CHIEF COMPLAINT: Head Trauma

PRESENT ILLNESS: 43yoM s/p assault with bilateral frontal SDH and multiple facial
fractures (nasal and septal).

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: [**Name (NI) **] wife found dead on [**2126-8-4**]

SOCIAL HISTORY: Fisherman
Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Pneumonia, organism unspecified,Closed fracture of nasal bones,Unarmed fight or brawl,Other and unspecified open wound of head without mention of complication
Cl skul base fx w/o coma,Pneumonia, organism NOS,Nasal bone fx-closed,Unarmed fight or brawl,Open wound of head NEC
Admission Date:  [**2126-7-27**]              Discharge Date:   [**2126-8-11**]

Date of Birth:  [**2082-11-7**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 5880**]
Chief Complaint:
Head Trauma

Major Surgical or Invasive Procedure:
None

History of Present Illness:
43yoM s/p assault with bilateral frontal SDH and multiple facial
fractures (nasal and septal).

Past Medical History:
None

Social History:
Fisherman

Family History:
[**Name (NI) **] wife found dead on [**2126-8-4**]

Pertinent Results:
[**2126-7-27**] 07:28PM   HCT-33.3*
[**2126-7-27**] 11:30AM   HCT-33.7*
[**2126-7-27**] 09:35AM   TYPE-ART RATES-/20 TIDAL VOL-600 O2-100
PO2-592* PCO2-38 PH-7.40 TOTAL CO2-24 BASE XS-0 AADO2-101 REQ
O2-27 -ASSIST/CON INTUBATED-INTUBATED
[**2126-7-27**] 09:10AM   GLUCOSE-123* UREA N-7 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-111* TOTAL CO2-22 ANION GAP-15
[**2126-7-27**] 09:10AM   CALCIUM-8.4 PHOSPHATE-3.2 MAGNESIUM-1.6
[**2126-7-27**] 09:10AM   WBC-16.8* RBC-3.92* HGB-12.0* HCT-35.2*
MCV-90 MCH-30.7 MCHC-34.2 RDW-12.5
[**2126-7-27**] 09:10AM   PLT COUNT-199
[**2126-7-27**] 09:10AM   NEUTS-82.6* LYMPHS-12.8* MONOS-3.8 EOS-0.5
BASOS-0.2
[**2126-7-27**] 04:55AM   PH-7.38
[**2126-7-27**] 04:55AM   HGB-13.7* calcHCT-41 O2 SAT-97 CARBOXYHB-0.8
MET HGB-0.9
[**2126-7-27**] 04:55AM   freeCa-1.12
[**2126-7-27**] 04:20AM   UREA N-8 CREAT-0.8
[**2126-7-27**] 04:20AM   AMYLASE-128*
[**2126-7-27**] 04:20AM   ASA-NEG ETHANOL-135* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2126-7-27**] 04:20AM URINE  HOURS-RANDOM
[**2126-7-27**] 04:20AM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
[**2126-7-27**] 04:20AM   WBC-18.8* RBC-4.35* HGB-13.2* HCT-39.0*
MCV-90 MCH-30.2 MCHC-33.7 RDW-12.5
[**2126-7-27**] 04:20AM   PT-12.5 PTT-24.1 INR(PT)-1.0
[**2126-7-27**] 04:20AM   FIBRINOGE-294
[**2126-7-27**] 04:20AM URINE  BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
[**2126-7-27**] 04:20AM URINE  RBC-1 WBC-1 BACTERIA-RARE YEAST-NONE
EPI-1

CT HEAD W/O CONTRAST  [**2126-7-27**] 5:36 PM
IMPRESSION:
1. No significant interval change in bilateral anterior frontal
subdural hematomas.
2. Evolution of subarachnoid hemorrhage and intraparenchymal
hemorrhages in the inferior frontal lobes and anterior temporal
lobes again consistent with hemorrhagic contusion.

CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST  [**2126-7-27**] 5:32 AM
There are bilateral comminuted fractures of the nasal bones and
nasal septum. There is a segmental depressed fracture of the
wall of the left maxillary sinus. There appears to be a fracture
of the medial portion of the left inferior orbital wall. There
are multiple foci of air within the subcutaneous tissues
overlying the left face. There is dense material within the left
maxillary sinus consistent with hemorrhage. There is near total
opacification of the left maxillary sinus. There is partial
opacification of the sphenoid sinuses and partial opacification
of the ethmoid sinuses. The globes appear to be intact. The
optic nerves appear to be intact. The lenses are not dislocated.
Linear fracture of right frontal bone is seen with contusions in
frontal lobes further evaluated with head CT.


Brief Hospital Course:
Patient admited to the Trauma ICU, good evolution. Transfer to
the floor. He was notified of his wife death. [**Name2 (NI) **] was schedule
and canceled for Plastic Surgery for his face fractures. Plastic
surgery decide non-operative managment. The patient was sent
home with family support.

Medications on Admission:
None

Discharge Medications:
1. Haloperidol 1 mg Tablet Sig: 1-2 Tablets PO twice a day as
needed for agitation.
Disp:*30 Tablet(s)* Refills:*1*
2. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) patch
Transdermal once a day: do not wear if you are going to smoke.
Disp:*14 patches* Refills:*2*
3. Wellbutrin 75 mg Tablet Sig: One (1) Tablet PO twice a day:
DO NOT USE WHILE STILL ON HALDOL!.
Disp:*30 Tablet(s)* Refills:*2*


Discharge Disposition:
Home

Discharge Diagnosis:
Head Trauma with Bilateral Frontal Subdural Hematoma & Facial
Fractures

Discharge Condition:
Stable, oriented, alert, tolerating diet.

Discharge Instructions:
-Follow up with Psychiatry


Completed by:[**2126-8-11**]
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Pneumonia, organism unspecified,Closed fracture of nasal bones,Unarmed fight or brawl,Other and unspecified open wound of head without mention of complication'}


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: Head Trauma

PRESENT ILLNESS: 43yoM s/p assault with bilateral frontal SDH and multiple facial
fractures (nasal and septal).

MEDICAL HISTORY: None

MEDICATION ON ADMISSION: None

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: 

FAMILY HISTORY: [**Name (NI) **] wife found dead on [**2126-8-4**]

SOCIAL HISTORY: Fisherman 

### Response:
{'Closed fracture of base of skull with subarachnoid, subdural, and extradural hemorrhage, with no loss of consciousness,Pneumonia, organism unspecified,Closed fracture of nasal bones,Unarmed fight or brawl,Other and unspecified open wound of head without mention of complication'}
