CHIEF COMPLAINT: 31 year old male s/p fall of [**2106**] feet.

PRESENT ILLNESS: 31 year old male with a mechanical fall of [**2106**] while on
construction site performing a roof repair. Patient was brought
to the ED in obtunded state.  There was a failed intubation at
the scene of the accident. Patient was intubated in the ED and
evaluated for injuries.

MEDICAL HISTORY: Substance Abuse

MEDICATION ON ADMISSION: none

ALLERGIES: Egg

PHYSICAL EXAM: Gen: Well-appearing, NAD
HEENT:  neck is sore, but with normal ROM
Chest:  CTAB
CV: RRR
Abd: Soft, non-tender, non-distended.
Msk:  Neurovasculary intact in extremities.

FAMILY HISTORY: NC

SOCIAL HISTORY: Married and lives with wife.
[**Name (NI) 85176**] abuse.
Other alteration of consciousness,Accidental fall from or out of building or other structure,Opioid type dependence, unspecified,Pain in joint, lower leg
Other alter consciousnes,Fall from building,Opioid dependence-unspec,Joint pain-l/leg
Admission Date:  [**2201-7-22**]              Discharge Date:   [**2201-7-26**]

Date of Birth:  [**2169-5-2**]             Sex:   M

Service: SURGERY

Allergies:
Egg

Attending:[**First Name3 (LF) 2534**]
Chief Complaint:
31 year old male s/p fall of [**2106**] feet.

Major Surgical or Invasive Procedure:
none

History of Present Illness:
31 year old male with a mechanical fall of [**2106**] while on
construction site performing a roof repair. Patient was brought
to the ED in obtunded state.  There was a failed intubation at
the scene of the accident. Patient was intubated in the ED and
evaluated for injuries.

Past Medical History:
Substance Abuse

Social History:
Married and lives with wife.
[**Name (NI) 85176**] abuse.

Family History:
NC

Physical Exam:
Gen: Well-appearing, NAD
HEENT:  neck is sore, but with normal ROM
Chest:  CTAB
CV: RRR
Abd: Soft, non-tender, non-distended.
Msk:  Neurovasculary intact in extremities.

Pertinent Results:
[**7-21**] - CT scans of Head, C-Spine, Abdomen, Pelvis all show no
acute injury.

Lab results below show stable Hematocrit.
[**2201-7-23**] 03:41AM BLOOD WBC-9.6 RBC-4.53* Hgb-13.4* Hct-39.4*
MCV-87 MCH-29.5 MCHC-33.9 RDW-13.8 Plt Ct-243
[**2201-7-22**] 09:05PM BLOOD WBC-7.4 RBC-4.31* Hgb-12.8* Hct-37.1*
MCV-86 MCH-29.7 MCHC-34.5 RDW-14.1 Plt Ct-278

Brief Hospital Course:

32M s/p fall from 15 ft onto soft ground, intubated in ED for
airway protection, reported GCS 3. In TSICU able to MAE and
follow commands, exam w/o e/o trauma. Patient was extubated,
found to be stable and transferred to the floor. Patient was
found to have no acute injuries on clinical exam or on CT scans.
 Patient will be discharged to home.

Medications on Admission:
none

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) for 1 months.
Disp:*60 Capsule(s)* Refills:*0*
2. Oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3)
Tablet Sustained Release 12 hr PO every eight (8) hours as
needed for pain  for 1 weeks.
Disp:*40 Tablet Sustained Release 12 hr(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
status post fall.
possible nasal septal fracture, no acute intracranial process.


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


Discharge Instructions:
Call if fever >101 F.   Call if dizziness, weakness of
extremities, fainting spells or other symptoms of concern. Call
with any questions or concerns. Call if increasing pain.
Ambulate daily.
Call in any symptoms are concerning.

Followup Instructions:
Follow up Primary Care Physcian in one week/
Patient will f/u with Orthopaedics, Dr. [**Last Name (STitle) 85177**].



Completed by:[**2201-7-27**]
{'Other alteration of consciousness,Accidental fall from or out of building or other structure,Opioid type dependence, unspecified,Pain in joint, lower leg'}


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: 31 year old male s/p fall of [**2106**] feet.

PRESENT ILLNESS: 31 year old male with a mechanical fall of [**2106**] while on
construction site performing a roof repair. Patient was brought
to the ED in obtunded state.  There was a failed intubation at
the scene of the accident. Patient was intubated in the ED and
evaluated for injuries.

MEDICAL HISTORY: Substance Abuse

MEDICATION ON ADMISSION: none

ALLERGIES: Egg

PHYSICAL EXAM: Gen: Well-appearing, NAD
HEENT:  neck is sore, but with normal ROM
Chest:  CTAB
CV: RRR
Abd: Soft, non-tender, non-distended.
Msk:  Neurovasculary intact in extremities.

FAMILY HISTORY: NC

SOCIAL HISTORY: Married and lives with wife.
[**Name (NI) 85176**] abuse. 

### Response:
{'Other alteration of consciousness,Accidental fall from or out of building or other structure,Opioid type dependence, unspecified,Pain in joint, lower leg'}
