CHIEF COMPLAINT: CC:[**CC Contact Info 70573**]

PRESENT ILLNESS: HPI: 32 y/o female transferred from [**Last Name (un) 70574**] General after
being
shot in the head around 9:00pm this evening by her boyfriend 357
Magnum gun used. At [**Hospital 70574**] [**Hospital3 **] was awake but
unable to speak.  Also has ? gun shot wound to left hand.

MEDICAL HISTORY: PMH: None per brother
ALL: None per brother

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 96.8 BP 101/52 p 75 HR 14 100%
Intubated sedated last sedation 45 minutes prior and
paralyzation
1 hour prior
Pupils 2.5 minimal reactive
Blood coming out of mouth.  Appears to have enterance wound near
right ear/mandibular area.
Lungs clear
Heart RRR s1 s2
Abd soft non distended
Neuro:
Pupils eyes 2.5 minimally reactive, no repsonse in any extremity
to deep painful stimuli.  No corneal, + gag

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Social: Unknown
Open fracture of base of skull with cerebral laceration and contusion, unspecified state of consciousness,Acute posthemorrhagic anemia,Pneumonia due to other gram-negative bacteria,Assault by shotgun,Open fracture of base of other metacarpal bone(s),Abrasion or friction burn of shoulder and upper arm, without mention of infection
Op skl base fx/cereb lac,Ac posthemorrhag anemia,Pneumo oth grm-neg bact,Assault-shotgun,Fx metacarp base NEC-opn,Abrasion shoulder/arm
Admission Date:  [**2149-10-21**]              Discharge Date:   [**2149-11-10**]

Date of Birth:  [**2117-9-3**]             Sex:   F

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
CC:[**CC Contact Info 70573**]

Major Surgical or Invasive Procedure:
Subooccipital Craniotomy

History of Present Illness:
HPI: 32 y/o female transferred from [**Last Name (un) 70574**] General after
being
shot in the head around 9:00pm this evening by her boyfriend 357
Magnum gun used. At [**Hospital 70574**] [**Hospital3 **] was awake but
unable to speak.  Also has ? gun shot wound to left hand.


Past Medical History:
PMH: None per brother
ALL: None per brother


Social History:
Social: Unknown


Family History:
noncontributory

Physical Exam:
PE: 96.8 BP 101/52 p 75 HR 14 100%
Intubated sedated last sedation 45 minutes prior and
paralyzation
1 hour prior
Pupils 2.5 minimal reactive
Blood coming out of mouth.  Appears to have enterance wound near
right ear/mandibular area.
Lungs clear
Heart RRR s1 s2
Abd soft non distended
Neuro:
Pupils eyes 2.5 minimally reactive, no repsonse in any extremity
to deep painful stimuli.  No corneal, + gag


Pertinent Results:
CT: There is a large metallic foreign body in the left posterior
fossa. At the left cerebellopontine angle is a 2.4 cm focus of
intraparenchymal hemorrhage.  There is diffuse subarachnoid
hemorrhage within the basal cisterns.  There is a large degree
of
mass effect on the pons at the level of the middle cerebellar
peduncles, left greater than right and effacement of the
quadrigeminal cistern.  The supratentorial ventricles and sulci
are grossly normal.  The [**Doctor Last Name 352**]-white matter differentiation is
preserved.  The surrounding soft tissue structures show soft
tissue swelling over the right lateral face
with air tracking into the medial to the right mandibular
condyle
and within the temporal fossa.  The surrounding osseous
structures show fracture of the left skull base with few bony
fragments sitting in the inferior aspect of the left posterior
fossa.  The imaged portions of the paranasal sinuses show
mucosal thickening within the ethmoid air cells and fluid
filling
the nasopharynx.


Brief Hospital Course:
Pt was admitted and emergently brought to the OR for bilateral
posterior craniotomy and placement of EVD. Patient tolerated the
procedure and was sent to the T/SICU for close monitoring.
Initially she remained unresponsive, and would not open her
eyes, but her pupils remained equal and reactive, she localized
to pain with her left UE, and withdrew to pain with BLE's. She
was started on mannitol and decadron postoperatively. Post-op CT
revealed expected postoperative changes.
[**10-23**] transfused, tf's started
[**10-24**] trach/peg
[**10-25**] transfused she was transferred to the neurostep down unit,
where neurologically she began making excellent neurologic
process, she began moving her extremities to command, opening
her eyes and tracking the examiner and attempting to mouth
words.
On [**10-29**] she had her left hand bullet wound repaired by plastics
without difficulty.  We began to wean her ventriculostomy drain
to 15 mm above the trageus. She had low grade fevers in 101
range, she had multiple cultures which were negative and no sign
of csf leak from bullet enterance on right side of face.  We
consulted ID to assist with fevers but also to suggest need or
need of antibiotics due to bullet fragment.  Neurologically she
continued to improve following commands and answering yes/no
questions appropriately.

