CHIEF COMPLAINT: Trauma - s/p assault

PRESENT ILLNESS: This patient is a 85 year old male who complains of S/P
ASSAULT. Afebrile male who was in bed at the nursing home
when he was assaulted by his roommate, kicked in the head
and abdomen, seen at L5 Hospital and transferred here for
possible intracranial hemorrhage and questionable liver
laceration.

MEDICAL HISTORY: PMH: prostate ca, dementia, psychosis, HTN
PSH: unknown

MEDICATION ON ADMISSION: Atenolol 50 mg po daily, tylenol 650mg po Q8H, trazodone 25mg po
qhs and 50mg po q 2 pm, depakote 500mg po q noon and 750 mg po q
pm, MVI, Vit D 1,200 units po daily, ASA 81 mg po daily, colace
100 mg po daily, trazodone 25 mg po Q6H prn, prns: tylenol, MOM,
bisacodyl, [**Name2 (NI) **] enema

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Constitutional: Calm
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact; abrasion to face
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Rectal: No gross blood
Extr/Back: No cyanosis, clubbing or edema; no step-offs or
deformities of the spine
Skin: No rash, Warm and dry
Neuro: awake, moving all extremities

FAMILY HISTORY: NC

SOCIAL HISTORY: dementia, lives in group home
Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Personal history of malignant neoplasm of prostate,Assault by other specified means,Person awaiting admission to adequate facility elsewhere
Subdural hem w/o coma,Mental disor NEC oth dis,Hypertension NOS,Hx-prostatic malignancy,Assault NEC,Wait adm to oth facility
Admission Date:  [**2197-8-5**]              Discharge Date:   [**2197-8-11**]


Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 3223**]
Chief Complaint:
Trauma - s/p assault

Major Surgical or Invasive Procedure:
none

History of Present Illness:
This patient is a 85 year old male who complains of S/P
ASSAULT. Afebrile male who was in bed at the nursing home
when he was assaulted by his roommate, kicked in the head
and abdomen, seen at L5 Hospital and transferred here for
possible intracranial hemorrhage and questionable liver
laceration.



Past Medical History:
PMH: prostate ca, dementia, psychosis, HTN
PSH: unknown


Social History:
dementia, lives in group home

Family History:
NC

Physical Exam:
Constitutional: Calm
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact; abrasion to face
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Rectal: No gross blood
Extr/Back: No cyanosis, clubbing or edema; no step-offs or
deformities of the spine
Skin: No rash, Warm and dry
Neuro: awake, moving all extremities

Pertinent Results:
CT Head:
Isodense small subdurals bilaterally are visualized on the left
side approximately 4 mm and 3 mm on the right side without
significant mass
effect on the adjacent brain. No evidence of a hyperdense
intra-axial
hemorrhage or extra-axial hemorrhage identified. Clinical
correlation
recommended to determine the significance. Moderate brain
atrophy.

CT C-spine:
No acute traumatic process, with no evidence of fracture or
malalignment.

CT abd:
IMPRESSION:
1. 14 x 9 mm pulmonary nodule identified in the right lower lobe
for which
correlation with prior imaging or PET-CT is recommended if not
evaluated
previously.
2. Hypoattenuating regions within the liver intermittently
crossing the right
hepatic lobe and also seen adjacent to the IVC as described
above, that in
setting of trauma raises concern for liver laceration. Limited
study secondary
to technique and other possibilities include fatty infiltration.
A repeat
dedicated CT can be obtained for further delineation when
clinically feasible.
3. Extensive atherosclerotic calcification.

RUQ Ultrasound:
1. No perihepatic fluid or ascites.

2. Area of relative echogenicity in the liver, adjacent to the
inferior vena
cava, correlating to areas of hypodensity seen on CT. This is
not a typical
apearance of hematoma or free fluid. Overall, these findings are
nonspecific
and considerations still include, though do not favor traumatic
injury. A
leading alternative in the differential is focal fatty
deposition.

Please correlate with mechanism of assult; these findings could
be further
evaluated with a MRI (if the patient is able) or dedicated
repeat CT with
appropriate patient positioning and contrast timing.

[**2197-8-5**] 11:15AM BLOOD WBC-10.1 RBC-4.17* Hgb-13.2* Hct-38.0*
MCV-91 MCH-31.7 MCHC-34.7 RDW-12.9 Plt Ct-175
[**2197-8-5**] 06:00PM BLOOD Hct-39.9*
[**2197-8-6**] 02:43AM BLOOD WBC-11.4* RBC-4.44* Hgb-12.8* Hct-40.5
MCV-91 MCH-28.8 MCHC-31.6 RDW-12.9 Plt Ct-178
[**2197-8-6**] 01:54PM BLOOD Hct-34.0*
[**2197-8-6**] 05:40PM BLOOD WBC-11.9* RBC-4.18* Hgb-13.0* Hct-37.8*
MCV-90 MCH-31.1 MCHC-34.4 RDW-12.7 Plt Ct-170
[**2197-8-7**] 02:33AM BLOOD WBC-9.9 RBC-4.36* Hgb-13.4* Hct-39.9*
MCV-91 MCH-30.6 MCHC-33.5 RDW-12.9 Plt Ct-174
[**2197-8-6**] 05:40PM BLOOD PT-13.6* PTT-27.5 INR(PT)-1.2*
[**2197-8-6**] 02:43AM BLOOD Glucose-151* UreaN-18 Creat-1.2 Na-141
K-4.7 Cl-104 HCO3-29 AnGap-13
[**2197-8-7**] 02:33AM BLOOD Glucose-124* UreaN-12 Creat-1.2 Na-141
K-4.1 Cl-103 HCO3-29 AnGap-13
[**2197-8-5**] 11:15AM BLOOD Valproa-34*
[**2197-8-5**] 11:15AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
[**2197-8-5**] 11:18AM BLOOD Glucose-115* Lactate-2.1* Na-144 K-4.3
Cl-97* calHCO3-27

