CHIEF COMPLAINT: s/p fall with right globe rupture

PRESENT ILLNESS: [**Age over 90 **] y/o female [**Hospital 100**] Rehab resident with h/o dementia, CAD s/p
CABG, CHF, hyperlipidemia, DM s/p unwitnessed fall on [**9-18**].
Staff at NH state that "thud" was heard and pt was found face
down on floorwith serosanguinous discharge from R eye, lens
extruded from R orbit, HR 100, BP 180/80, FS=223, T 99.  Per NH
and stepdaughter (pt's HCP), pt had been slightly more
disoriented and agitated the day preceding the fall.

MEDICAL HISTORY: 1.CAD s/p CABG [**2109**]
2.NIDDM, diet controlled and on oral meds
3.hyperlipidemia
4peptic ulcer dz with h/o OB+stool in past; last EGD [**6-27**] with
multiple nonbleeding 5 mm ulcers from 5-7 mm in antrum; +ulcers
in duodenum
5.severe dementia, likely multifactorial
6. CHF,

MEDICATION ON ADMISSION: Calcium carbonate 650 mg [**Hospital1 **]
Lasix 40 mg PO QD
Glyburide
Metformin 500 [**Hospital1 **]
MVI
Simvastatin 40 QD
Sorbitol 15 cc PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: sleeping, arousable to voice
HEENT: MMM, patch over right eye,
Neck: 6-7cm JVD
CV: regular, no mrg, +ectopic beats
Lungs: anterior exam, clear, no crackles
Abd: Quite distended, soft, +BS
Ext: warm, no pulses palpable, hallux valgus-metatarsal varus
deformities
Neuro: sleeping, arousable, does not follow commands, opens
eyes, moves left arm and leg spontaneously (unsure about right
arm and leg)

FAMILY HISTORY: 

SOCIAL HISTORY: [**Hospital 100**] rehab resident.  Step daughter is HCP: [**Name (NI) 15359**] [**Name (NI) **]
[**Telephone/Fax (1) 98458**], cell#[**Telephone/Fax (1) 98459**]
Rupture of eye with partial loss of intraocular tissue,Closed fracture of orbital floor (blow-out),Hyphema of iris and ciliary body,Vitreous hemorrhage,Mechanical complication due to ocular lens prosthesis,Closed dislocation of shoulder, unspecified
Rupture eye w tissu loss,Fx orbital floor-closed,Hyphema,Vitreous hemorrhage,Lens prosthesis malfunc,Disloc shoulder NOS-clos
Admission Date:  [**2124-9-19**]              Discharge Date:   [**2124-9-25**]


Service: MED

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1630**]
Chief Complaint:
s/p fall with right globe rupture

Major Surgical or Invasive Procedure:
Right globe exploration and repair [**9-19**]
1) R eye surgery
2) Intubation


History of Present Illness:
[**Age over 90 **] y/o female [**Hospital 100**] Rehab resident with h/o dementia, CAD s/p
CABG, CHF, hyperlipidemia, DM s/p unwitnessed fall on [**9-18**].
Staff at NH state that "thud" was heard and pt was found face
down on floorwith serosanguinous discharge from R eye, lens
extruded from R orbit, HR 100, BP 180/80, FS=223, T 99.  Per NH
and stepdaughter (pt's HCP), pt had been slightly more
disoriented and agitated the day preceding the fall.

In [**Name (NI) **], pt eval by optho and Plastics services.  CT scan of eye
with nondisplaced orbital floor fx, minimally lateral orbital
wall fx, and mildly displaced zygoma fx with R globe rupture.
Eval by plastics who felt that pt's facial fractures were
non-operative. Was eval by ophtholmalogy in ED who proceeded
with exploration and repair of R globe, surgery without
complications with minimal EBL, given 2.5 L IVF
intraoperatively.  Initial CXR with LLL collapse after R
mainstem intubation, repeat CXR with still with partial
collapse.  Pt admitted to [**Hospital Unit Name 153**] for post-op monitoring, weaning
of her vent and C spine clearance after pt was extubated.