ID recommended full culture work which has been negative with
exception of gram + rods in sputum.  An abd CT showed no source
of infection.  Ceftriaxone was started for broader coverage
recommended full 14 days of treatmen.

Her ventricular drain was gradually raised and pulled on [**11-4**]
her follow up CTs showed small ventricles her neurologic status
improved on a daily basis.  She was following commands and
orientated X3 when given choices.  She had left arm weakness.

On [**11-5**] her sutures were removed and middle portion of the
incision was noted to have an open area she was resutured and
started on a two weeks of Keflex.

She pulled out her PEG on [**11-1**] and repeat swallowing test showed
aspiration so a new PEG was placed by IR on [**11-6**].

On [**11-10**], Tracheostomy Tube was downsized from #8 portex to #6
portex at bedside.
Patient d/c'd to rehab on [**11-10**].

Medications on Admission:
none

Discharge Medications:
1. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One
(1)  Intravenous  Q24H (every 24 hours) for 1 doses.
2. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 1 days.
3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every
4 to 6 hours) as needed.
4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1)
injection Injection [**Hospital1 **] (2 times a day).
5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1)  PO BID (2
times a day).
6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
7. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs
PO Q4-6H (every 4 to 6 hours) as needed for pain.
8. Lorazepam 2 mg/mL Syringe Sig: One (1)  Injection Q4H (every
4 hours) as needed for agitation.
9. Metoprolol Tartrate 5 mg/5 mL Solution Sig: Five (5) ml
Intravenous  Q6PRN ().
10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 85**] - [**Location (un) 86**]

Discharge Diagnosis:
Gun Shot wound to head

Discharge Condition:
Neurologically stable

Discharge Instructions:
??????	Watchyour incision daily for signs of infection
??????	Take your pain medicine as prescribed
??????	Exercise should be limited to walking; no lifting, straining,
excessive bending
??????	You may wash your hair only after sutures and/or staples have
been removed
??????	You may shower before this time with assistance and use of a
shower cap
??????	Increase your intake of fluids and fiber as pain medicine
(narcotics) can cause constipation
??????	Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, aspirin, Advil,
Ibuprofen etc.
??????	If you have been prescribed an anti-seizure medicine, take it
as prescribed and follow up with laboratory blood drawing as
ordered
??????	Clearance to drive and return to work will be addressed at
your post-operative office visit
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:

??????	New onset of tremors or seizures
??????	Any confusion or change in mental status
??????	Any numbness, tingling, weakness in your extremities
??????	Pain or headache that is continually increasing or not
relieved by pain medication
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, drainage
??????	Fever greater than or equal to 101?????? F


Followup Instructions:
PLEASE RETURN TO THE OFFICE IN 5 DAYS FOR REMOVAL OF YOUR
SUTURES

PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR.
[**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS.
YOU WILL NEED A CAT SCAN OF THE BRAIN  WITHOUT CONTRAST
YOU WILL NOT NEED AN MRI OF THE BRAIN WITH OR WITHOUT GADOLIDIUM



Completed by:[**2149-11-10**]
{'Open fracture of base of skull with cerebral laceration and contusion, unspecified state of consciousness,Acute posthemorrhagic anemia,Pneumonia due to other gram-negative bacteria,Assault by shotgun,Open fracture of base of other metacarpal bone(s),Abrasion or friction burn of shoulder and upper arm, without mention of infection'}


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: CC:[**CC Contact Info 70573**]

PRESENT ILLNESS: HPI: 32 y/o female transferred from [**Last Name (un) 70574**] General after
being
shot in the head around 9:00pm this evening by her boyfriend 357
Magnum gun used. At [**Hospital 70574**] [**Hospital3 **] was awake but
unable to speak.  Also has ? gun shot wound to left hand.

MEDICAL HISTORY: PMH: None per brother
ALL: None per brother

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: 96.8 BP 101/52 p 75 HR 14 100%
Intubated sedated last sedation 45 minutes prior and
paralyzation
1 hour prior
Pupils 2.5 minimal reactive
Blood coming out of mouth.  Appears to have enterance wound near
right ear/mandibular area.
Lungs clear
Heart RRR s1 s2
Abd soft non distended
Neuro:
Pupils eyes 2.5 minimally reactive, no repsonse in any extremity
to deep painful stimuli.  No corneal, + gag

FAMILY HISTORY: noncontributory

SOCIAL HISTORY: Social: Unknown 

### Response:
{'Open fracture of base of skull with cerebral laceration and contusion, unspecified state of consciousness,Acute posthemorrhagic anemia,Pneumonia due to other gram-negative bacteria,Assault by shotgun,Open fracture of base of other metacarpal bone(s),Abrasion or friction burn of shoulder and upper arm, without mention of infection'}
