CHIEF COMPLAINT: s/p Fall

PRESENT ILLNESS: 43yo man with h/o alcoholism and withdrawal seizures who reports
a seizure this morning with a fall. He was brought to OSH where
he received a head CT that showed a 6mm parafalcine SDH without
midline shift. Other injury included left nasal bone fracture.
He was medflighted to [**Hospital1 18**] for further care.

MEDICAL HISTORY: EtOH abuse, HTN, Anxiety, Depression, Scabies/Lice

MEDICATION ON ADMISSION: Neurontin 900'''

ALLERGIES: lansoprazole / Zolpidem

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**]:
PE: 83, 150/85, 13, 95% RA
NAD, in c-collar
Alert and oriented to person and date but not place (knows
[**Location (un) **]
but not where in [**Location (un) **])
No lac's on head. Impressive left facial swelling and
ecchymoses.
No battle's sign
No CSF leakage from ears. Tympanic membranes intact
No rhinorrhea, no septal hemtoma
EOMI. PERRL.
CN's [**3-3**] intact
No pronator drift.
Able to perform [**Doctor First Name 6361**] and finger-nose-finger
5/5 strength throughout bilateral UE's. SILT r/m/u nerve
distributions.
[**5-25**] hip flexion, knee flex/ext and ankle dorsi/plantar flexion.
Minimal toe flexion/ext which is baseline per pt (neuropathy).
Decreased sensation in bilateral feet.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: 
Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Closed fracture of mandible, condylar process,Alcohol withdrawal,Alkalosis,Epilepsy, unspecified, without mention of intractable epilepsy,Alcoholic polyneuropathy,Other and unspecified alcohol dependence, continuous,Acute gouty arthropathy,First degree atrioventricular block,Unspecified essential hypertension,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Alcohol abuse, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Lack of housing,Unspecified fall
Traumatic subdural hem,Ot pul insuf fol trm/srg,Fx condyl proc mandib-cl,Alcohol withdrawal,Alkalosis,Epilep NOS w/o intr epil,Alcoholic polyneuropathy,Alcoh dep NEC/NOS-contin,Acute gouty arthropathy,Atriovent block-1st degr,Hypertension NOS,Anxiety state NOS,Depressive disorder NEC,Alcohol abuse-unspec,Idio periph neurpthy NOS,Lack of housing,Fall NOS
Admission Date:  [**2115-5-19**]              Discharge Date:   [**2115-5-29**]

Date of Birth:  [**2072-1-22**]             Sex:   M

Service: SURGERY

Allergies:
lansoprazole / Zolpidem

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Fall

Major Surgical or Invasive Procedure:
[**2115-5-21**] Closed Reduction right subcondylar Mandible Fracture


History of Present Illness:
43yo man with h/o alcoholism and withdrawal seizures who reports
a seizure this morning with a fall. He was brought to OSH where
he received a head CT that showed a 6mm parafalcine SDH without
midline shift. Other injury included left nasal bone fracture.
He was medflighted to [**Hospital1 18**] for further care.

Past Medical History:
 EtOH abuse, HTN, Anxiety, Depression, Scabies/Lice

Family History:
Noncontributory

Physical Exam:
Upon presentation to [**Hospital1 18**]:
PE: 83, 150/85, 13, 95% RA
NAD, in c-collar
Alert and oriented to person and date but not place (knows
[**Location (un) **]
but not where in [**Location (un) **])
No lac's on head. Impressive left facial swelling and
ecchymoses.
No battle's sign
No CSF leakage from ears. Tympanic membranes intact
No rhinorrhea, no septal hemtoma
EOMI. PERRL.
CN's [**3-3**] intact
No pronator drift.
Able to perform [**Doctor First Name 6361**] and finger-nose-finger
5/5 strength throughout bilateral UE's. SILT r/m/u nerve
distributions.
[**5-25**] hip flexion, knee flex/ext and ankle dorsi/plantar flexion.
Minimal toe flexion/ext which is baseline per pt (neuropathy).
Decreased sensation in bilateral feet.


