CHIEF COMPLAINT: Trauma:  assault:

PRESENT ILLNESS: HISTORY OF PRESENTING ILLNESS

MEDICAL HISTORY: unknown
                  Medications: unknown
      Allergies and Reactions: unknown
               Family History: unknown
               Social History: unknown

MEDICATION ON ADMISSION: ? klonopin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION upon admission

FAMILY HISTORY: unknown
               Social History: unknown

SOCIAL HISTORY: unknown
Closed fracture of malar and maxillary bones,Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol withdrawal,Assault by unspecified means,Open wound of forehead, without mention of complication,Open wound of ear, part unspecified, without mention of complication,Other and unspecified alcohol dependence, continuous,Thrombocytopenia, unspecified,Anemia, unspecified
Fx malar/maxillary-close,Subarachnoid hem-no coma,Alcohol withdrawal,Assault NOS,Open wound of forehead,Open wound of ear NOS,Alcoh dep NEC/NOS-contin,Thrombocytopenia NOS,Anemia NOS
Admission Date:  [**2160-9-15**]              Discharge Date:   [**2160-10-2**]

Date of Birth:  [**2118-12-13**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 598**]
Chief Complaint:
Trauma:  assault:

Lt frontal & falx cerebri SDH
nasal bone fx
head lacs



Major Surgical or Invasive Procedure:
repair of facial laceration


History of Present Illness:

HISTORY OF PRESENTING ILLNESS

transfer from OSH. Found with head injury, abrasions &
lacerations to face. Agitated at OSH. Intubated prior to
transfer for increased agitation. At OSH, head CT with SDH.
Per report, CT c-spine negativbe for fx.

PAST FAMILY AND SOCIAL HISTORY

Nursing triage/initial assessment reviewed and confirmed

Past Medical History: unknown
                  Medications: unknown
      Allergies and Reactions: unknown
               Family History: unknown
               Social History: unknown



Past Medical History:
PHYSICAL EXAMINATION

Constitutional: intubated
HEENT: multiple lacerations to forehead, rt & left parietal
area, occipital area, midface stable
bleeding in oropharynx
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended, small abrasion
right abdomen, left flank
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: intubated, moves all extremities nonpurposefully,
does not follow commands
Psych: Normal mood



Social History:
unknown

Family History:
unknnow

Physical Exam:
PHYSICAL EXAMINATION upon admission

Constitutional: intubated
HEENT: multiple lacerations to forehead, rt & left parietal
area, occipital area, midface stable
bleeding in oropharynx
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended, small abrasion
right abdomen, left flank
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash, Warm and dry
Neuro: intubated, moves all extremities nonpurposefully,
does not follow commands
Psych: Normal mood


Pertinent Results:
[**2160-9-26**] 01:00AM BLOOD WBC-15.7* RBC-2.76* Hgb-10.3* Hct-29.4*
MCV-107* MCH-37.2* MCHC-34.9 RDW-13.3 Plt Ct-576*
[**2160-9-25**] 01:13AM BLOOD WBC-11.8*# RBC-2.88* Hgb-10.6* Hct-30.2*
MCV-105* MCH-36.9* MCHC-35.2* RDW-13.0 Plt Ct-534*#
[**2160-9-22**] 01:24AM BLOOD WBC-7.2 RBC-2.40* Hgb-9.1* Hct-24.9*
MCV-104* MCH-38.1* MCHC-36.8* RDW-13.1 Plt Ct-329
[**2160-9-21**] 12:00AM BLOOD WBC-8.4 RBC-2.45* Hgb-9.3* Hct-25.6*
MCV-105* MCH-37.9* MCHC-36.2* RDW-12.7 Plt Ct-294
[**2160-9-15**] 08:25PM BLOOD WBC-10.0 RBC-3.13* Hgb-12.2* Hct-34.4*
MCV-110* MCH-39.0* MCHC-35.5* RDW-13.2 Plt Ct-152
[**2160-9-26**] 01:00AM BLOOD Plt Ct-576*
[**2160-9-25**] 01:13AM BLOOD Plt Ct-534*#
[**2160-9-26**] 01:00AM BLOOD Glucose-114* UreaN-10 Creat-0.7 Na-135
K-4.2 Cl-100 HCO3-26 AnGap-13
[**2160-9-25**] 01:13AM BLOOD Glucose-144* UreaN-7 Creat-0.7 Na-135
K-3.8 Cl-99 HCO3-23 AnGap-17
[**2160-9-22**] 01:24AM BLOOD Glucose-228* UreaN-5* Creat-0.6 Na-139
K-4.7 Cl-108 HCO3-21* AnGap-15
[**2160-9-19**] 03:08AM BLOOD ALT-30 AST-29 LD(LDH)-266* AlkPhos-59
TotBili-0.9
[**2160-9-18**] 12:23AM BLOOD ALT-43* AST-52* LD(LDH)-305* AlkPhos-51
TotBili-0.7
[**2160-9-15**] 08:25PM BLOOD Lipase-43
[**2160-9-15**] 08:25PM BLOOD Lipase-51
[**2160-9-26**] 01:00AM BLOOD Calcium-9.8 Phos-4.7* Mg-1.9
[**2160-9-25**] 01:13AM BLOOD Calcium-9.8 Phos-4.6* Mg-1.7
[**2160-9-15**] 08:25PM BLOOD ASA-NEG Ethanol-112* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2160-9-15**] 08:25PM BLOOD ASA-NEG Ethanol-149* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2160-9-16**] 10:57AM BLOOD Type-ART pO2-173* pCO2-44 pH-7.37
calTCO2-26 Base XS-0 Intubat-INTUBATED
[**2160-9-15**] 09:42PM BLOOD Type-ART pO2-526* pCO2-43 pH-7.26*
calTCO2-20* Base XS--7
[**2160-9-15**] 09:00PM BLOOD Glucose-118* Lactate-1.9 Na-144 K-3.7
Cl-113* calHCO3-19*