 In [**Name (NI) 153**], pt was requiring high doses of Fentanyl and Propofol
for pain control and sedation.  Eval by optho in [**Hospital Unit Name 153**] on [**9-20**]
who recommended d/c Abx and stated that pt had relatively poor
prognosis for maintaining R eye.  Pt extubated on [**9-20**] without
difficulty.  Still with C collar in place awaiting C spine
clearance.  Since extubation, pt has also been somewhat
confused, restless, and agitated requiring IV haldol.

At baseline, ambulates with walker


Past Medical History:
1.CAD s/p CABG [**2109**]
2.NIDDM, diet controlled and on oral meds
3.hyperlipidemia
4peptic ulcer dz with h/o OB+stool in past; last EGD [**6-27**] with
multiple nonbleeding 5 mm ulcers from 5-7 mm in antrum; +ulcers
in duodenum
5.severe dementia, likely multifactorial
6. CHF,


Social History:
[**Hospital 100**] rehab resident.  Step daughter is HCP: [**Name (NI) 15359**] [**Name (NI) **]
[**Telephone/Fax (1) 98458**], cell#[**Telephone/Fax (1) 98459**]

Physical Exam:
Gen: sleeping, arousable to voice
HEENT: MMM, patch over right eye,
Neck: 6-7cm JVD
CV: regular, no mrg, +ectopic beats
Lungs: anterior exam, clear, no crackles
Abd: Quite distended, soft, +BS
Ext: warm, no pulses palpable, hallux valgus-metatarsal varus
deformities
Neuro: sleeping, arousable, does not follow commands, opens
eyes, moves left arm and leg spontaneously (unsure about right
arm and leg)

Pertinent Results:
CBC
[**2124-9-19**] 01:55AM   WBC-17.9*# RBC-3.97* HGB-12.4 HCT-36.0 MCV-91
MCH-31.1 MCHC-34.4 RDW-12.7
[**2124-9-19**] 01:55AM   NEUTS-79* BANDS-9* LYMPHS-8* MONOS-4 EOS-0
BASOS-0 ATYPS-0 METAS-0 MYELOS-0
[**2124-9-20**] 04:50AM BLOOD WBC-12.9* RBC-3.77* Hgb-12.0 Hct-34.5*
MCV-91 MCH-31.9 MCHC-34.8 RDW-13.0 Plt Ct-241#
[**2124-9-21**] 04:30AM BLOOD WBC-10.0 RBC-3.43* Hgb-10.9* Hct-32.8*
MCV-96 MCH-31.7 MCHC-33.1 RDW-12.7
[**2124-9-21**] 04:30AM BLOOD Neuts-80* Bands-1 Lymphs-10* Monos-9
Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0

Coags
[**2124-9-19**] 01:55AM   PT-12.6 PTT-22.6 INR(PT)-1.0

Chemistries
[**2124-9-19**] 01:55AM   GLUCOSE-261* UREA N-22* CREAT-1.0 SODIUM-143
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-27 ANION GAP-20
[**2124-9-19**] 01:55AM   CALCIUM-9.4 PHOSPHATE-3.3 MAGNESIUM-1.8
[**2124-9-20**] 04:50AM BLOOD Glucose-140* UreaN-15 Creat-0.9 Na-144
K-3.3 Cl-107 HCO3-27 AnGap-13
[**2124-9-20**] 04:50AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.8
[**2124-9-21**] 04:30AM BLOOD Glucose-147* UreaN-11 Creat-0.8 Na-144
K-4.3 Cl-110* HCO3-24 AnGap-14
[**2124-9-21**] 04:30AM BLOOD Calcium-8.2* Phos-3.4 Mg-2.1

U/A
[**2124-9-19**] 06:25AM URINE  BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2124-9-19**] 06:25AM URINE  RBC-0-2 WBC-0-2 BACTERIA-NONE YEAST-NONE
EPI-0-2

