CHIEF COMPLAINT: s/p assault

PRESENT ILLNESS: 36 year old female transferred from OSH for further care s/p
unwitnessed assault.  By report she was hit multiple times with
a glass 40oz beer bottle.  She was intubated at the outside
hospital.

MEDICAL HISTORY: MVC 5 months ago with dislocated jaw, pelvis fracture and
right eye injury

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: afebrile,VSS
NAD
PERRL
wounds c/d/i
cervical collar in place
RRR, CTAB
abd: soft NT/ND
neurologically intact

FAMILY HISTORY: non contributory

SOCIAL HISTORY: +cocaine and EtOH on arrival to ED
C5-C7 level with unspecified spinal cord injury,Acute posthemorrhagic anemia,Assault by striking by blunt or thrown object,Open wound of auricle, ear, without mention of complication,Open wound of shoulder region, without mention of complication,Cocaine abuse, unspecified
C5-c7 spin cord inj NOS,Ac posthemorrhag anemia,Assault-striking w obj,Open wound of auricle,Open wound of shoulder,Cocaine abuse-unspec
Admission Date:  [**2104-3-10**]              Discharge Date:   [**2104-3-17**]

Date of Birth:  [**2067-10-1**]             Sex:   F

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 1556**]
Chief Complaint:
s/p assault

Major Surgical or Invasive Procedure:
[**2104-3-10**] bedside repair of ear laceration, left upper extremity
laceration
[**2104-3-10**] C5-7 laminectomy/decompression


History of Present Illness:
36 year old female transferred from OSH for further care s/p
unwitnessed assault.  By report she was hit multiple times with
a glass 40oz beer bottle.  She was intubated at the outside
hospital.

Past Medical History:
MVC 5 months ago with dislocated jaw, pelvis fracture and
right eye injury

Social History:
+cocaine and EtOH on arrival to ED

Family History:
non contributory

Physical Exam:
afebrile,VSS
NAD
PERRL
wounds c/d/i
cervical collar in place
RRR, CTAB
abd: soft NT/ND
neurologically intact


Pertinent Results:
[**2104-3-10**] 12:15PM BLOOD WBC-20.8* RBC-3.14* Hgb-8.4* Hct-26.1*
MCV-83 MCH-26.8* MCHC-32.2 RDW-16.5* Plt Ct-316

[**2104-3-14**] 06:10AM BLOOD WBC-14.2* RBC-3.12* Hgb-8.5* Hct-25.8*
MCV-83 MCH-27.3 MCHC-33.1 RDW-15.9* Plt Ct-257
[**2104-3-13**] 02:09AM BLOOD PT-12.4 PTT-26.0 INR(PT)-1.0
[**2104-3-14**] 06:10AM BLOOD Glucose-100 UreaN-6 Creat-0.7 Na-136
K-4.0 Cl-105 HCO3-23 AnGap-12
[**2104-3-11**] 03:20AM BLOOD Glucose-110* UreaN-5* Creat-0.7 Na-135
K-4.1 Cl-106 HCO3-23 AnGap-10

[**3-10**] CT Cspine: Hyperdense thickening of the anterior dura along
C5-C7 level which raises concern for epidural hematoma

[**3-10**] CT head: 1. Superficial hematoma of the left preauricular
region containing multiple tiny foreign bodies. Foreign bodies
also within the right preseptal and right frontal soft tissues.
2. No fractures or intracranial hemorrhage.

[**3-11**] MRI Cspine: Intermediate signal epidural process extending
from C5/6 to the C6- C7 level, which likely represents an
epidural hematoma and less likely disc extrusion.  Laminectomy
extending from C5-C7.  No cord signal abnormalities. No canal
stenosis.

[**3-13**] flexion/extension views Cspine: No fracture or
spondylolisthesis. No abnormal motion detected on flexion and
extension views. Status post laminectomy with post-surgical skin
staples as above.

[**3-13**] CT face: No evidence of acute fracture. Status post wiring
of the maxilla and mandibular teeth. There is an old,
nondisplaced fracture of the left mandibular ramus extending
into the angle. There is an old medial blowout fracture of the
orbital wall on the right and an old nasal bone fracture.


