CHIEF COMPLAINT: s/p Moped crash

PRESENT ILLNESS: 56 yo male driver who took his motor bike to a friend's to have
it fixed. Afterward he decided to try to drive the motor bike
home, and per his report hit a patch of sand in the road and
lost control. He sustained trauma to his torso and head. He was
transportedto [**Hospital1 18**] for further care.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: Denies

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admisison:
BP: 152/72 HR: 94  R 18 O2Sats 100% RA
Gen: comfortable, NAD.
HEENT: Pupils: 1 mm and non-reactive; sclera glazed  EOMs:
intact
Neck: Supple, full ROM
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused; several abrasions over left
torso, shoulder and face.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH
Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of five ribs,Closed fracture of malar and maxillary bones,Head injury, unspecified,Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring motorcyclist,Alcohol abuse, unspecified
Cl skul base fx w/o coma,Traum pneumothorax-close,Fracture five ribs-close,Fx malar/maxillary-close,Head injury NOS,Abrasion NEC,Loss control mv-mocycl,Alcohol abuse-unspec
Admission Date:  [**2158-9-11**]              Discharge Date:   [**2158-9-14**]

Date of Birth:  [**2102-7-28**]             Sex:   M

Service: SURGERY

Allergies:
Patient recorded as having No Known Allergies to Drugs

Attending:[**First Name3 (LF) 4691**]
Chief Complaint:
s/p Moped crash

Major Surgical or Invasive Procedure:
None

History of Present Illness:
56 yo male driver who took his motor bike to a friend's to have
it fixed. Afterward he decided to try to drive the motor bike
home, and per his report hit a patch of sand in the road and
lost control. He sustained trauma to his torso and head. He was
transportedto [**Hospital1 18**] for further care.


Past Medical History:
Denies

Social History:
+EtOH

Family History:
Noncontributory

Physical Exam:
Upon admisison:
BP: 152/72 HR: 94  R 18 O2Sats 100% RA
Gen: comfortable, NAD.
HEENT: Pupils: 1 mm and non-reactive; sclera glazed  EOMs:
intact
Neck: Supple, full ROM
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused; several abrasions over left
torso, shoulder and face.

Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, slightly off on date
(states [**9-9**]), but knows day of week.

Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.

Cranial Nerves:
I: Not tested
II: Pupils equally round ~1 mm and non-reactive to light. Visual
fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice and finger rub.
IX, X: Palatal elevation symmetrical.
[**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power [**5-22**] throughout, except for the
right
deltoid which is pain limited.

Sensation: Intact to light touch, propioception, and
vibration bilaterally. Refused to cooperate with PP testing.

Reflexes: B T Br Pa Ac
Right     2 - 2  2  2
Left      2 2 2  2  2
(right tri not tested secondary to large abrasion over elbow)

Pt refused babinski reflex testing

Coordination: normal on finger-nose-finger, rapid finger tap,
heel to shin


Pertinent Results:
[**2158-9-11**] 07:20PM   GLUCOSE-118* UREA N-6 CREAT-0.6 SODIUM-143
POTASSIUM-3.5 CHLORIDE-108 TOTAL CO2-25 ANION GAP-14
[**2158-9-11**] 07:20PM   ALT(SGPT)-31 AST(SGOT)-42* LD(LDH)-265* ALK
PHOS-101 AMYLASE-36 TOT BILI-0.2
[**2158-9-11**] 07:20PM   ALBUMIN-4.2 CALCIUM-8.2* PHOSPHATE-2.8
MAGNESIUM-1.6
[**2158-9-11**] 07:20PM   WBC-12.0* RBC-4.19* HGB-12.6* HCT-35.8*
MCV-86 MCH-30.0 MCHC-35.1* RDW-13.7
[**2158-9-11**] 07:20PM   PLT COUNT-224
[**2158-9-11**] 07:20PM   PT-11.9 PTT-20.9* INR(PT)-1.0
[**2158-9-11**] 03:50PM   ASA-NEG ETHANOL-159* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
[**2158-9-11**] 03:50PM URINE  bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG

Head CT scan [**2158-9-13**]
FINDINGS: Within the right temporal lobe, there is an 11-mm x 6
mm area of
hyperattenuation consistent with an area of hemorrhage. There is
significant
surrounding vasogenic edema which appears to have increased
compared to prior
examination. There is no evidence for midline shift or uncal
herniation.
However, there is slight effacement of the sulci within the
right temporal
lobe compared to prior study.

Along the right frontal convexity, there is an area of
heterogeneous signal on
images (2:12) which could represent a subdural hematoma and was
not well
evaluated on prior studies. There are small areas of
questionable low
attenuation within the posterior limbs of the right and left
internal
capsules, which could represent areas of ischemia and were not
well seen on
prior examination. Within the left frontal lobe, there is an
area of low
attenuation which could represent an area of chronic infarction.


There is a fracture of the right temporal bone as well as the
right zygomatic
arch. Nasal fractures were better characterized on prior CT
examination.
There is extensive mucosal thickening and opacification of
bilateral maxillary
sphenoid, and ethmoid sinuses. The frontal sinuses and mastoid
air cells are
well aerated.

There are no new areas of fracture or no new areas of hemorrhage
identified.

IMPRESSION:

1. Stable appearance of high attenuation area of hemorrhage
within the right
temporal lobe. However, there is significantly more surrounding
vasogenic
edema. There is no shift of midline and there is no evidence for
uncal
herniation. However, there is mild effacement of the right
temporal sulci.

2. Within the right frontal convexity, there is an area of
heterogeneous
signal, which could represent a subdural hematoma and we would
recommend short
interval followup to further evaluate.

