CHIEF COMPLAINT: Fall, pneumothorax, rib fractures

PRESENT ILLNESS: 67M transfer from OSH after developing progressive subcutaneous
emphysema/facial swelling and subsequent respiratory distress
requiring intubation. He was treated in the OSH ED with
epinephrine, solumedrol, and benadryl with no effect, and
subsequently was intubated for worsening respiratory distress.
Upon arrival to the ED here he had CT scans of the chest,
abdomen, pelvis, and c-spine which revealed extensive
pneumomediastinum, right sided pneumothorax, a smaller
left-sided pneumothorax, and extensive subcutaneous emphysema.

MEDICAL HISTORY: Hypertension

MEDICATION ON ADMISSION: MEDS AT HOME: Amlodipine 10', Atenolol 50', Lisinopril 40',ASA,

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission: Intubated and sedated
Vitals: BP: 123/80 HR 102
Intubated CMV 60% /5  : ABG pH 7.32 pCO2 42 pO2 56 HCO3 23
GEN: Sedated
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Bilateral subcutaneus emphysema. Decreased blt respiratory
sounds
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: NC

SOCIAL HISTORY: possible alcohol abuse
Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of multiple ribs, unspecified,Hyposmolality and/or hyponatremia,Unspecified fall,Traumatic subcutaneous emphysema,Unspecified essential hypertension,Late effects of cerebrovascular disease, speech and language deficit, unspecified
Traum pneumothorax-close,Fx mult ribs NOS-closed,Hyposmolality,Fall NOS,Traum subcutan emphysema,Hypertension NOS,Late ef-spch/lng def NOS
Admission Date:  [**2154-1-5**]              Discharge Date:   [**2154-1-9**]

Date of Birth:  [**2084-6-4**]             Sex:   M

Service: SURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**Last Name (NamePattern1) 4659**]
Chief Complaint:
Fall, pneumothorax, rib fractures

Major Surgical or Invasive Procedure:
[**2154-1-5**]: Right sided chest tube

History of Present Illness:
67M transfer from OSH after developing progressive subcutaneous
emphysema/facial swelling and subsequent respiratory distress
requiring intubation. He was treated in the OSH ED with
epinephrine, solumedrol, and benadryl with no effect, and
subsequently was intubated for worsening respiratory distress.
Upon arrival to the ED here he had CT scans of the chest,
abdomen, pelvis, and c-spine which revealed extensive
pneumomediastinum, right sided pneumothorax, a smaller
left-sided pneumothorax, and extensive subcutaneous emphysema.


Past Medical History:
Hypertension

Social History:
possible alcohol abuse

Family History:
NC

Physical Exam:
On admission: Intubated and sedated
Vitals: BP: 123/80 HR 102
Intubated CMV 60% /5  : ABG pH 7.32 pCO2 42 pO2 56 HCO3 23
GEN: Sedated
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Bilateral subcutaneus emphysema. Decreased blt respiratory
sounds
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused

Physical examination upon discharge:  [**2154-1-9**]:

Vital signs:  t=96, bp=90/54, hr=81, resp. rate 20, room air 95%

General:  Sitting in chair, NAD, garbled speech related to no
dentures

CV:  Ns1, s2, -s3, -s4
LUNGS:  decreased bs bases
ABDOMEN:  soft, non-tender
EXT:  Weak dp bil., ext. cool, mottled, + radial bil. left hand
cool
no calf tendeness, no pedal edema bil
NEURO:  alert and oriented x 3, speech garbled, no tremors
SKIN:  Crepitus clavicles bil., uppper ant. chest wall, mandible
and neck.

Pertinent Results:
[**2154-1-7**] 02:18AM BLOOD WBC-8.4 RBC-3.30* Hgb-11.8* Hct-33.0*
MCV-100* MCH-35.7* MCHC-35.7* RDW-12.4 Plt Ct-215
[**2154-1-6**] 01:14AM BLOOD WBC-11.5* RBC-3.12* Hgb-10.6* Hct-30.6*
MCV-98 MCH-33.9* MCHC-34.6 RDW-12.7 Plt Ct-171
[**2154-1-5**] 01:53AM BLOOD Neuts-95.3* Lymphs-4.0* Monos-0.6*
Eos-0.1 Baso-0.1
[**2154-1-4**] 09:46PM BLOOD Neuts-96.9* Lymphs-1.8* Monos-1.1*
Eos-0.1 Baso-0.1
[**2154-1-7**] 02:18AM BLOOD Plt Ct-215
[**2154-1-7**] 02:18AM BLOOD Glucose-92 UreaN-8 Creat-0.8 Na-135 K-4.0
Cl-98 HCO3-28 AnGap-13
[**2154-1-6**] 05:30PM BLOOD Glucose-100 UreaN-8 Creat-0.8 Na-137
K-3.3 Cl-101 HCO3-27 AnGap-12
[**2154-1-6**] 01:14AM BLOOD ALT-32 AST-51* AlkPhos-95 TotBili-0.3
[**2154-1-7**] 02:18AM BLOOD Calcium-8.9 Phos-3.2 Mg-2.1
[**2154-1-6**] 05:30PM BLOOD Calcium-8.7 Phos-2.8 Mg-1.7
[**2154-1-5**] 01:12PM BLOOD Lactate-0.2*
[**2154-1-5**] 02:54AM BLOOD Lactate-2.0