[**2160-9-15**]:  cat scan of head:

Wet Read: PBec MON [**2160-9-15**] 10:25 PM
1. previously noted l frontal lobe SDH and cerebral falx not as
well seen. 2. bilateral crescentric isodensities noted overlying
both convexities now seen - may represent redistribution of
prior SDH or more apparent chronic SDH.
3. linear focus of extra-axila hyperdensity at R frontal vertex,
appears vascular.
4. global atrophy.
5. nasal bone fx better eval on sinus CT.

[**2160-9-15**]: cat scan of abdomen and pelvis:

 IMPRESSION:
1. No acute process or fracture identified.
2. Nasogastric tube with tip in the stomach and side port at
level of the GE
junction. Would recommend advancing approximately 5 cm.
3. Endotracheal tube with tip at the level of the clavicle.
4. Jejunojejunal intussception in the left abdomen without
evidence of
obstruction. In an adult patient, this finding is likely
transient.

[**2160-9-15**]: cat scan of sinus and mandible:

IMPRESSION: Bilateral nasal bone fractures and fracture of the
nasal spine of the maxilla

[**2160-9-16**]: cat scan of the head:

 IMPRESSION:

1. Redistribution of small subdural hematomas along the
bilateral convexities and along the falx.

2. Stable single focus of subarachnoid hemorrhage in a right
frontal
paramedian sulcus.

3. Stable bifrontal hypodense subdural collections, which may
represent
subdural effusions.

4. Bilateral subgaleal hematomas, scalp lacerations, and
bilateral nasal bone fractures are again noted.

[**2160-9-17**]:  chest x-ray:

FINDINGS: Interval removal of endotracheal tube and nasogastric
tube.
Cardiomediastinal contours are within normal limits for
technique, and lungs are grossly clear.

[**2160-9-25**]:  ekg:

 Sinus tachycardia. Other than rate, normal tracing. No previous
tracing
available for comparison.

[**2160-9-30**]:  EKG:

 Sinus tachycardia. Baseline artifact. Normal ST segments. Sinus
arrhythmia.
As on tracing #1, abnormal T waves are a known finding and are
not new.
TRACING #2

[**2160-9-16**]:

 [**2160-9-16**] 9:36 pm BLOOD CULTURE      Source: Venipuncture.

                            **FINAL REPORT [**2160-9-22**]**

   Blood Culture, Routine (Final [**2160-9-22**]):    NO GROWTH.

  [**2160-9-16**] 9:25 pm URINE      Source: Catheter.

                            **FINAL REPORT [**2160-9-17**]**

   URINE CULTURE (Final [**2160-9-17**]):    NO GROWTH.

[**2160-9-22**] 1:23 am MRSA SCREEN      Source: Nasal swab.

                            **FINAL REPORT [**2160-9-24**]**

   MRSA SCREEN (Final [**2160-9-24**]):    No MRSA isolated.

repeat CBC [**2160-10-2**]:  wbc=9.0, hct =30.0




Brief Hospital Course:
49 year old gentleman admitted to the acute care service after
he was assaulted. He was transferred from an OSH where he was
intubated for agitation.  Upon arrival he was admitted to the
intensive care unit.  He was made NPO, given intravenous fluids,
and underwent radiographic imaging.  He was reported to have a
subdural hematoma, facial lacerations, and a nasal fracture.
Plastic surgery was consulted for his comminuted nasal fracture
which was minimally displaced.  No surgical intervention was
necessary.  He was followed by Neurosurgery who followed him
with head cat scans to assess any increase in his subdural
hematoma. His head cat scans remained stable. To prevent
seizures, he was placed on a keppra for 1 week.