3. Within the right and left posterior limbs of the internal
capsule there
are areas of questionable low attenuation, which could represent
areas of
ischemia and would recommend short interval followup with CT or
MRI if patient
can clinically tolerated to further evaluate.

4. Extensive fracture through the right temporal bone as well as
zygomatic
arch, which appears stable. There is extensive associated
opacification of
bilateral maxillary, sphenoid, and ethmoid sinuses.

[**2158-9-12**] THREE VIEWS OF THE RIGHT SHOULDER: There are fractures
involving at least the
second through eighth right ribs. Many of these are displaced
and involve
both the posterior and lateral portions of individual ribs. No
fracture or
dislocation is seen involving the shoulder. Probable small right
apical PTX.
Clavicle intact. Overall appearance is little changed from
recent exams.



[**2158-9-11**] CT FACIAL BONES: There is a minimally displaced right
mastoid fracture
extending into the right squamosal temporal bone (2:61), and an
adjacent small
locule of pneumocephalus. There is a nondisplaced horizontal
fracture of the
right pterygoid plate (2:70). There is a minimally displaced
nasal bone
fracture (2:26). There are additional fractures throught the
anterior and
lateral right maxillary sinus, and right medial lamina paprycea,
all
non/minimally displaced. There is mucosal thickening of the
ethmoid and
maxillary sinuses bilaterally, consistent with chronic sinus
disease. No
large hematoma is appreciated.

IMPRESSION:

1. Right temporal bone fracture.
2. Small locule of adjacent pneumocephalus.
3. Right pterygoid bone fracture.
4. Minimally displaced nasal bone fracture.
5. Fractures throught the right medial orbital wall and right
maxillary
sinus.

These findings were posted to ED dashboard at 11 p.m. on
[**2158-9-11**], but were
discussed at the time the patient was brought to the emergency
department with
the team caring for the patient (Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]).







Brief Hospital Course:
He was admitted to the Trauma Service and taken to the Trauma
ICU for close monitoring. Neurosurgery was consulted given his
head and facial injuries; operative intervention was not
warranted. He did not require any anti-convulsant therapy. He
will follow up as an outpatient in [**Hospital 4695**] clinic with Dr.
[**First Name (STitle) **] for repeat head imaging in 1 month.

Later he was transferred to the regular nursing unit; he was
started on an aggressive pain regimen because of his rib
fractures and instructed on coughing, deep breathing and use of
incentive spirometer.

He was seen by Social Work due to a positive blood alcohol
level. He was offered information on alcohol counseling and
rehab.

Physical therapy was consulted to assess gait; he was cleared
for discharge to home.

Medications on Admission:
Denies

Discharge Medications:
1. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff
Inhalation Q6H (every 6 hours) as needed for shortness of breath
or wheezing.
Disp:*1 * Refills:*1*
2. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. Milk of Magnesia 800 mg/5 mL Suspension Sig: Thirty (30) ML's
PO twice a day as needed for constipation.


Discharge Disposition:
Home

Discharge Diagnosis:
s/p Moped crash
Right temporal bone fracture
Right ptyergoid fracture
Small right apical pneumothorax
Multiple right rib fractures 1,2,4,6,8

Discharge Condition:
Hemodynamically stable, tolerating a regular diet, pain
controlled.

Discharge Instructions:
It is important that you cough, deep breathe and use the
incentive spirometer every hour that you are awake.

Take your medication as prescribed. Take the stool softeners and
laxatives while you are on narcotics in order to avoid
constipation.

AVOID alcoholic beverages and use of any illicit drugs while
taking the narcotics.

Return to the Emergency room if you develop any fevers, chills,
headache, hearing loss, productive cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, constipation,
diarrhea and/or any other symptoms that are concerning to you.

Followup Instructions:
Please follow-up with Dr. [**First Name (STitle) **] of Neurosurgery in 4 weeks.
You will need to call ([**Telephone/Fax (1) 1669**] to schedule an appointment.
 When you call ask to have them help you schedule another CT
scan of your head.

Follow up in Trauma Clinic with Dr. [**Last Name (STitle) **]  in [**1-18**] weeks, call
[**Telephone/Fax (1) 6429**] for an appointment.


Completed by:[**2158-9-21**]
{'Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of five ribs,Closed fracture of malar and maxillary bones,Head injury, unspecified,Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring motorcyclist,Alcohol 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 Moped crash

PRESENT ILLNESS: 56 yo male driver who took his motor bike to a friend's to have
it fixed. Afterward he decided to try to drive the motor bike
home, and per his report hit a patch of sand in the road and
lost control. He sustained trauma to his torso and head. He was
transportedto [**Hospital1 18**] for further care.

MEDICAL HISTORY: Denies

MEDICATION ON ADMISSION: Denies

ALLERGIES: Patient recorded as having No Known Allergies to Drugs

PHYSICAL EXAM: Upon admisison:
BP: 152/72 HR: 94  R 18 O2Sats 100% RA
Gen: comfortable, NAD.
HEENT: Pupils: 1 mm and non-reactive; sclera glazed  EOMs:
intact
Neck: Supple, full ROM
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused; several abrasions over left
torso, shoulder and face.

FAMILY HISTORY: Noncontributory

SOCIAL HISTORY: +EtOH 

### Response:
{'Closed fracture of base of skull without mention of intra cranial injury, with no loss of consciousness,Traumatic pneumothorax without mention of open wound into thorax,Closed fracture of five ribs,Closed fracture of malar and maxillary bones,Head injury, unspecified,Abrasion or friction burn of other, multiple, and unspecified sites, without mention of infection,Motor vehicle traffic accident due to loss of control, without collision on the highway, injuring motorcyclist,Alcohol abuse, unspecified'}
