the superior
aspect of right acetabulum, which may represent small avulsion
fracture. Otherwise, no gross fracture or diastasis is seen.
Bowel gas pattern is unremarkable. Bilateral SI joints are
symmetric.
IMPRESSION: Small bone fragment at the superior aspect of the
right acetabulum, which may represent an accessory ossification
center or avulsed bone fragment, as noted on the prior CT scan.
.
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: TRAUMA,FALL FROM FOURTH FLOOR
Field of view: 34 Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from [**Location (un) **]
REASON FOR THIS EXAMINATION:
? inj
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old male with fall.
TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and
pelvis were obtained with the administration of IV contrast
[**Doctor Last Name 360**], 150 cc of Optiray. Multiplanar reformation images are
reconstructed.
No comparison.
FINDINGS: There is no evidence of mediastinal hematoma. The
patient is status post placement of endotracheal tube and
nasogastric tube. No evidence of pneumothorax. The heart is
normal in size, and there is no evidence of pericardial or
pleural effusion. In the lung window, note is made of patchy
peribronchial opacities in right lower lobe, probably due to
aspiration. Dependent atelectasis are seen. Note is made of
centrilobular emphysema. There is mucous secretion in the right
main bronchus.
ABDOMEN: There is no evidence of intraperitoneal bleeding. No
evidence of free air. Liver, gallbladder, spleen, pancreas,
adrenal glands, and the visualized portion of large and small
intestines are within normal limits. Note is made of bilateral
renal cysts. No ascites. No lymphadenopathy.
PELVIS: The visualized portion of large and small intestines are
within normal limits. No evidence of bleeding. No ascites. No
lymphadenopathy.
No fracture seen.
IMPRESSION:
1. Patchy peribronchial opacity in right lower lobe, which may
due to aspiration.
.
CT C-SPINE W/O CONTRAST
Reason: ? [**Hospital **]
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from [**Location (un) **]
REASON FOR THIS EXAMINATION:
? inj
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old man status post fall.
TECHNIQUE: Contiguous axial CT images of the C-spine.
COMPARISON: No comparison.
FINDINGS: Note is made of extensive degenerative disc disease
with osteophyte formation and vacuum phenomena at multiple
levels, however, there is no significant fracture or dislocation
is noted. The patient is status post intubation. Nasogastric
tube is noted. The prevertebral soft tissue is unremarkable.
Note is made of fluid in the nasopharynx. Emphysema is seen in
the apices.
IMPRESSION: Marked degenerative disc disease. No evidence of
fracture or dislocation.
.
CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST
Reason: TRAUMA,FALL FROM FOURTH FLOOR
Field of view: 34 Contrast: [**Hospital 13288**]
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from [**Location (un) **]
REASON FOR THIS EXAMINATION:
? inj
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old male with fall.
TECHNIQUE: Contiguous axial CT images of the chest, abdomen, and
pelvis were obtained with the administration of IV contrast
[**Doctor Last Name 360**], 150 cc of Optiray. Multiplanar reformation images are
reconstructed.
No comparison.
FINDINGS: There is no evidence of mediastinal hematoma. The
patient is status post placement of endotracheal tube and
nasogastric tube. No evidence of pneumothorax. The heart is
normal in size, and there is no evidence of pericardial or
pleural effusion. In the lung window, note is made of patchy
peribronchial opacities in right lower lobe, probably due to
aspiration. Dependent atelectasis are seen. Note is made of
centrilobular emphysema. There is mucous secretion in the right
main bronchus.
ABDOMEN: There is no evidence of intraperitoneal bleeding. No
evidence of free air. Liver, gallbladder, spleen, pancreas,
adrenal glands, and the visualized portion of large and small
intestines are within normal limits. Note is made of bilateral
renal cysts. No ascites. No lymphadenopathy.
PELVIS: The visualized portion of large and small intestines are
within normal limits. No evidence of bleeding. No ascites. No
lymphadenopathy.
No fracture seen.
IMPRESSION:
1. Patchy peribronchial opacity in right lower lobe, which may
due to aspiration.
.
CT HEAD W/O CONTRAST  [**2114-4-29**] 4:08 AM
CT HEAD W/O CONTRAST
Reason: ? fractures, injuries
[**Hospital 93**] MEDICAL CONDITION:
s/p fall from [**Location (un) **]
REASON FOR THIS EXAMINATION:
? fractures, injuries
CONTRAINDICATIONS for IV CONTRAST: None.
INDICATION: 54-year-old man status post fall.
TECHNIQUE: Contiguous axial CT images of the head.
There is no definite acute intracranial hemorrhage. Note is made
of somewhat questionable area of hyperdensity anterior to the
pons in the posterior fossa, at the area of beam-hardening
artifact, most likely artifactual. No mass effect is seen. The
osseous and soft tissue structures are unremarkable.
IMPRESSION: No definite evidence of intracranial hemorrhage.
Questionable area of hypodensity anterior to the pons, which is
felt to be artifactual, however, please perform short time
followup if clinically warranted.