[**2154-1-4**]:  chest x-ray:

IMPRESSION:
1. Bilateral pneumothoraces and pneumomediastinum not well seen
on this study but are seen on subsequent CT.
2. Endotracheal tube ends 3.7 cm above the carina.

[**2154-1-4**]:  cat scan of the head:

 IMPRESSION: Extensive subcutaneous air as described above. No
intracranial air. No acute intracranial injury.

[**2154-1-4**]:  cat scan of the abdomen:

 IMPRESSION:
1. Multiple right-sided rib fractures with bilateral small
pneumothoraces,
extensive pneumomediastinum and tracking of subcutaneous air
along the body wall.

2. Severe pulmonary emphysema with biapical scarring.

3. No solid organ injury in the abdomen or pelvis.

4. Extensive atherosclerosis with abdominal aortic aneurysm to
3.3 cm.

5. ETT and NGT in appropriate position

[**2154-1-4**]:  cat scan of the c-spine:

IMPRESSION:
1. No acute fracture or malalignment.
2. Extensive subcutaneous air.

[**2154-1-5**]:  chest x-ray:

FINDINGS: Again seen is severe bilateral subcutaneous emphysema
which limits the assessment for small pneumothorax.
Pneumomediastinum is again visualized.
There is a right-sided chest tube. There is mild mediastinal
shift to the
right. A small left basilar pneumothorax is visualized and
probable right
medial pneumothorax.

[**2154-1-7**]:  chest x-ray:

Severe widespread subcutaneous emphysema throughout the chest
wall and neck, and severe pneumomediastinum are unchanged over
the past several days. No definite pneumothorax, right pleural
tube in place. Bibasilar atelectasis or aspiration changes,
unchanged since [**1-5**] at 12:29 a.m. Heart size is normal

[**2154-1-7**]:  chest x-ray:

There is no large right pneumothorax or appreciable pleural
fluid collection following removal of the right pleural tube,
although a small amount of pleural air would be difficult to
detect in the setting of persistent severe subcutaneous
emphysema and pneumomediastinum. Left basal atelectasis has
cleared. Emphysema is severe. There is probably a small to
moderate left pneumothorax, which has remained stable since the
earliest chest radiographs here on [**1-4**]. Heart is not
enlarged.





Brief Hospital Course:
Mr [**Known lastname 5579**] arrived to [**Hospital1 18**], s/p fall and developed sudden
onset of right sided facial swelling.  He was intubated for
increasing respiratory distress.  He was taken to the Trauma ICU
for monitoring.  Imaging showed right rib fractures and
bilateral pneumothorax.  Soon after arrival a right-sided chest
tube was placed by the thoracic surgery team and he was observed
in the ICU until transfer to the floor on [**2154-1-7**].

NEURO: He received acetaminophen and oxycodone with good effect
and adequate pain control.

CV: He exhibited consisent mild-moderate hypertension, so he was
given IV
metoprolol. Once tolerating PO intake, he was transitioned to
oral metoprolol.

PULM: He had a chest tube placed [**1-5**] and was extubated on
[**2154-1-6**], hospital day 2. His chest tube showed a small air leak
the first day it was placed, but no residual pneumothorax was
seen on CXR. The thoracic team removed his chest tube on [**2154-1-7**].
 Repeat chest x-ray on [**1-8**] showed no pneumothorax but increased
subcutaneous air in upper chest. His respiratory status was not
compromised.

GI/GU/FEN: While intubated, he was NPO with IV fluids. He was
hyponatremic on arrival, which improved readily after several
liters of NS followed by 1/2 NS.  His current sodium is 135.
He had a bedside swallow eval performed [**1-7**] and he was started
on a regular diet.

ID: He had no infectious issues, no antibiotics were indicated.

Endocrine: His blood sugar was monitored throughout his stay and
was maintained on an insulin sliding scale until his blood
glucose values returned to [**Location 213**].

Hematology: His complete blood count was examined routinely; no
transfusions were required.

Prophylaxis: He received subcutaneous heparin and venodyne boots
were used during this stay and was encouraged to ambulate as
early as possible.

