CHIEF COMPLAINT: s/p presumed assault

PRESENT ILLNESS: This is a 43 year old female who was found lying in the
street by police near her home.  When approached she ran into
her
home where she was found with numerous pills scattered about the
floor with the home in disarray per reports of EMS.  The patient
was taken to [**Hospital3 26615**] Hospital where she was wake but drowsy
with a 2cm laceration at the occiput.  A head CT was performed
that was consistent with [**Hospital1 **] frontal SDH, SAH, and occipital bone
fracture.  The Urine toxicology screen was positive for cocaine,
methadone, oxycodone.  The patient was intubated for airway
protection and transported here for further evaluation.

MEDICAL HISTORY: cholecystectomy- other unknown, possibly depression

MEDICATION ON ADMISSION: unknown

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: BP: 119/78  HR:88    R:19       O2Sats:100%
Gen: Intubated,+ gag/cough/corneals GCS 10 T, No raccoon/battle
sign, no hemotympanum or otorrhea or rhinorrhea
HEENT:1.5 cm laceration on the occiput present Pupils:[**2-10**]

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Cerebral edema,Hypopotassemia,Open wound of scalp, complicated,Leukocytosis, unspecified,Hemorrhage of rectum and anus,Assault by other specified means,Other specified noninflammatory disorders of vagina,Disorders of phosphorus metabolism,Nonspecific abnormal toxicological findings,Accidents occurring in unspecified place
Cl skl base fx/menin hem,Cerebral edema,Hypopotassemia,Open wound scalp-compl,Leukocytosis NOS,Rectal & anal hemorrhage,Assault NEC,Noninflam dis vagina NEC,Dis phosphorus metabol,Abn toxicologic finding,Accident in place NOS
Admission Date:  [**2179-7-26**]              Discharge Date:   [**2179-8-12**]

Date of Birth:  [**2130-6-19**]             Sex:   F

Service: NEUROSURGERY

Allergies:
No Known Allergies / Adverse Drug Reactions

Attending:[**First Name3 (LF) 78**]
Chief Complaint:
s/p presumed assault

Major Surgical or Invasive Procedure:
None


History of Present Illness:
This is a 43 year old female who was found lying in the
street by police near her home.  When approached she ran into
her
home where she was found with numerous pills scattered about the
floor with the home in disarray per reports of EMS.  The patient
was taken to [**Hospital3 26615**] Hospital where she was wake but drowsy
with a 2cm laceration at the occiput.  A head CT was performed
that was consistent with [**Hospital1 **] frontal SDH, SAH, and occipital bone
fracture.  The Urine toxicology screen was positive for cocaine,
methadone, oxycodone.  The patient was intubated for airway
protection and transported here for further evaluation.

There is a toxicology significant other in the waiting room that
is unable to provide reliable history.  He states that he can
not
remember exactly, but thinks that he last saw the patient at
approximately 1145 pm [**7-25**]. He also states that the diamond from
her engagement ring is missing.  He is unsure what her medical
history is or what her current medications are.


Past Medical History:
cholecystectomy- other unknown, possibly depression


Social History:
unknown


Family History:
unknown


Physical Exam:
O: BP: 119/78  HR:88    R:19       O2Sats:100%
Gen: Intubated,+ gag/cough/corneals GCS 10 T, No raccoon/battle
sign, no hemotympanum or otorrhea or rhinorrhea
HEENT:1.5 cm laceration on the occiput present Pupils:[**2-10**]

EOMs grossly intact
Neck: hard collar in place
GU/GI: rectal and vaginal blood present
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation:GCS off propofol 15 mins- 10 T
Recall/Language: intubated but follows commands off sedation

Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
mm bilaterally. Visual fields- unable to test
III, IV, VI: Extraocular movements- grossly intact but not
cooperative with formal exam
V, VII: Facial strength- grossly intact- but not cooperative
with
exam
VIII: Hearing grossly intact to voice.
IX, X,[**Doctor First Name 81**],XII: unable to evaluate at this time

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
Strength- antigravity all four extremities.  patient gave thumbs
up sign on right and showed two fingers on left- wiggled toes
bilaterally .Spontaneously - pt is moving all extremities with
good strength/localizing and attempting to roll over on the
stretcher.