Brief Hospital Course:
Mr [**Known lastname **] was combative and in severe pain upon entry into the
hospital. He was intubated and subsequently taken to the OR for
an ORIF (intramedullary nail) of the right tibia and fibula on
[**2114-4-29**]. He stayed in the Trauma ICU and was extubated POD 1. Pt
had a couple episodes of post op fever which resolved with
pulmonary toilet (studies negative for source of fever).

Physical therapy saw the patient for the duration of his stay.
He was ultimately cleared with partial weight bearing status on
crutches.

For anticoagulation, the patient was maintained on lovenox
during his stay. However, he indicated that he would not do the
injections under any circumstances outside the hospital. In
discussion with the orthopedists, it was decided that Aspirin
325mg EC PO BID was the next best option for him.

The patient was discharged in stable condition with his friend.


Medications on Admission:
none

Discharge Medications:
1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day: Take with food.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for indigestion.
Disp:*60 Tablet(s)* Refills:*2*
3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed for pain for 7 days:
maximum: 12 pills in 24 hours.
Disp:*25 Tablet(s)* Refills:*0*
4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation for 1 weeks: do not take
the medicine if you have more than 1 BM per day.
Disp:*14 Capsule(s)* Refills:*0*
5. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO Q6H (every 6 hours) as needed for constipation for 1
weeks.
Disp:*1 bottle (at least 800ml)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
Fracture of tibia and fibula.


Discharge Condition:
good.


Discharge Instructions:
You broke your lower leg bones. You should only partially bear
weight on that leg. Follow the instructions of the orthopedic
doctors and the physical therapists about how to partially
weight bear.

Take your medications as directed.

Followup Instructions:
Call Dr. [**First Name (STitle) **] of orthopedics at ([**Telephone/Fax (1) 2007**] for a follow up
appointment in 2 weeks. You need to do this to get more
medicines and to look at your broken leg. If you cannot follow
up because you're moving to [**State 4565**] as you mentioned, you
should either go to an Orthopedic doctor there, or go to the ER
to have the staples out.
{'Unspecified fracture of ankle, open,Alcohol abuse, unspecified,Accidental fall from or out of building or other structure'}


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

PRESENT ILLNESS: 40M fell while intoxicated w/ alcohol from the [**Location (un) **] and
broke his leg, open tib-fib.

MEDICAL HISTORY: noncontributory

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 119 181/108 100% on O2 bag
Combative, subsequently intubated.
RRR
CTA bilaterally anteriorly
abd soft nd
pelvis stable
rectal tone: nl; guaiac neg
Neck/back: no stepoffs, no deformity
extr: palp distal pulses; RLE 1cm lac c/w bone, not puncture
wound; RLE externally rotated.

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: +etoh
denies illicits
denies tob 

### Response:
{'Unspecified fracture of ankle, open,Alcohol abuse, unspecified,Accidental fall from or out of building or other structure'}
