CHIEF COMPLAINT: s/p 8ft fall from ladder

PRESENT ILLNESS: 45 y/o otherwise healthy man who fell 8 feet from ladder
sustaining left [**2-2**] rib fractures and left nondisplaced radial
head fracture. He was transported to [**Hospital1 18**] for further care.

MEDICAL HISTORY: GERD
T10 compression fracture

MEDICATION ON ADMISSION: Tums

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**]:
100.0  BP: 104/59   HR:68    R 22      O2Sats 100 NC
Gen: WD/WN, SOB

FAMILY HISTORY: Noncontibutory

SOCIAL HISTORY: 
Closed fracture of eight or more ribs,Traumatic pneumohemothorax without mention of open wound into thorax,Accidental fall from ladder,Closed fracture of head of radius,Esophageal reflux
Fx eight/more rib-closed,Traum pneumohemothor-cl,Fall from ladder,Fx radius head-closed,Esophageal reflux
Admission Date:  [**2145-6-7**]              Discharge Date:   [**2145-6-9**]

Date of Birth:  [**2099-8-22**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 371**]
Chief Complaint:
s/p 8ft fall from ladder

Major Surgical or Invasive Procedure:
None

History of Present Illness:
45 y/o otherwise healthy man who fell 8 feet from ladder
sustaining left [**2-2**] rib fractures and left nondisplaced radial
head fracture. He was transported to [**Hospital1 18**] for further care.

Past Medical History:
GERD
T10 compression fracture

Family History:
Noncontibutory

Physical Exam:
Upon presentation to [**Hospital1 18**]:
100.0  BP: 104/59   HR:68    R 22      O2Sats 100 NC
Gen: WD/WN, SOB

Neck: Supple.

Cardiac: RRR.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.

Language: Speech fluent with good comprehension .

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-26**] throughout.

Sensation: Intact to light touch
Reflexes: B T Br Pa Ac
Right     2----------
Left      2----------

Toes downgoing bilaterally
No Clonus

diffuse back tenderness at T7-9, difficult to accurately asses
given severe chest discomfort from rib fractures.


Pertinent Results:
[**2145-6-7**] 05:24PM   GLUCOSE-96 UREA N-15 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-30 ANION GAP-10
[**2145-6-7**] 05:24PM   CALCIUM-8.6 PHOSPHATE-3.0 MAGNESIUM-2.0
[**2145-6-7**] 03:29AM   WBC-7.8 RBC-4.33* HGB-13.0* HCT-39.7* MCV-92
MCH-30.0 MCHC-32.8 RDW-13.3
[**2145-6-7**] 03:29AM   PLT COUNT-176
[**2145-6-6**] 08:30PM   ALT(SGPT)-28 AST(SGOT)-37 ALK PHOS-47 TOT
BILI-0.7

IMAGING:
CT abd ([**6-7**]): small left sided pneumothorax. small left
hemothorax. multiple rib fracturesfrom the left 1st through 12th
ribs. mild wedge compression fracture of T10, of unknown
chronicity
Wrist ([**6-7**]): There are likely fractures of the radial
styloid without significant displacement or articular surface
incongruity and of the triquetrum.
CT head ([**6-7**]): No acute intracranial process


Brief Hospital Course:
He was admitted to the Trauma Service and transferred to the
trauma ICU for close monitoring and pain control related to his
rib fractures. Discussions took place with patient and the Acute
Pain service for epidural catheter. Patient declined this
option; instead was placed on PCA Dilaudid with adjunct oral
analgesics. He initially has only fair control with this regimen
requiring increase in his PCA dose. he was eventually changed to
an all oral regimen with adequate control.

His radius fracture was evaluated by orthopedics and was managed
non operatively at this time; he will follow up in 2 weeks in
orthopedics clinic for repeat imaging.

He is ambulating independently and tolerating a regular diet. He
is being discharged to home with instructions for follow up.

Medications on Admission:
Tums

Discharge Medications:
1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3
hours) as needed for pain.
Disp:*90 Tablet(s)* Refills:*0*
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for cold symptoms.
5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day)
as needed for constipation.
6. Toradol 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours for 3 days.
Disp:*12 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
s/p 8ft Fall
Multiple rib fractures on left [**2-2**]
Left radius fracture

Secondary diagnosis:
Chronic T10 compression fracture

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

Discharge Instructions:
You were hospitalized following a fall from a ladder; as a
result you sustained multiple rib fractures and a fracture of
your left radius (wrist) bone. Your injuries did not require any
operations; you were kept in the hospital for pain management
and respiratory monitoring.

DO NOT bear weight on your left wrist because of your fracture.

DO NOT lift weight greater than 10 lbs; avoid ladders or any
other heights greater than 3 ft.

You are prescribed a narcotic for pain control, take as
directed. DO NOT drink alcohol, drive, operate heavy machinery,
or take illicit drugs while on the narcotics.

Take stool softener and laxative while on the narcotics to
prevent constipation.


Followup Instructions:
Follow up next week in Trauma clinic with Dr. [**Last Name (STitle) **] for
evaluation of your rib fractures; call [**Telephone/Fax (1) 2359**] for an
appointment.

Follow up in 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP orthopedic
trauma for your radius fracture; call [**Telephone/Fax (1) 1228**] for an
appointment.



Completed by:[**2145-6-9**]
{'Closed fracture of eight or more ribs,Traumatic pneumohemothorax without mention of open wound into thorax,Accidental fall from ladder,Closed fracture of head of radius,Esophageal reflux'}


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 8ft fall from ladder

PRESENT ILLNESS: 45 y/o otherwise healthy man who fell 8 feet from ladder
sustaining left [**2-2**] rib fractures and left nondisplaced radial
head fracture. He was transported to [**Hospital1 18**] for further care.

MEDICAL HISTORY: GERD
T10 compression fracture

MEDICATION ON ADMISSION: Tums

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**]:
100.0  BP: 104/59   HR:68    R 22      O2Sats 100 NC
Gen: WD/WN, SOB

FAMILY HISTORY: Noncontibutory

SOCIAL HISTORY:  

### Response:
{'Closed fracture of eight or more ribs,Traumatic pneumohemothorax without mention of open wound into thorax,Accidental fall from ladder,Closed fracture of head of radius,Esophageal reflux'}