Cardiac Enzymes
[**2124-9-20**] 04:50AM BLOOD CK(CPK)-225* TotBili-0.9
[**2124-9-19**] 08:14PM BLOOD CK(CPK)-147*
[**2124-9-20**] 04:50AM BLOOD CK-MB-3 cTropnT-0.05*
[**2124-9-19**] 08:14PM BLOOD CK-MB-3 cTropnT-0.06*

EKG
Sinus arrhythmia
Short PR interval
Extensive ST-T changes may be due to myocardial ischemia or
metabolic changes
Prolonged Q-Tc interval
Since previous tracing of [**2124-9-19**], long QTc interval is seen -
clinical
correlation is suggested

CXR
No focal consolidations

CT C spine
IMPRESSION:
1. Extensive degenerative disease, most pronounced at C3-4 and
C4-5 with disc herniations.
2. No acute fracture seen.
3. Subluxation at C3-4 probably degenerative but
flexion-extension views are recommended.

Left humerus plain film
IMPRESSION:
1) No fracture detected, but evaluation is limited secondary to
diffuse demineralization. If there is continued concern for
fracture, a CT or MRI may be considered for further evaluation.
2) Superior subluxation of the humeral head, suggesting a
rotator cuff injury.

CT Orbit
IMPRESSION:
1) Fractures of the right orbital floor, right maxillary sinus
and right zygomatic bone as described above.
2) Right globe hyphema and vitreous hemorrhage.

Ophtho surgery
PREOPERATIVE DIAGNOSES:  Ruptured globe of the right eye.
POSTOPERATIVE DIAGNOSES:  Ruptured globe of the right eye.
PROCEDURE:  Exploration and repair of ruptured globe of the
right eye.
DESCRIPTION OF PROCEDURE:  The patient had been intubated in
the Emergency Room for evaluation.  The patient was brought
from the Emergency Room to the operating room, intubated
under general anesthesia. In the operating room, the patient
was then prepped and draped in the usual fashion. The lids
were maintained in an open position using a Barraquer wire
lid speculum.  A peritomy was created from 9 o'clock to 3
o'clock using [**Doctor Last Name 6013**] scissors.  This was created
superiorly.  It was immediately apparent that as the
conjunctiva was taken down, that there was a large
corneoscleral rupture extending for approximately 180
degrees, consistent with the old extra capsular cataract
wound site.  Previously, the lens had been retrieved when it
was expelled at the time of the initial injury and presenting
through the ruptured wound was extensive amounts of vitreous
hemorrhage and uveal tissue.

The area was gently explored and cleaned.  The extent of the
old wound was determined.  In an effort to close the eye, the
uvea was gently reposited in the eye using [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2281**] spatula.
Initially, an 8-0 silk suture was placed at the 12 o'clock
position, first running temporally.  Two additional 8-0 silk
sutures were placed and then running nasally, two additional
8-0 silk sutures were placed. Once this had helped to reform
the globe, 10-0 nylon sutures were placed in between the 8-0
sutures. Careful efforts were made to reposit the uvea, using
the [**Doctor First Name 2281**] spatula and attempts to not incarcerate it in the
wound were made.

At the conclusion of this procedure, the wound was felt to be
water tight.  The sutures were all trimmed and buried.  The
anterior chamber was well formed and firm. There was an
extensive amount of hemorrhage in the anterior chamber,
obscuring any view of the posterior pole.  To assure that no
other wounds were present, the conjunctiva was taken down for
360 degrees using [**Doctor Last Name 6013**] scissors. The sclera was evaluated
and explored to as far back as the insertion of the muscles.
No other areas of injury or rupture were found.  The
conjunctiva was then brought back into position and sutured
in place using fast-absorbing chromic.  At the conclusion of
the procedure, the wound was felt to be water tight.  The
globe was intact.  The conjunctiva had been replaced over the
sclera.  A subconjunctival injection of Keflex and
Dexamethasone was administered.  Maxitrol ophthalmic ointment
was placed in the eye and a light pressure dressing was
applied to the eye.  The patient was taken from the operating
room, intubated to the medical Intensive Care Unit, where she
will be extubated later this evening.


