CHIEF COMPLAINT: Bike vs car accident

PRESENT ILLNESS: HPI: Called to evaluate trauma patient in the emergency room.
The
patient is a 27y/o male BIBA s/p bicycle struck by vehicle,
brief
+LOC per witness. Patient was riding his bike to the video
store,
was grazed by a car on the street. Patient was not wearing a
helmet, has no recollection of the event. Patient now complains
of headache, is frightened and confused about exactly what
happened, but oriented. CT head reveals extra- axial blood in
the
left temporal parietal region and nondisplaced fractures of
temporal and parietal bones. Patient is accompanied by
girlfriend
who was called to ER after patient arrived.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: Gen- NAD
Chest- RRR
Lungs- CTAB
Abd- soft NTND
Ext- no c/c/e
Neuro: alert & oriented x 3, fluent speech, follows commands
PERRLA, VFFTC, EOMI
Hearing intact to FR
Palate/tongue midline
Shoulder shrug [**5-24**]
CN II-XII intact
Blood in left ear canal, suspect but unable to visualize
hemotympanum
Motor [**5-24**] throughout
No pronator drift
Sensory intact to LT throughout
DTRs [**2-21**] throughout
Downgoing toes
GCS 15

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Social: recently moved to [**Location (un) 86**] with girlfriend, no family
local
area. denies tobacco, occasional alcohol.
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Motor vehicle traffic accident involving collision with other vehicle injuring pedal cyclist,Street and highway accidents
Cl skul base fx/brf coma,Mv-oth veh coll-ped cycl,Accid on street/highway
Admission Date:  [**2188-1-8**]              Discharge Date:   [**2188-1-12**]

Date of Birth:  [**2160-5-22**]             Sex:   M

Service: NEUROSURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1835**]
Chief Complaint:
Bike vs car accident

Major Surgical or Invasive Procedure:
Left hemicraniectomy with evacuation epidural and subdural
hematoms


History of Present Illness:
HPI: Called to evaluate trauma patient in the emergency room.
The
patient is a 27y/o male BIBA s/p bicycle struck by vehicle,
brief
+LOC per witness. Patient was riding his bike to the video
store,
was grazed by a car on the street. Patient was not wearing a
helmet, has no recollection of the event. Patient now complains
of headache, is frightened and confused about exactly what
happened, but oriented. CT head reveals extra- axial blood in
the
left temporal parietal region and nondisplaced fractures of
temporal and parietal bones. Patient is accompanied by
girlfriend
who was called to ER after patient arrived.

Past Medical History:
none

Social History:
Social: recently moved to [**Location (un) 86**] with girlfriend, no family
local
area. denies tobacco, occasional alcohol.


Family History:
non-contributory

Physical Exam:
PE: Gen- NAD
Chest- RRR
Lungs- CTAB
Abd- soft NTND
Ext- no c/c/e
Neuro: alert & oriented x 3, fluent speech, follows commands
PERRLA, VFFTC, EOMI
Hearing intact to FR
Palate/tongue midline
Shoulder shrug [**5-24**]
CN II-XII intact
Blood in left ear canal, suspect but unable to visualize
hemotympanum
Motor [**5-24**] throughout
No pronator drift
Sensory intact to LT throughout
DTRs [**2-21**] throughout
Downgoing toes
GCS 15



Pertinent Results:
[**2188-1-8**] 05:30PM   PT-12.4 PTT-19.5* INR(PT)-1.0
[**2188-1-8**] 05:30PM   WBC-13.6* RBC-5.16 HGB-16.3 HCT-43.0 MCV-83
MCH-31.6 MCHC-38.0* RDW-12.8
[**2188-1-8**] 05:30PM   PLT COUNT-486*
[**2188-1-8**] 05:30PM   ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2188-1-8**] 05:40PM   GLUCOSE-149* LACTATE-2.3* NA+-140 K+-3.6
CL--100 TCO2-23
[**2188-1-8**] 05:30PM   UREA N-21* CREAT-0.9
[**2188-1-8**] 06:20PM URINE  COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.043*
[**2188-1-8**] 06:20PM URINE  RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-[**6-29**]