Brief Hospital Course:
Trauma evaluation and imaging performed revealed:
[**8-5**]- CXR - negative
[**8-5**]- CT head - Isodense small subdurals bilaterally are
visualized on the L ~4 mm and 3 mm on R without significant mass
effect on the adjacent brain. Moderate brain atrophy
[**8-5**]- CT cspine - negative
[**8-5**]- CT torso - 14 x 9 mm pulmonary nodule identified in RLL.
Hypoattenuating regions within liver intermittently crossing the
R hepatic lobe and also to IVC, raises concern for liver
laceration.

Due to the concern for a liver laceration he was admitted to the
ICU for hemodynamic monitoring and underwent serial Hct checks.
His Hct remained stable and on [**2197-8-6**] he underwent an ultrasound
of his liver to assess for any evidence of bleeding or large
laceration.  This revealed no perihepatic fluid or ascites. Area
of relative echogenicity in the liver, adjacent to the inferior
vena  cava, correlating to areas of hypodensity seen on CT.

Speech and swallow evaluated the patient had he was recommended
for:
1. PO diet: ground solids, thin liquids
2. PO meds crushed in puree
3. TID oral care
4. 1:1 supervision and assistance with PO intake for standard
aspiration precautions.
5. Nutrition f/u
6. Repeat swallowing evaluation in [**2-1**] days.
 regular

Social work was also consulted as the patient had been assaulted
at his facility.

He remained stable and his diet was advanced.
He was called out to the surgical floor.  By the time of
discharge he was tolerating a regular diet and his pain was well
controlled.


Medications on Admission:
Atenolol 50 mg po daily, tylenol 650mg po Q8H, trazodone 25mg po
qhs and 50mg po q 2 pm, depakote 500mg po q noon and 750 mg po q
pm, MVI, Vit D 1,200 units po daily, ASA 81 mg po daily, colace
100 mg po daily, trazodone 25 mg po Q6H prn, prns: tylenol, MOM,
bisacodyl, [**Name2 (NI) **] enema

Discharge Medications:
1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for HTN.
2. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. Trazodone 50 mg Tablet Sig: One (1) Tablet PO Q 1400 ().
4. Multivitamin,Tx-Minerals     Tablet Sig: One (1) Tablet PO
DAILY (Daily).
5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN
(as needed) as needed for discomfort.
8. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Three (3)
Tablet PO DAILY (Daily).
10. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. Depakote 500 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO at bedtime.
12. Depakote 250 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO at bedtime.


Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] of [**Location (un) 4693**]

Discharge Diagnosis:
s/p assault - small bilateral subdural hematomas


Discharge Condition:
Level of Consciousness: Alert and interactive.
Mental Status: Confused - baseline dementia


Discharge Instructions:
Call if:
Fever greater than 101
Chills
Any other symptoms that concern you
Dizziness or lightheadedness
Numbness or tingling
Change in vision

Followup Instructions:
Please call your PCP to schedule follow up in [**12-31**] weeks


                             [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]



Name:  [**Known lastname 13851**],[**Known firstname 13852**]            Unit No:   [**Numeric Identifier 13853**]

Admission Date:  [**2197-8-5**]              Discharge Date:   [**2197-8-11**]

Date of Birth:  [**2111-12-10**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4216**]
Addendum:
Mr. [**Known lastname **] was hospitalized a few additional days while proper
placement was obtained.  His status is unchanged, vital signs
are stable and his appetite is good with assistance.

Discharge Disposition:
Extended Care

Facility:
[**Location (un) **] of [**Location (un) **]

                             [**First Name11 (Name Pattern1) 499**] [**Last Name (NamePattern4) 4218**] MD [**MD Number(2) 4219**]

Completed by:[**2197-8-11**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Personal history of malignant neoplasm of prostate,Assault by other specified means,Person awaiting admission to adequate facility elsewhere'}


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 - s/p assault

PRESENT ILLNESS: This patient is a 85 year old male who complains of S/P
ASSAULT. Afebrile male who was in bed at the nursing home
when he was assaulted by his roommate, kicked in the head
and abdomen, seen at L5 Hospital and transferred here for
possible intracranial hemorrhage and questionable liver
laceration.

MEDICAL HISTORY: PMH: prostate ca, dementia, psychosis, HTN
PSH: unknown

MEDICATION ON ADMISSION: Atenolol 50 mg po daily, tylenol 650mg po Q8H, trazodone 25mg po
qhs and 50mg po q 2 pm, depakote 500mg po q noon and 750 mg po q
pm, MVI, Vit D 1,200 units po daily, ASA 81 mg po daily, colace
100 mg po daily, trazodone 25 mg po Q6H prn, prns: tylenol, MOM,
bisacodyl, [**Name2 (NI) **] enema

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Constitutional: Calm
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact; abrasion to face
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
Rectal: No gross blood
Extr/Back: No cyanosis, clubbing or edema; no step-offs or
deformities of the spine
Skin: No rash, Warm and dry
Neuro: awake, moving all extremities

FAMILY HISTORY: NC

SOCIAL HISTORY: dementia, lives in group home 

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, with no loss of consciousness,Other persistent mental disorders due to conditions classified elsewhere,Unspecified essential hypertension,Personal history of malignant neoplasm of prostate,Assault by other specified means,Person awaiting admission to adequate facility elsewhere'}