Pertinent Results:
[**2115-5-19**] 04:30PM   GLUCOSE-104* UREA N-8 CREAT-0.6 SODIUM-134
POTASSIUM-3.7 CHLORIDE-90* TOTAL CO2-23 ANION GAP-25*
[**2115-5-19**] 04:30PM   CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-1.5*
[**2115-5-19**] 04:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2115-5-19**] 04:30PM   WBC-7.6 RBC-3.92* HGB-12.9* HCT-40.3 MCV-103*
MCH-33.0* MCHC-32.1 RDW-13.0
[**2115-5-19**] 04:30PM   PLT COUNT-106*
[**2115-5-19**] 04:30PM   PT-10.9 PTT-30.5 INR(PT)-1.0

IMAGING:
[**5-19**]: CT head: parafalcine subdural hematoma 6mm
[**5-19**]: CT sinus: Right mandible fracture dislocation
[**5-19**]: CT Cspine: No evidence of of cervical spine fracture.
Fracture of the right mandibular condylar process with
dislocation of the right mandibular condyle.
[**5-21**]: Mandible: Right mandibular condylar process fracture. CT is
recommended for further evaluation.
[**5-21**]: MRI C-spine: There is no evidence of acute cervical
fracture or malalignment. The signal intensity throughout the
cervical spinal cord is normal with no evidence of focal or
diffuse lesions.
[**5-23**]: ET tube tip is 6.7 cm above the carina. NG tube tip is out
of view below the diaphragm. There are low lung volumes.
Bibasilar opacities consistent with atelectasis have improved.
There is no evident pneumothorax or pleural effusion. Cardiac
size is top normal.


Brief Hospital Course:
He was admitted to the Acute Care Surgery team and transferred
to the Trauma ICU for close monitoring. He was placed on CIWA
protocol given his alcohol use history but continued to have
withdrawal symptoms including seizures.  Neurology was consulted
for concern that his seizures may not be related to his alcohol
withdrawal and adjustments to anti seizure prophylaxis was made.
Neurosurgery was consulted for the subdural hemorrhage; serial
exams were followed and clinically he did not show any signs of
worsening hemorrhage. His neurological status remained stable
with no progression of his SDH.  He eventually was stable to go
for reduction of his right mandibular fracture on [**2115-5-21**] after
no c-spine injury was determined on an MRI.  Nasotracheal
intubation was attempted in the ICU without success and oral
tracheal intubation was performed for the operation.  He
remained intubated following his right mandibular reduction
without wiring secondary to persistent agitation and inability
to protect his own airway as well as concern for extensive
pharyngeal edema.  He was finally extubated on POD 4 without
complications and remained stable during the rest of his time in
the ICU on a CIWA scale for his persistent withdrawal symptoms.
Indomethacin was started on POD 1 for concern of a gout flare of
his right foot and was stopped on POD 4 when he had significant
improvement in his right foot.  He was transferred to the floor
on POD 5 with improved control of his withdrawal symptoms with
Ativan and the addition of clonidine.  He underwent further
repair of his right mandibular fracture with wiring performed on
[**2115-5-26**].  At the time of transfer out-of-the-ICU to the floor,
his mental status was stable with a GCS 15, alert and oriented
but remained on a CIWA scale.  He had no cardiovascular issues.
His respiratory status was stable with no concern for airway
compromise.  He had been advanced to a pureed diet, which he was
tolerating.

His course on the regular nursing unit continued to progress
slowly primarily limited by intermittent agitation and pain
control issues. He required several adjustments in his pain
medications and is currently on oral narcotics in liquid form.
He continued on his Ativan per CIWA protocol for about 9 days
and was changed to prn Ativan for anxiety issues; his Clonidine
was increased as well to help stabilize any agitation. His
Neurontin that he reported as taking at home for neuropathy was
restarted at a slightly lower dose given his creatinine
clearance.

He was evaluated by Physical and Occupational therapy and
initally was recommended for rehab but after a few more sessions
with Physical therapy he was cleared for discharge to home.