Brief Hospital Course:
Patient had CTA while in ER which showed expanding epidural
hematoma and he was taken emergently to OR for left
hemicraniectomy and evacuation of epidural and subdural
hematoma.  Post operatively he was monitored in the trauma
ICU.SBP was kept less than 140, loaded with Dilantin and covered
with prophylactic antibiotics. Post op CT showed resolution of
epidural hematoma and right temporal contusion.  ENT was
consulted for blood in left canal and left temporal bone fx.
They recommended temporal bone CT which showed the fracture
through the external auditory canal to the middle ear space with
is malleo-incal disruption.  They recommend follow up appt with
audiogram 2-3 weeks, and 7 days of cipro drops in the ear canal.
 His activity and diet were advanced.  He was transferred to the
floor.  PT evaluated the pt.  Meds were transferred to oral.
His incision was clean dry and intact.  He was given helmet to
be worn at all times when out of bed. On POD #4, pt was d/ced to
home with instructions to follow up for staple removal, to have
the bone flap replaced, and with ENT to further evaluate his
hearing.


Medications on Admission:
none

Discharge Medications:
1. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3
to 4 Hours) as needed for pain.
Disp:*35 Tablet(s)* Refills:*0*
2. Phenytoin Sodium Extended 100 mg Capsule Sig: One (1) Capsule
PO TID (3 times a day).
Disp:*90 Capsule(s)* Refills:*2*
3. Ciprofloxacin 0.3 % Drops Sig: 1-2 Drops Ophthalmic  Q4H
(every 4 hours) for 5 days.
Disp:*qs mL* Refills:*0*
4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Take while taking Hydromorphone for pain.
Disp:*60 Capsule(s)* Refills:*2*


Discharge Disposition:
Home With Service

Facility:
Case management notified that provider not entered

Discharge Diagnosis:
Head trauma with epidural/subdural hematoma


Discharge Condition:
Neurologically stable


Discharge Instructions:
Keep staples dry.  Call for fever or any signs of infection -
redness, swelling or drainage from wound.  Wear helmet whenever
out of bed.

Followup Instructions:
Follow up with Dr. [**Last Name (STitle) **] for staple removal on [**1-18**].  Call the
office ([**Telephone/Fax (1) 88**]) to arrange for the appointment.
You will also need a second appointment with Dr.[**Name (NI) 9034**] office
around 6 to 8 weeks after your surgery to have a second surgery
to place the bone flap back.  These arrangements can be made at
the time of staple removal.

Follow up with Dr. [**Last Name (STitle) 3878**] (Call [**Telephone/Fax (1) 2349**] for appt) for
audiogram and follow up in 2 to 3 weeks.



Completed by:[**2188-1-12**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Motor vehicle traffic accident involving collision with other vehicle injuring pedal cyclist,Street and highway accidents'}


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: Bike vs car accident

PRESENT ILLNESS: HPI: Called to evaluate trauma patient in the emergency room.
The
patient is a 27y/o male BIBA s/p bicycle struck by vehicle,
brief
+LOC per witness. Patient was riding his bike to the video
store,
was grazed by a car on the street. Patient was not wearing a
helmet, has no recollection of the event. Patient now complains
of headache, is frightened and confused about exactly what
happened, but oriented. CT head reveals extra- axial blood in
the
left temporal parietal region and nondisplaced fractures of
temporal and parietal bones. Patient is accompanied by
girlfriend
who was called to ER after patient arrived.

MEDICAL HISTORY: none

MEDICATION ON ADMISSION: none

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: PE: Gen- NAD
Chest- RRR
Lungs- CTAB
Abd- soft NTND
Ext- no c/c/e
Neuro: alert & oriented x 3, fluent speech, follows commands
PERRLA, VFFTC, EOMI
Hearing intact to FR
Palate/tongue midline
Shoulder shrug [**5-24**]
CN II-XII intact
Blood in left ear canal, suspect but unable to visualize
hemotympanum
Motor [**5-24**] throughout
No pronator drift
Sensory intact to LT throughout
DTRs [**2-21**] throughout
Downgoing toes
GCS 15

FAMILY HISTORY: non-contributory

SOCIAL HISTORY: Social: recently moved to [**Location (un) 86**] with girlfriend, no family
local
area. denies tobacco, occasional alcohol. 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with brief [less than one hour] loss of consciousness,Motor vehicle traffic accident involving collision with other vehicle injuring pedal cyclist,Street and highway accidents'}