Pronator drift- unable to evaluate

Sensation:unable to perform vs patient does not cooperate at
this
time

Toes downgoing bilaterally

Coordination: unable to perform

Exam on discharge:

Patient arousable to voice and stimulation, often uncooperative
with exam, but moves all extemities and walks in the halls with
nursing.


Pertinent Results:
CT HEAD W/O CONTRAST [**2179-7-26**]
1. Multicompartmental intracranial hemorrhage including
bilateral frontal and temporal lobe contusions, bilateral
subdural hematomas, and small amounts of subarachnoid blood.
2. Minimal leftward shift of normally midline structures. No
evidence of
central herniation.
3. Left paramedian occipital bone fracture extending into the
foramen magnum.

CT C-SPINE W/O CONTRAST [**2179-7-26**]:
IMPRESSION:
1. No acute cervical fracture or evidence of malalignment.
2. Left paramedian occipital bone fracture extending into the
foramen magnum, as described fully on the accompanying head CT
dated [**2179-7-26**].
3. Small hypodense nodule within the left lobe of the thyroid
can be further evaluated with non-emergent ultrasound, if
clinically indicated.
4. 2-mm nodule at the right lung apex does not require further
followup if
the patient is a nonsmoker and has no known history of cancer.
Otherwise,
evaluation with CT in 12 months is recommended.

CT Torso [**2179-7-26**]:
IMPRESSION:
1. No evidence of acute traumatic injury within the chest,
abdomen, or
pelvis. No traumatic injury seen to the visualized vertebral
bodies or other bones.
2. Small hypodensity in the pancreatic tail measuring up to 4 mm
which may
represent a side branch IPMN. Per departmental guidelines, a
follow up study (CT or MRI) in 1 year is recommended to ensure
stability.

CT Head [**2179-7-26**]:
IMPRESSION:
1. No significant interval change in multi-compartmental
intracranial
hemorrhage
2. Possible increased compression of the third ventricle,
without enlargement of the lateral ventricles. Recommend
continued close follow up.
3. Occipital bone, right clivus and left sphenoid fractures are
again noted.

CT Head [**2179-7-27**]:
IMPRESSION: No significant interval change.

CT head [**2179-8-2**]:
1. Slight increase in edema surrounding the right and left
frontal
hemorrhagic contusions, however, there is no change in mass
effect or midline shift.
2. Decreased amount of blood and fluid in the sphenoid sinuses.

3. The remaining findings are unchanged since prior study.

CT head [**2179-8-3**]:
Unchanged hemorrhagic contusions and subdural hemorrhage,
without increased mass effect or evidence of other new
intracranial abnormalities.


Brief Hospital Course:
43 y/o F s/p assault presented to ED with multiple head trauma
with vaginal and rectal bleeding. CT head revealed R frontal SDH
and SAH in the left temporal region as well as a nondisplaced
occipital bone fracture. She was evaluated by the ACS service as
well and transferred to the TSICU for close monitoring. On
examination, patient is able to follow commands on the BUE, EO
to voice and wiggles toes.

A SANE test was started to rule out sexual assault and rape.
Blood cultures were sent to rule out bacteremia given a WBC of
27. Mannitol was administered upon arrival. Urine tox screen at
OSH was positive for methadone, cocaine and oxycodone. In
addition, patient was started on HAART therapy for HIV
prophylaxis.

A repeat head CT on the evening of [**7-26**] showed evolution of the
right frontal contusion and subdrual hematoma, but the patient
remained clinically stable and was rescanned on [**7-27**] and
subsequently extubated. Overnight, she was restless and agitated
requiring some mild sedation. The patient had a SAN exam on [**7-26**]
and HAART was started prophalactically.

On [**7-28**], she remained stable and begain following commands. She
was tranferred to the floor in stable condition on [**7-29**]. She did
require intermittent Haldol for agitation on this day with good
result. She remained in [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] bed and wrist restraints for her
own safety. On [**7-31**] She improved neurologically.  A repeat head
Ct was obtained on [**8-2**] for follow-up as she continued to
progress slowly.  This showed interval increase in swelling vs.
normal evolution of frontal contusion and hemorrhage.  A repeat
head CT on [**8-3**] was unchanged. On [**8-4**], she remain neuro stable
and was transferred to floor.  She continued to be
neurologically intact and PT/OT recommended acute rehab.