He will require follow up in Neurosurgery and OMFS clinics after
discharge - appointments were made prior to his discharge.

Medications on Admission:
 Neurontin 900'''

Discharge Medications:
1. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ML's PO BID
(2 times a day).
Disp:*qs ML's* Refills:*2*
2. Milk of Magnesia 400 mg/5 mL Suspension Sig: Ten (10) ML's PO
twice a day as needed for constipation.
3. oxycodone 5 mg/5 mL Solution Sig: [**6-4**] ML's PO every [**4-26**]
hours as needed for pain.
Disp:*350 ML's* Refills:*0*
4. gabapentin 250 mg/5 mL Solution Sig: Six Hundred (600) MG PO
Q8H (every 8 hours).
Disp:*qs ML's* Refills:*2*
5. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML
Mucous membrane TID (3 times a day).
Disp:*750 ML's* Refills:*2*
6. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO twice a day:
Take 1 tablet 2x/day for 3 days then 1 tablet 1x/day for 3 days
then stop after last dose.
Disp:*9 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Fall
Injuries:
1. Parafalcine subdural hemorrhage
2. Right mandibular dislocation/fracture
3. Seizures


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


Discharge Instructions:
You were admitted to the hospital following afall felt secondary
to seizure activity related to your alcohol use. You sustained a
bleeding injury to your brain and currently being treated with
an anti-seizure medications called Keppra which will continue
until [**2115-5-30**]. You will then need to come back to see the
Neurosurgeon in approximately 4 weeks for a repeat head CT scan
(this appointment will be made for you). You also sustained a
broken jaw which required an operation to repair and your jaw is
wired shut. You will need to also follow up withthe Oral
surgeons in clinic to have the wires removed from your jaw.

It is very important that you refrain from drinking alcohol
while you are healing from your injuries and also if you are
taking narcotics you should avoid alcohol.

Stool softeners and laxatives are also being recommended in
order to prevent constipation.

Postoperative instructions following jaw surgery

Wound care: Do not disturb or probe the surgical area with any
objects. The sutures placed in your mouth are usually the type
that self dissolve. If you have any sutures on the skin of your
face or neck, your surgeon will remove them on the day of your
first follow up appointment. SMOKING is detrimental to healing
and will cause complications.

Bleeding: Intermittent bleeding or oozing overnight is normal.
Placing fresh gauze over the area and biting on the gauze for
30-45 minutes at a time may control the bleeding. If you had
nasal surgery, you may have occasional slow oozing from your
nostril for the first 2-3 days. Bleeding should never be severe.
If bleeding persists or is severe or uncontrollable, please call
our office immediately. If it is after normal business hours,
please come to the emergency room and request that the oral
surgery resident on call be paged.

Healing: Normal healing after oral surgery should be as follows:
the first 2-3 days after surgery, are generally the most
uncomfortable and there is usually significant swelling. After
the first week, you should be more comfortable. The remainder of
your postoperative course should be gradual, steady improvement.
If you do not see continued improvement, please call our office.

Physical activity: It is recommended that you not perform any
strenuous physical activity for a few weeks after surgery. Do
not lift any heavy loads and avoid physical sports unless you
obtain permission from your surgeon.

Swelling & Ice applications: Swelling is often associated with
surgery. Swelling can be minimized by using a cold pack, ice bag
or a bag of frozen peas wrapped in a towel, with firm
application to face and neck areas. This should be applied 20
minutes on and 20 minutes off during the first 2-3 days after
surgery. If you have been given medicine to control the
swelling, be sure to take it as directed.

Hot applications: Starting on the 3rd or 4th day after surgery,
you may apply warm compresses to the skin over the areas of
swelling (hot water bottle wrapped in a towel, etc), for 20
minutes on and 20 min off to help soothe tender areas and help
to decrease swelling and stiffness. Please use caution when
applying ice or heat to your face as certain areas may feel numb
after surgery and extremes of temperature may cause serious
damage.