Brief Hospital Course:
1. Ruptured globe: The patient presented s/p unwitnessed fall.
She was taken emergently to surgery and from there to the MICU
where she was successfully extubated but required a great deal
of pain/agitation narcotics.  She was transferred to the floor
two days s/p repair, with the thought being that she may never
regain vision in the right eye.  She was followed by
optholmology throughout her hospitalization.  Per optho, pt will
likely not regain vision and may eventually need enucleation.
The patient was placed on acetazolamide (to decrease intraocular
pressure), prednisolone, atropine sulfate, and cipro eyedrops.
She was also placed on Ancef IV for 3 days post-op. Now
acetazolamide and ancef d/c'd.
*
2. C spine: Pt had C spine films/CT which showed no acute
fractures but significant degenerative change.  She was
maintained in a cervical collar given that she was too sedated
to clinically clear her c-spine.  C-collar now d/c'd.
*
3. Fall: The etiology of her fall was unclear.  Cardiac
troponins checked, which were slightly elev initially at 0.06,
but then decreased to 0.5 with neg MB fraction, so likely the
cause was not cardiac.  Possibly could be combination of
advanced dementia with macular degeneration.  [**Female First Name (un) 1634**] fellow was
able to contact [**Name (NI) **] Rehab for more information re: previous
falls.  Her rehab suggested that she had only fallen twice over
the past 1.5 years and so had not been considered a fall risk.
She was kept on fall precautions.
*
4. CAD: as mentioned above, CKs checked with neg MB fractions,
slightly elev troponins but not significant and trending
downward.  Her statin and other cardiac medications were
continued.
*
5. DM: The patient was maintained on a RISS and a qid FS.  When
transferred to the floor, her FS were high likely [**2-28**] D51/2NS
that she was being given as she was so sedated that she was
unable to tolerate pos.
*
6. Agitation: Likely ICU delirium on overlying dementia, s/p
high doses of narcotics for pain and sedation s/p intubation.
She received as much as 10 mg IV haldol in [**Hospital Unit Name 153**] and on transfer
to the floor was heavily sedated.  She was written for low dose
SL Zyprexa or lower dose Haldol 1-2 mg prn agitation with
monitoring of QT interval for prolongation.  The fentanyl patch
that she had been on in the ICU was discontinued on transfer to
the floor as it was long acting and patient was very sedated.
Her pain was controlled with morphine RTC initially (short
acting), and was decreased over the next days as tolerated.
Currently the pt is quite somnolent [**2-28**] pain medication.
However, she now does responds to voice.
*
7. FEN: On transfer to the floor the patient had an NG tube but
was receiving D51/2NS at 75cc/hr.  She failed a speech and
swallow test so was kept NPO. The NGT was taken on on [**9-22**].
Speech and swallow was reconsulted when her MS cleared.  The
patient was also placed on Bisacodyl HS standing for abdominal
distention.
*
8. Proph: heel protectors, SQ heparin, ppi, soft restraints [**2-28**]
agitation (renewed daily as needed).
*
9. Dispo: Code DNR/DNI, HCP is [**Name (NI) 98460**] [**Name (NI) **] (stepdaughter),
dc to [**Hospital 100**] Rehab when stable.

Medications on Admission:
Calcium carbonate 650 mg [**Hospital1 **]
Lasix 40 mg PO QD
Glyburide
Metformin 500 [**Hospital1 **]
MVI
Simvastatin 40 QD
Sorbitol 15 cc PO QD