He is afebrile and his blood pressure is borderline.  His
anti-hypertensives have been held today because of a blood
pressure of 90/50.  He is able to ambulate without dizziness or
shortness of breath.  His blood pressure was monitored
throughtout the day and has increased to 122/70.  He is
tolerating a regular diet.  His electrolytes have normalized and
his hematocrit is stable.

He is preparing for discharge home with VNA services who will
monitor his blood pressure. He also has  instructions to follow
up with the acute care service and with his primary care
provider to [**Name9 (PRE) 38002**] his anti-hypertensive agents.

Medications on Admission:
MEDS AT HOME: Amlodipine 10', Atenolol 50', Lisinopril 40',ASA,

Folic Acid, Cyanocobalamin, MVI, Thiamine


Discharge Medications:
1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please check BP prior to dose: hold for bp <100, hr <60.
2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily):
please check blood pressure prior to dose: hold for blood
pressure <100, hr <60.
3. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily):
please check blood pressure prior to dose: hold for blood
pressure <100, hr <60.
4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
hold for loose stools.
7. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for pain.
8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.


Discharge Disposition:
Home With Service

Facility:
All Care VNA of Greater [**Location (un) **]

Discharge Diagnosis:
Trauma:  fall

Blt Pneumo R > L / pneumomediastinum
R Rib fx [**8-14**] / 10 is displaced.


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 had fallen.  You
developed swelling of your face, neck and upper chest. You were
also found to have a collapsed lung and rib fractures.  You had
an breathing tube placed at the outside hospital and you were
monitored in the intensive care unit.  Because of your injuries,
you had swelling of the neck, face and chest.  Your vital signs
have stablized and the swelling is decreasing.  You are now
preparing for discharge home with the following instructions:

  Your injury caused rigth sided [**8-14**] rib fractures which can
cause severe pain and subsequently cause you to take shallow
breaths because of the pain.

*  You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.

*  Pneumonia is a complication of rib fractures.  In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake.  This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.

*  You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.

*  Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.

*  Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.

*  Do NOT smoke

*  If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.

*  Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs ( crepitus ).

Followup Instructions:
Name:[**Doctor Last Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 91892**],MD
Specialty: Primary Care
Location: NORTHSHORE PHYSICIANS GROUP
Address: 900 [**Doctor Last Name **] CENTER STE 107T, [**Hospital1 420**],[**Numeric Identifier 15489**]
Phone: [**Telephone/Fax (1) 50485**]
When: Monday, Febrauary 13th at 1:45pm

Department: GENERAL SURGERY/[**Hospital Unit Name 2193**]
When: MONDAY [**2154-1-28**] at 3:30 PM
With: ACUTE CARE CLINIC [**Telephone/Fax (1) 600**]
Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage
You will need a chest x-ray prior to this appointment. Please go
to [**Hospital1 7768**], [**Hospital Ward Name 517**] Clinical Center, [**Location (un) **]
Radiology 30 minutes prior to your appointment


                             [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Name8 (MD) **] MD, [**MD Number(3) 4661**]

Completed by:[**2154-1-10**]
{'Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of multiple ribs, unspecified,Hyposmolality and/or hyponatremia,Unspecified fall,Traumatic subcutaneous emphysema,Unspecified essential hypertension,Late effects of cerebrovascular disease, speech and language deficit, 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, pneumothorax, rib fractures

PRESENT ILLNESS: 67M transfer from OSH after developing progressive subcutaneous
emphysema/facial swelling and subsequent respiratory distress
requiring intubation. He was treated in the OSH ED with
epinephrine, solumedrol, and benadryl with no effect, and
subsequently was intubated for worsening respiratory distress.
Upon arrival to the ED here he had CT scans of the chest,
abdomen, pelvis, and c-spine which revealed extensive
pneumomediastinum, right sided pneumothorax, a smaller
left-sided pneumothorax, and extensive subcutaneous emphysema.

MEDICAL HISTORY: Hypertension

MEDICATION ON ADMISSION: MEDS AT HOME: Amlodipine 10', Atenolol 50', Lisinopril 40',ASA,

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: On admission: Intubated and sedated
Vitals: BP: 123/80 HR 102
Intubated CMV 60% /5  : ABG pH 7.32 pCO2 42 pO2 56 HCO3 23
GEN: Sedated
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Bilateral subcutaneus emphysema. Decreased blt respiratory
sounds
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No LE edema, LE warm and well perfused

FAMILY HISTORY: NC

SOCIAL HISTORY: possible alcohol abuse 

### Response:
{'Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of multiple ribs, unspecified,Hyposmolality and/or hyponatremia,Unspecified fall,Traumatic subcutaneous emphysema,Unspecified essential hypertension,Late effects of cerebrovascular disease, speech and language deficit, unspecified'}