Tooth brushing: Begin your normal oral hygiene the day after
surgery. Soreness and swelling may nor permit vigorous brushing,
but please make every effort to clean your teeth with the bounds
of comfort. Any toothpaste is acceptable. Please remember that
your gums may be numb after surgery. To avoid injury to the gums
during brushing, use a child size toothbrush and brush in front
of a mirror staying only on teeth.

Mouth rinses: Keeping your mouth clean after surgery is
essential. Use 1 teaspoon of salt dissolved in an 8 ounce glass
of warm water and gently rinse with portions of the solution,
taking 5 min to use the entire glassful. Repeat as often as you
like, but you should do this at least 4 times each day. If your
surgeon has prescribed a specific rinse, use as directed.

Showering: You may shower 1-2 days after surgery, but please ask
your surgeon about this. If you have any incisions on the skin
of your face or body, you should cover them with a water
resistant dressing while showering. DO NOT SOAK SURGICAL SITES.
This will avoid getting the area excessively wet. As you may
physically feel weak after surgery, initially avoid extreme hot
or cold showers, as these may cause some patients to pass out.
Also it is a good idea to make sure someone is available to
assist you in case if you may need help.

Sleeping: Please keep your head elevated while sleeping. This
will minimize swelling and discomfort and reduce pain while
allowing you to breathe more easily. One or two pillows may be
placed beneath your mattress at the head of the bed to prop the
bed into a more vertical position.

Pain: Most facial and jaw reconstructive surgery is accompanied
by some degree of discomfort. You will usually have a
prescription for pain medication. Some patients find that
stronger pain medications cause nausea, but if you precede each
pain pill with a small amount of food, chances of nausea will be
reduced. The effects of pain medications vary widely among
individuals. If you do not achieve adequate pain relief at first
you may supplement each pain pill with an analgesic such as
Tylenol or Motrin. If you find that you are taking large amounts
of pain medications at frequent intervals, please call our
office.
If your jaws are wired shut with elastics, you may have been
prescribed liquid pain medications. Please remember to rinse
your mouth after taking liquid pain medications as they can
stick to the braces and can cause gum disease and damage teeth.

Diet: Unless otherwise instructed, only a cool, clear liquid
diet is allowed for the first 24 hours after surgery. After 48
hours, you can increase to a full liquid diet, but please check
with your doctor before doing this. Avoid extreme hot and cold.
If your jaws are not wired shut, then after one week, you may be
able to gradually progress to a soft diet, but ONLY if your
surgeon instructs you to do so. It is important not to skip any
meals. If you take nourishment regularly you will feel better,
gain strength, have less discomfort and heal faster. Over the
counter meal supplements are helpful to support nutritional
needs in the first few days after surgery. A nutrition guidebook
will be given to you before you are discharged from the
hospital. Remember to rinse your mouth after any food intake,
failure to do this may cause infections and gum disease and
possible loss of teeth.

Nausea/Vomiting: Nausea is not uncommon after surgery. Sometimes
pain medications are the cause. Precede each pill with a small
amount of soft food. Taking pain pills with a large glass of
water can also reduce nausea. Try taking clear fluids and
minimizing taking pain medications, but call us if you do not
feel better. If your jaws are wired shut with elastics and you
experience nausea/vomiting, try tilting your head and neck to
one side. This will allow the vomitus to drain out of your
mouth. If you feel that you cannot safely expel the vomitus in
this manner, you can cut elastics/wires and open your mouth.
Inform our office immediately if you elect to do this. If it is
after normal business hours, please come to the emergency room
at once, and have the oral surgery on call resident paged.

Graft Instructions: If you have had a bone graft or soft tissue
graft procedure, the site where the graft was taken from (rib,
head, mouth, skin, clavicle, hip etc) may require additional
precautions. Depending on the site of the graft harvest, your
surgeon will [**Month/Day/Year 8146**] you regarding specific instructions for
the care of that area. If you had a bone graft taken from your
hip, we encourage you to ambulate on the day of surgery with
assistance. It is important to start slowly and hold onto stable
structures while walking. As you progressively increase your
ambulation, the discomfort will gradually diminish. If you have
any problems with urination or with bowel movements, call our
office immediately.