He was extubated 24 hours after admission.  His cervical and
thoracic spine was cleared and he was taken of log-roll
precautions. He was evaluated by speech and swallow who adviced
thickened liquids to decrease his risk of aspiration.   During
this time, he became febrile and was cultured.  His blood
cultures showed no growth.  He  began to exhibit signs of
alcohol withdrawal and required ativan and haldol to reduce his
anxiety. The agitation progressed to the point that he need to
be started on precedex.  His precedex was weaned on on HD #5 and
his agitation was controlled with valium and haldol. Psychiatry
was consulted and recommended zyprexa and intermittent haldol
for his delirium and agitation.  After his mental status
improved, he was evaluated by physical and occupational therapy.


He was transferred to the surgical floor on [**9-26**].  Psychiatry
continued to monitor his status and provided recommendations for
his care.  At this point, he was off his benzodiazapines and
only on zyprexa.   As his mental status cleared, he was
gradually re-introduced to a soft diet with progression to a
regular diet with no evidence of aspiration.

Upon discharge, he  is oriented and cooperative.  His vital
signs are stable and he is afebrile. His white blood cell count
is 9.0 and his hematocrit is stable.  He is tolerating a regular
diet and ambulating without difficulty.

He was discharged to a shelter with recommendations to follow up
with the acute care service, and with Neurology in [**5-7**] week
where he will need a repeat non-contrast head cat scan to
evaluate his subdural hematoma.   An appointment was set up in 1
week with Dr. [**Last Name (STitle) 91173**], who patient identified as his primary
care provider.  [**Name10 (NameIs) **] importance of follow-up visits were
stressed.

Medications on Admission:
? klonopin

Discharge Medications:
none

Discharge Disposition:
Home

Discharge Diagnosis:
Trauma:  assault

Lt frontal & falx cerebri SDH
nasal bone fx
head lacs


Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.


Discharge Instructions:
You were admitted to the hospital after you were assaulted.  You
sustained a small bleed in your head and a nasal bone fracture.
You are slowly recovering and you are now ready for discharge
home with the following instructions:

Please report/return to the emergency room if you experience:

*headache
*double vision or any other change in vision
*difficulty speaking
*weakness on one side of your body
*difficulty breathing
*change in your balance
*nausea/vomitting
*fever
*chills
Or any other symptoms that concern you

You will need to follow-up with the acute care service,
neurology, and your primary doctor.  It is very important that
you keep these appointments.

Followup Instructions:
Please follow up your primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 91173**], on
[**2160-10-8**] at 11am.  His office is now at [**Hospital **] Medical Walk-in
  [**Last Name (un) **]., [**Hospital1 487**], Mass.  The telephone number is
[**Telephone/Fax (1) 72680**]

Follow up with acute care service in 2 weeks.  The telephone
number is #[**Telephone/Fax (1) 600**].

Please follow -up with Neurosurgery, Dr. [**First Name (STitle) **] in [**5-7**] weeks.
Please let them know that you will need a non-contrast head cat
scan prior to your visit.  The telephone number to schedule this
appointment is # [**Telephone/Fax (1) 1669**]


                             [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**]

Completed by:[**2160-10-9**]
{'Closed fracture of malar and maxillary bones,Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol withdrawal,Assault by unspecified means,Open wound of forehead, without mention of complication,Open wound of ear, part unspecified, without mention of complication,Other and unspecified alcohol dependence, continuous,Thrombocytopenia, unspecified,Anemia, 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: Trauma:  assault:

PRESENT ILLNESS: HISTORY OF PRESENTING ILLNESS

MEDICAL HISTORY: unknown
                  Medications: unknown
      Allergies and Reactions: unknown
               Family History: unknown
               Social History: unknown

MEDICATION ON ADMISSION: ? klonopin

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: PHYSICAL EXAMINATION upon admission

FAMILY HISTORY: unknown
               Social History: unknown

SOCIAL HISTORY: unknown 

### Response:
{'Closed fracture of malar and maxillary bones,Subarachnoid hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Alcohol withdrawal,Assault by unspecified means,Open wound of forehead, without mention of complication,Open wound of ear, part unspecified, without mention of complication,Other and unspecified alcohol dependence, continuous,Thrombocytopenia, unspecified,Anemia, unspecified'}
