CHIEF COMPLAINT: s/p assualt

PRESENT ILLNESS: This is a 36 y/o man s/p assault w/ multiple facial contusions,
presented to [**Hospital 27217**] Hospital. Per report there was no LOC but
pt cannot remember details of the event. He states he stepped
outside a nightclub and immediately found himself on the ground
covered in blood. No nausea or vomiting.

MEDICAL HISTORY: stab wound to right eye, which has left him with a blown pupil
on that side.

MEDICATION ON ADMISSION: None.

ALLERGIES: Penicillins

PHYSICAL EXAM: 98.8, HR 87, 160/p, 98% on ventilator in the trauma bay.
Intubated, sedated.
Surgical R pupil, L reactive 2->1
No facial instability, multiple contusions bil.
CTA bil.
Cor reg.
Abd soft, ND.
Pelvis stable.
Normal rectal tone, guaiac neg.
Spine w/ no stepoffs or gross deformity, in c-collar.
No edema, 2+ palp F/P/DP/PT bil. Warm feet.

FAMILY HISTORY: N/C

SOCIAL HISTORY: married, smoker x 20 years.
Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Mechanical complication due to ocular lens prosthesis,Closed fracture of malar and maxillary bones,Assault by unspecified means
Cl skul base fx w/o coma,Lens prosthesis malfunc,Fx malar/maxillary-close,Assault NOS
Admission Date:  [**2165-4-14**]              Discharge Date:   [**2165-4-17**]

Date of Birth:  [**2129-3-28**]             Sex:   M

Service: SURGERY

Allergies:
Penicillins

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p assualt

Major Surgical or Invasive Procedure:
None.

History of Present Illness:
This is a 36 y/o man s/p assault w/ multiple facial contusions,
presented to [**Hospital 27217**] Hospital. Per report there was no LOC but
pt cannot remember details of the event. He states he stepped
outside a nightclub and immediately found himself on the ground
covered in blood. No nausea or vomiting.

Past Medical History:
stab wound to right eye, which has left him with a blown pupil
on that side.

Social History:
married, smoker x 20 years.

Family History:
N/C

Physical Exam:
98.8, HR 87, 160/p, 98% on ventilator in the trauma bay.
Intubated, sedated.
Surgical R pupil, L reactive 2->1
No facial instability, multiple contusions bil.
CTA bil.
Cor reg.
Abd soft, ND.
Pelvis stable.
Normal rectal tone, guaiac neg.
Spine w/ no stepoffs or gross deformity, in c-collar.
No edema, 2+ palp F/P/DP/PT bil. Warm feet.

Pertinent Results:
[**2165-4-14**] 09:13AM   GLUCOSE-103 UREA N-8 CREAT-1.0 SODIUM-136
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-23 ANION GAP-18
[**2165-4-14**] 09:13AM   CALCIUM-8.5 PHOSPHATE-3.1 MAGNESIUM-1.6
[**2165-4-14**] 09:13AM   WBC-14.9* RBC-4.57* HGB-14.4 HCT-41.6 MCV-91
MCH-31.5 MCHC-34.6 RDW-13.1
[**2165-4-14**] 09:13AM   PLT COUNT-197
[**2165-4-14**] 05:40AM   PH-7.35 COMMENTS-GREEN TOP
[**2165-4-14**] 05:40AM   GLUCOSE-134* LACTATE-3.6* NA+-144 K+-3.6
CL--95* TCO2-26
[**2165-4-14**] 05:20AM   AMYLASE-89
[**2165-4-14**] 05:20AM   ASA-NEG ETHANOL-136* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2165-4-14**] 05:20AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2165-4-14**] 05:20AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG

Brief Hospital Course:
Pt was admitted as a transfer from [**Hospital 26380**] Hospital for plastic
surgery/facial evaluation. Facial CT revealed bilateral ZMC
fractures, and a dislocated R orbital lens implant. Outside
imaging had demonstrated a skull base fracture-- a repeat head
CTA was performed, which showed a non-displaced R sphenoid sinus
fracture but no vascular injury. All other imaging performed
demonstrated no abnormality: TLS spine XR, AP chest + pelvis,
C-spine CT.

The pt was admitted to the ICU overnight on hospital day 1. He
was extubated without event and transferred to the floor. His
cervical collar was cleared once he was awake and denied any
pain on cervical exam. He was seen by the ophthalmology service
for a dislocated right lens, and was told to follow up with them
for reconstruction at a later date. Plastic/Facial surgery
evaluated his facial fractures and felt them to be
non-operative. His diet was advanced, his Foley removed, and his
pain was controlled at discharged. He was maintained on
clindamycin x 2 week course for his sinus fractures.

Medications on Admission:
None.

Discharge Medications:
1. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed.
2. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO
Q4-6H (every 4 to 6 hours) as needed.
Disp:*30 Tablet(s)* Refills:*0*
3. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO three
times a day for 10 days.
Disp:*30 Capsule(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
1) bilateral zygomaxillary complex fractures
2) displaced right eye lens
3) basilar skull fracture

Discharge Condition:
Good.

Discharge Instructions:
1) Return to ED or call the trauma surgery clinic if you have
any questions or any of the following symptoms:
** fevers greater than 101.5 degrees.
** increased redness or thick yellow drainage around your wounds
2) Resume all your home medications at their usual doses, plus
those listed below.

Followup Instructions:
1) Call your PCP or go to your local ER on [**2165-4-19**] to have your
stitches removed.
2) Provider: [**Name10 (NameIs) 13128**], call [**Telephone/Fax (1) 66492**] to schedule an
appointment.
3) Trauma Clinic only if needed, call [**Telephone/Fax (1) 6439**] for an
appointment.



Completed by:[**2165-4-17**]
{'Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Mechanical complication due to ocular lens prosthesis,Closed fracture of malar and maxillary bones,Assault by unspecified means'}


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: s/p assualt

PRESENT ILLNESS: This is a 36 y/o man s/p assault w/ multiple facial contusions,
presented to [**Hospital 27217**] Hospital. Per report there was no LOC but
pt cannot remember details of the event. He states he stepped
outside a nightclub and immediately found himself on the ground
covered in blood. No nausea or vomiting.

MEDICAL HISTORY: stab wound to right eye, which has left him with a blown pupil
on that side.

MEDICATION ON ADMISSION: None.

ALLERGIES: Penicillins

PHYSICAL EXAM: 98.8, HR 87, 160/p, 98% on ventilator in the trauma bay.
Intubated, sedated.
Surgical R pupil, L reactive 2->1
No facial instability, multiple contusions bil.
CTA bil.
Cor reg.
Abd soft, ND.
Pelvis stable.
Normal rectal tone, guaiac neg.
Spine w/ no stepoffs or gross deformity, in c-collar.
No edema, 2+ palp F/P/DP/PT bil. Warm feet.

FAMILY HISTORY: N/C

SOCIAL HISTORY: married, smoker x 20 years. 

### Response:
{'Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Mechanical complication due to ocular lens prosthesis,Closed fracture of malar and maxillary bones,Assault by unspecified means'}