Elastics: Depending on the type of surgery, you may have
elastics and/or wires placed on your braces. Before discharge
from the hospital, the doctor [**First Name (Titles) **] [**Last Name (Titles) 8146**] you regarding these
wires/elastics. If for any reason, the elastics or wires break,
or if you feel your bite is shifting, please call our office.


Followup Instructions:
Where:[**Hospital6 **] at Yawkey Bldg ACC5
With: The Oral and Maxillofascial Surgery Clinic
When: Friday [**2115-6-7**] at 10:00 am
Phone: [**Telephone/Fax (1) 68463**]

Department: RADIOLOGY
When: THURSDAY [**2115-6-27**] at 10:00 AM
With: CAT SCAN [**Telephone/Fax (1) 590**]
Building: CC [**Location (un) 591**] [**Location (un) **]
Campus: WEST     Best Parking: [**Street Address(1) 592**] Garage

Department: NEUROSURGERY
When: THURSDAY [**2115-6-27**] at 11:00 AM
With: [**Name6 (MD) **] [**Last Name (NamePattern4) 7746**], MD [**Telephone/Fax (1) 3666**]
Building: LM [**Hospital Unit Name **] [**Location (un) **]
Campus: WEST     Best Parking: [**Hospital Ward Name **] Garage



Completed by:[**2115-5-29**]
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Closed fracture of mandible, condylar process,Alcohol withdrawal,Alkalosis,Epilepsy, unspecified, without mention of intractable epilepsy,Alcoholic polyneuropathy,Other and unspecified alcohol dependence, continuous,Acute gouty arthropathy,First degree atrioventricular block,Unspecified essential hypertension,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Alcohol abuse, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Lack of housing,Unspecified fall'}


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

PRESENT ILLNESS: 43yo man with h/o alcoholism and withdrawal seizures who reports
a seizure this morning with a fall. He was brought to OSH where
he received a head CT that showed a 6mm parafalcine SDH without
midline shift. Other injury included left nasal bone fracture.
He was medflighted to [**Hospital1 18**] for further care.

MEDICAL HISTORY: EtOH abuse, HTN, Anxiety, Depression, Scabies/Lice

MEDICATION ON ADMISSION: Neurontin 900'''

ALLERGIES: lansoprazole / Zolpidem

PHYSICAL EXAM: Upon presentation to [**Hospital1 18**]:
PE: 83, 150/85, 13, 95% RA
NAD, in c-collar
Alert and oriented to person and date but not place (knows
[**Location (un) **]
but not where in [**Location (un) **])
No lac's on head. Impressive left facial swelling and
ecchymoses.
No battle's sign
No CSF leakage from ears. Tympanic membranes intact
No rhinorrhea, no septal hemtoma
EOMI. PERRL.
CN's [**3-3**] intact
No pronator drift.
Able to perform [**Doctor First Name 6361**] and finger-nose-finger
5/5 strength throughout bilateral UE's. SILT r/m/u nerve
distributions.
[**5-25**] hip flexion, knee flex/ext and ankle dorsi/plantar flexion.
Minimal toe flexion/ext which is baseline per pt (neuropathy).
Decreased sensation in bilateral feet.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY:  

### Response:
{'Subdural hemorrhage following injury without mention of open intracranial wound, unspecified state of consciousness,Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery,Closed fracture of mandible, condylar process,Alcohol withdrawal,Alkalosis,Epilepsy, unspecified, without mention of intractable epilepsy,Alcoholic polyneuropathy,Other and unspecified alcohol dependence, continuous,Acute gouty arthropathy,First degree atrioventricular block,Unspecified essential hypertension,Anxiety state, unspecified,Depressive disorder, not elsewhere classified,Alcohol abuse, unspecified,Unspecified hereditary and idiopathic peripheral neuropathy,Lack of housing,Unspecified fall'}