Brief Hospital Course:
The patient was seen by trauma surgery, plastic surgery, social
work and neurosurgery in the ED.  Her ear laceration was
repaired by plastic surgery in the ED.  She was taken  to the
operating room from the ED for C5-7 laminectomy/decompression
for the finding of an epidural hematoma.  She tolerated the
procedure well and was transferred to the ICU postoperatively.
She remained intubated per the neurosurgery team for 48 hours
post op.  Her left arm laceration was sutured in the ICU post
operatively.  She was seen by ophthalmology on [**3-11**] and was not
felt to have any foreign bodies in the right eye.  She was
extubated on [**3-12**] and continued to do well.  She had a bedside
swallowing eval on [**3-13**] and was recommended for nectar thick
liquids and pureed food, which was advanced to thin
liquids/ground solids on [**3-14**] and then a regular diet.  She was
transferred to the floor on [**3-13**] and seen by physical therapy
and cleared for discharge.  She was stable for discharge on
[**2104-3-17**].  She met with social work during her stay and the
patient felt safe for discharge home.

She will follow up with Dr. [**Last Name (STitle) **] in 10 days for suture removal
and in 6 weeks with a CT Cspine prior to the appointment.  She
will also follow up in plastic surgery clinic on [**3-21**] for
removal of the arch bars and removal of her ear and left arm
sutures.

Medications on Admission:
unknown

Discharge Medications:
1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*1*
2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO
every 4-6 hours as needed for pain for 1 weeks.
Disp:*45 Tablet(s)* Refills:*0*
3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).

4. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr
Transdermal DAILY (Daily).
Disp:*30 Patch 24 hr(s)* Refills:*0*
5. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic Q2H
(every 2 hours) as needed for dry eye.
Disp:*1 1* Refills:*1*
6. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) as needed for lower back pain for 3 days.
Disp:*15 Tablet(s)* Refills:*0*


Discharge Disposition:
Home

Discharge Diagnosis:
C5-7 epidural hematoma
ear laceration, left upper extremity laceration


Discharge Condition:
stable


Discharge Instructions:
Wear the cervical collar at all times, Dr. [**Last Name (STitle) **] will give you
further instructions at your follow up appointment.

Keep your wounds clean and dry.

Call your doctor or return to the emergency department for fever
>101.5, any redness or drainage from your wounds, any
numbness/tingling in your arms or legs, any increased difficulty
swallowing, worsening pain or difficulty breathing.

Followup Instructions:
Please call [**Telephone/Fax (1) 1669**] for an appointment with Dr. [**Last Name (STitle) **]
regarding your neck surgery.  You should have an appointment on
the 25th for staple removal and then an appointment in 6 weeks
for follow up.  You will need a CT of your neck prior to the
appointment in 6 weeks, which the office will arrange.

Please also follow up with Dr. [**First Name (STitle) **] in plastic surgery on Friday
[**3-21**] for suture removal from your ear and left upper arm and
arch bar removal, call [**Telephone/Fax (1) 274**] to make an appointment.

Follow up with your primary care physician for further
prescriptions for nicotine patch and smoking cessation
assistance
{'C5-C7 level with unspecified spinal cord injury,Acute posthemorrhagic anemia,Assault by striking by blunt or thrown object,Open wound of auricle, ear, without mention of complication,Open wound of shoulder region, without mention of complication,Cocaine abuse, 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 assault

PRESENT ILLNESS: 36 year old female transferred from OSH for further care s/p
unwitnessed assault.  By report she was hit multiple times with
a glass 40oz beer bottle.  She was intubated at the outside
hospital.

MEDICAL HISTORY: MVC 5 months ago with dislocated jaw, pelvis fracture and
right eye injury

MEDICATION ON ADMISSION: unknown

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: afebrile,VSS
NAD
PERRL
wounds c/d/i
cervical collar in place
RRR, CTAB
abd: soft NT/ND
neurologically intact

FAMILY HISTORY: non contributory

SOCIAL HISTORY: +cocaine and EtOH on arrival to ED 

### Response:
{'C5-C7 level with unspecified spinal cord injury,Acute posthemorrhagic anemia,Assault by striking by blunt or thrown object,Open wound of auricle, ear, without mention of complication,Open wound of shoulder region, without mention of complication,Cocaine abuse, unspecified'}