Patient has had very complicated social issues thrugout her
hospitalization.  Her Sons do not get along with her husband and
there have been a few near altercations. Their legal marital
status has been in question but was cleared when [**Last Name (un) 90808**] [**Doctor Last Name 19276**],
her husband, provided their marrige certificate to our social
work staff. He also provided HCP paperwork. She had a
nutritional consult and caloried counts. Her head laceration
looked infection and Keflex was started on [**8-9**]. Rehab screen
was in place.

Patient remained clinically stable for the remainder of her stay
and was discharged to acute rehab with out patient follow up.


Medications on Admission:
unknown


Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily).
3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for pain.
4. darunavir 400 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily)
for 28 days.
5. ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily) for 28 days.
6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1)
Injection TID (3 times a day).
8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. emtricitabine-tenofovir 200-300 mg Tablet Sig: One (1)
Tablet PO DAILY (Daily) for 28 days.
11. cephalexin 250 mg Capsule Sig: Two (2) Capsule PO Q12H
(every 12 hours) for 7 days: End Date [**2179-8-16**].
12. Fioricet 50-325-40 mg Tablet Sig: 1-2 Tablets PO every [**3-17**]
hours as needed for headache.


Discharge Disposition:
Extended Care

Facility:
[**Hospital3 7665**] in [**Location (un) 12017**]

Discharge Diagnosis:
R frontal SDH
L temporal SAH
L occipital fx
Cerebral edema


Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).


Discharge Instructions:
??????	Have a friend/family member check your incision daily for
	Take your pain medicine as prescribed.
??????	Exercise should be limited to walking; no lifting, straining,
or excessive bending.
??????	Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
	Clearance to drive and return to work will be addressed at your
post-operative office visit.
??????	Make sure to continue to use your incentive spirometer while
at home, unless you have been instructed not to.

CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING

??????	New onset of tremors or seizures.
??????	Any confusion or change in mental status.
??????	Any numbness, tingling, weakness in your extremities.
??????	Pain or headache that is continually increasing, or not
relieved by pain medication.
??????	Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
??????	Fever greater than or equal to 101?????? F.


Followup Instructions:
Follow-Up Appointment Instructions
??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr.
[**First Name (STitle) **] , to be seen in ___6____weeks.
??????You will  need a CT scan of the brain without contrast.



Completed by:[**2179-8-12**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Cerebral edema,Hypopotassemia,Open wound of scalp, complicated,Leukocytosis, unspecified,Hemorrhage of rectum and anus,Assault by other specified means,Other specified noninflammatory disorders of vagina,Disorders of phosphorus metabolism,Nonspecific abnormal toxicological findings,Accidents occurring in unspecified place'}


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 presumed assault

PRESENT ILLNESS: This is a 43 year old female who was found lying in the
street by police near her home.  When approached she ran into
her
home where she was found with numerous pills scattered about the
floor with the home in disarray per reports of EMS.  The patient
was taken to [**Hospital3 26615**] Hospital where she was wake but drowsy
with a 2cm laceration at the occiput.  A head CT was performed
that was consistent with [**Hospital1 **] frontal SDH, SAH, and occipital bone
fracture.  The Urine toxicology screen was positive for cocaine,
methadone, oxycodone.  The patient was intubated for airway
protection and transported here for further evaluation.

MEDICAL HISTORY: cholecystectomy- other unknown, possibly depression

MEDICATION ON ADMISSION: unknown

ALLERGIES: No Known Allergies / Adverse Drug Reactions

PHYSICAL EXAM: O: BP: 119/78  HR:88    R:19       O2Sats:100%
Gen: Intubated,+ gag/cough/corneals GCS 10 T, No raccoon/battle
sign, no hemotympanum or otorrhea or rhinorrhea
HEENT:1.5 cm laceration on the occiput present Pupils:[**2-10**]

FAMILY HISTORY: unknown

SOCIAL HISTORY: unknown 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, unspecified state of consciousness,Cerebral edema,Hypopotassemia,Open wound of scalp, complicated,Leukocytosis, unspecified,Hemorrhage of rectum and anus,Assault by other specified means,Other specified noninflammatory disorders of vagina,Disorders of phosphorus metabolism,Nonspecific abnormal toxicological findings,Accidents occurring in unspecified place'}