Discharge Medications:
1. Ciprofloxacin 0.3 % Drops Sig: One (1) Drop Ophthalmic  QID
(4 times a day).
2. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-28**]
Puffs Inhalation Q6H (every 6 hours) as needed.
3. Albuterol Sulfate 0.083 % Solution Sig: One (1)  Inhalation
Q6H (every 6 hours) as needed.
4. Atropine Sulfate 1 % Drops Sig: One (1) Drop Ophthalmic  [**Hospital1 **]
(2 times a day).
5. Prednisolone Acetate 1 % Drops, Suspension Sig: Two (2) Drop
Ophthalmic  QID (4 times a day).
6. Lidocaine HCl 2 % Gel Sig: One (1) Appl Mucous membrane  PRN
(as needed).
7. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO BID (2 times a day) as needed for agitation.
8. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal
HS (at bedtime).
9. Haloperidol 2 mg IV Q6H:PRN
10. Famotidine 20 mg IV Q24H
11. D5 1/2 NS at 50cc/hr (per geriatrics recommendations)


Discharge Disposition:
Extended Care

Facility:
[**Hospital6 459**] for the Aged - Acute Rehab

Discharge Diagnosis:
1) right globe rupture s/p surgery
2) facial fractures
3) sedation


Discharge Condition:
Stable

Discharge Instructions:
Please take care of your right eye as per ophthomology
recommendations.  Please call your doctor or return to the
hospital if you or your providers notice fever, chills, nausea,
vomiting, pain, swelling or redness around your eye, or any
other symptoms concerning to you.

Followup Instructions:
Ophthalmology appointment 3:30pm with Dr.[**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] at
[**Hospital Ward Name 23**] Building [**Location (un) 442**].



Completed by:[**2124-9-25**]
{'Rupture of eye with partial loss of intraocular tissue,Closed fracture of orbital floor (blow-out),Hyphema of iris and ciliary body,Vitreous hemorrhage,Mechanical complication due to ocular lens prosthesis,Closed dislocation of shoulder, 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: s/p fall with right globe rupture

PRESENT ILLNESS: [**Age over 90 **] y/o female [**Hospital 100**] Rehab resident with h/o dementia, CAD s/p
CABG, CHF, hyperlipidemia, DM s/p unwitnessed fall on [**9-18**].
Staff at NH state that "thud" was heard and pt was found face
down on floorwith serosanguinous discharge from R eye, lens
extruded from R orbit, HR 100, BP 180/80, FS=223, T 99.  Per NH
and stepdaughter (pt's HCP), pt had been slightly more
disoriented and agitated the day preceding the fall.

MEDICAL HISTORY: 1.CAD s/p CABG [**2109**]
2.NIDDM, diet controlled and on oral meds
3.hyperlipidemia
4peptic ulcer dz with h/o OB+stool in past; last EGD [**6-27**] with
multiple nonbleeding 5 mm ulcers from 5-7 mm in antrum; +ulcers
in duodenum
5.severe dementia, likely multifactorial
6. CHF,

MEDICATION ON ADMISSION: Calcium carbonate 650 mg [**Hospital1 **]
Lasix 40 mg PO QD
Glyburide
Metformin 500 [**Hospital1 **]
MVI
Simvastatin 40 QD
Sorbitol 15 cc PO QD

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Gen: sleeping, arousable to voice
HEENT: MMM, patch over right eye,
Neck: 6-7cm JVD
CV: regular, no mrg, +ectopic beats
Lungs: anterior exam, clear, no crackles
Abd: Quite distended, soft, +BS
Ext: warm, no pulses palpable, hallux valgus-metatarsal varus
deformities
Neuro: sleeping, arousable, does not follow commands, opens
eyes, moves left arm and leg spontaneously (unsure about right
arm and leg)

FAMILY HISTORY: 

SOCIAL HISTORY: [**Hospital 100**] rehab resident.  Step daughter is HCP: [**Name (NI) 15359**] [**Name (NI) **]
[**Telephone/Fax (1) 98458**], cell#[**Telephone/Fax (1) 98459**] 

### Response:
{'Rupture of eye with partial loss of intraocular tissue,Closed fracture of orbital floor (blow-out),Hyphema of iris and ciliary body,Vitreous hemorrhage,Mechanical complication due to ocular lens prosthesis,Closed dislocation of shoulder, unspecified'}
